Ms. Martinez, a divorced working mother in her early 50s with two children in junior high school, was new in town and had to choose an insurance plan. She had difficulty knowing which plan to select for her family, but she chose CityCare because its cost was comparable to that of other options, and it had pediatric as well as adult practices nearby.

Once she had joined CityCare, she was asked to choose a primary care physician. After receiving some recommendations from a neighbor and several coworkers, she called several of the offices to sign up. The first two she called were not accepting new patients. Although she knew nothing about the practice she finally found, she assumed it would be adequate.

Juggling repairs on their new apartment, finding the best route to work, getting the children’s immunization records sent by mail, and making other arrangements to get them into a new school, Ms. Martinez delayed calling her new doctor’s office for several months. When she called for an appointment, she was told that the first available nonurgent appointment was in 2 months; she hoped she would not run out of her blood pressure medication in the interim.

When she went for her first appointment, she was asked to complete a patient history form in the waiting room. She had difficulty remembering dates and significant past events and doses of her medications. After waiting for an hour, she met with Dr. McGonagle and had a physical exam. Although her breast exam appeared to be normal, Dr. McGonagle noted that she was due for a mammogram.

Ms. Martinez called a site listed in her provider directory and was given an appointment for a mammogram in 6 weeks. The staff suggested that she arrange to have her old films mailed to her. Somehow, the films were never sent, and distracted by other concerns, she forgot to follow up.

A week after the mammogram, she received a call from Dr. McGonagle’s office notifying her of an abnormal finding and saying that she should make an ap-