Sunday, February 27, 2005

by the sea

The Death of "Call"

At the "tender" age of 42, now 10 years out of general surgery residency, I have finally come to the realization theat essentially none of the preconceived notions I had about the practice of surgery are true. Just as the salesman willing to go the extra mile to earn his customers' loyalty is rewarded with their recurring business, I bought wholeheartedly into the concept of the "3 A's" -- availablility, affability, and ability (in that order). I worker hard early in my career to ensure that no surgeon in town could outdo my efforts in being available and providing the best possible service for my patients and referring physicians. One of the best ways to connect with physicians who did not know me was to take extra ER call and be willing to see any and all patients sent my way.

Initially, that effort was rewarded and I am very humbled to say that I was able to receive the referrals of a wide range of docs, both new and well-established. The past few years, however, have brought changes to the delivery of primary care that I would never have anticipated. In particular, the advent of hospitalists has caused an enormous obstructing wall to be erected between (outpatient) primary care physicians and those (hospital-based) specialists who care for their acutely ill patients. Those patients now may recieve excellent, or inept, care without their PCP having any knowledge or the connection between PCP, patient to be sent, and receiving specialist is forever broken. Add to this the large volume of uninsured patients hitting the ER, and there is very little incentive left for any surgeon to be involved with ER call. When one can fill an elective schedule with easy hernia repairs and lap choles, what is the value to caring for the 82 year old diabetic, anticoagulated, obese patient at 1AM with perforated diverticulitis? Trauma call is in an even worse situation.

I suspect that the end result will be more paid ER call and more closed staffs. The losers will be those patients who still wish to choose their surgeon.

To paraphrase John Belushi, "Seven years of practice down the drain!

Up too long on call.....