Dr. Brenda Arnett is a third generation doctor. She doesn't take produce as payment, but in many ways, she's every bit the country doctor her dad is and grandfather was.
An internal medicine specialist who trained at Georgetown University in Washington DC, Arnett is thoroughly modern -- with a laptop instead of a traditional black bag -- but she still makes house calls. She takes phone calls from patients around the clock. She sometimes adjusts her fees for patients she knows are strapped. But she only accepts cash or credit cards, no health insurance.
She's in the second year of her solo journey back to a style of medicine that some say is the way primary care should be, but that others view as an indulgence only the well-heeled can afford.
Brenda Arnett's father, Jerome Jr., is a pulmonary specialist who still practices in Preston County, W.Va. and still makes house calls, but also still bills insurance. Her grandfather, Jerome, practiced in Rowlesburg, W.Va.,
Brenda Arnett tries not to see more than a dozen patients a day, but "days that I see less than eight are really nice," she said. "That will pay my bills, although it won't pay me."
As a member of a busy group practice in a nearby Shenandoah Valley town until last year, eight or more patients before lunch was normal.
"It was not a good way to practice, but the insurance payments were so low, you had to see 18 to 20 patients a day in 10 or 15 minute spurts. I was always worried that I would miss something important in the rush," Arnett said.
"I'm so much happier doing this. I don't make a ton of money, but I sleep well at night."
She never schedules a patient for less than 30 minutes, and first-time patients get 90 minutes.
A Scripps Howard News Service review found that access to primary care is deteriorating across much of the country, driving millions of people outside traditional family practices, or leaving them without care. And frustration insurance rules and assembly-line medicine is prompting thousands of doctors like Arnett to change the way they work.
With a regional medical center at its edge and 84 primary care doctors for about 25,000 residents, the independent city of Winchester has one of the highest concentrations of doctors per person in the nation, according to federal records.
But that didn't seem to be the case to Arnett as she picked a spot for her new practice. "I called around to several practices in the city to see if they were taking new patients and how long the wait for an appointment was, and those that were accepting people said it would be several weeks to get a new patient in,'' she recalled.
In fact, some of Arnett's patients drive from as far away as Washington, D.C., nearly 90 miles away, to see her.
"She just takes the time to listen and she's gone above and beyond the call for me several times,'' said Lori Ritchie, a 36-year-old mother of five who drives 45 minutes from her home near Front Royal, Va. to Arnett's office. "When I came to her, I'd been having these fevers and headaches but no other doctor I saw got to the bottom of them, until she got the imaging done to confirm that I had a raging sinus infection.
"I know I'm getting a whole lot better care for my money."
Arnett has about 450 patients now and doesn't plan to go above 600.
"Brenda just gets involved in finding out a little more about you than the average doctor, which may lead her to different answers. She always sees me through anything, keeps track of me even when I'm also seeing a specialist,'' said Brenda Jones, an office administrator for a private school near Front Royal whose job is about an hour away from Dr. Arnett.
"Paying her up front doesn't matter to me at all. The level of care that I get is worth twice what she's charging."
Arnett said as far as she knows, only four or five former patients decided not to join her new style of practice for financial reasons.
Dr. Vern Cherewatenko, a family practice doctor in Renton, Wash., was one of the pioneer dropouts from any relationship with health insurers a decade ago.
"It gives me maximum freedom to be a doctor,'' he said.
He also founded a national networking program, called SimpleCare, one of several services that links doctors in all sorts of specialties with patients interested in cash-only arrangements.
About 5,000 primary care doctors have reorganized their offices so that they do not accept any health insurance or require patients to pay fees be a member of a practice.
Dr. Thomas LaGrelius, a Torrance, Calif., physician and president of the Society for Innovative Medical Practice Design, said based on the recent surveys showing primary care doctor's dissatisfaction, another 17,000 could shift to the new styles of practice within the next three years.
Like several hundred other family doctors around the country who ask patients to pay as they receive services, Arnett bills by the hour. But she does give patients a universal insurance form so the patient can try to be reimbursed by insurance.
"It does take a little time to do the paperwork, but I have the time," Arnett said. "There are still some times that I have to do battle with the system to get my patients the care they need, like a CT scan or a certain blood test, but being an advocate for them is part of what I do. And my approach to medicine isn't dictated by insurance company guidelines."
With only a receptionist and one nurse on staff, she said, "I don't have to charge as much as other practices, because my overhead is still lower."
Although her father shares her distaste for insurance restrictions, Arnett said the nature of his patients in Preston County, W.Va., make it impossible to stop accepting insurance.
"He's a little bitter that I don't have to anymore, but we have very different practice styles."

(E-mail Lee Bowman at bowmanl(at)shns.com. Distributed by Scripps Howard News Service, http://www.scrippsnews.com)