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

July 27, 2006 1:30 am

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.

Parents also should understand that the pediatric hospitalists at MWH work for and answer to the hospital, which is another ambitious and cost-driven player in the high-stakes game of managed care.

It is important for patients to realize that there are no current standards for the training, performance, or evaluation of hospitalists as distinct from generally practicing physicians. Whichever hospitalist happens to be on duty will decide which tests to order (or not) and which specialists to call in (or not).

Conflict of interest issues can become as important as quality control.

Somewhat reduced length of hospital stays and lower costs are touted by the hospital and health insurance industries--but hospitalists with subspecialties actually raise costs, and I am aware of no studies of overall costs or number of readmissions after the initial hospital stay.

In-house hospitalist programs do not typically pay their own way, and we needn't wonder who will end up with the tab. It is also important to note that most studies evaluating these programs have been done from the point of view of the primary care physician and include only "perceived" notions of patient satisfaction.

Instead of focusing on a new hospital, MediCorp might better concentrate on the immediate community need for improved and expanded emergency services at MWH. The hospital needs more ER space and more ER staff, perhaps including specialists in pediatric emergency medicine.

All physicians, meanwhile, might consider the proposition that a doctor without a hospital is like a student without a classroom. It is better to burn out from stress than boredom.

The primary care physician, who is paid less to fix a child than a plumber to fix a faucet, is under mortal attack by a legal system that takes no prisoners and insurance companies whose executives bring home unimaginable salaries --$124.8 million to the CEO of UnitedHealthcare, which is enough to cover the average health insurance premiums of 34,000 people.

Doctors complain to each other but are otherwise passive--for some reason unwilling to fight for their professional integrity and the welfare of their patients.

Patrick Neustatter suggests that organizing physicians is like herding cats ["Insurers get between doc, his patients," Feb. 26]. There is a lot of truth to his comment, but the stakes have become ever higher over time.

The medical environment has grown far more dangerous since the early days of health insurance.

Until clinicians manage to collect themselves and begin seriously, together, to sort through and deal with the complex professional, philosophical, economic, and liability issues confronting them, American medicine will continue its downhill slide.

It may not be too late to "just say no." Bullies, in my experience, back down when confronted. I will risk including belligerent patients who demand the latest brand-name drugs as well as stone-walling bureaucrats who defend the gates of managed care.

If Dr. Jeffrey Poffenbarger's moving expression of medical sacred duty can rouse physicians from their depressed lethargy to a standing ovation ["MWH neurosurgeon honed his skills in Iraq war zone," April 20], we can hope that he has pricked in them hopes of things still possible.

ANN ROBINSON lives in Stafford County.