Primary care chaos--and what's really needed in ER in the 'Burg

ONE OF THE MOST overlooked and far-reaching consequences of rampant growth is the area's chronic shortage of physicians. Exorbitant malpractice premiums and judgments, frivolous lawsuits, too few medical slots and scarce faculty, the economic realities of insurance and government-regulated health care-- exacerbated by inflated local demand for medical services--have caused primary care chaos.

Family, internal medicine and pediatric generalists--undercompensated and overpressed--have turned in their hospital privileges for the pleasures of sleeping in, and it's hard to blame them. That being said, each doctor who leaves the hospital leaves another doctor to pick up the slack. Those hardy and conscientious souls left holding the bag have been falling like tenpins.

Enter the hospitalist.

A few of our primary care physicians, perhaps the best ones, still do take calls and make rounds. Many of them, interestingly, prefer a solo practice to dealing with partners. Their grateful patients repay loyalty and respect in kind.

I vividly remember a 4-year-old sobbing against her mother in the ER: "But I want my own doctor, not some stranger!" It was home truth from a baby's mouth. I was not surprised to learn that her doctor, Michael Childress, is one of the two local pediatricians who do not use the pediatric hospitalist service.

To be sure, there are good arguments to be made in favor of hospitalists--particularly the board-certified specialists and subspecialists on staff at large teaching hospitals.

While hospitalists may be the only viable solution to the growing problem of unassigned patients in community hospitals, there are significant disadvantages to a hospitalist system that should not be overlooked

The hospitalist team, which knows neither the patient nor his history, in- jects extra layers of care, which multi- ply opportunities for confusion, missed information, miscommunication, and misunderstanding. This model increases the risk of error and poor outcome.

There is no guarantee of appropriate follow-up, and there can be real and meaningful disruption to the primary care physician-patient relationship.

Doctors who do not make rounds have a responsibility to make it clear to their patients that the hospitalist group operates within a closed system and assumes sole authority for inpatient management.

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