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Second Opinion

The Physician Exodus

Leap, Edwin MD

doi: 10.1097/01.EEM.0000395831.80801.6c
    By Edwin Leap, MD
    By Edwin Leap, MD:
    By Edwin Leap, MD

    My partners and I have long struggled with the lack of specialty backup at our hospital. Semi-rural hospitals and out-of-the way facilities just can't always attract specialists. We're happy to have cardiologists every night, but understand that we only have an ENT every third night. We're thankful to have neurologists, even if they don't admit anyone. We're glad to have radiologists, even if they don't read plain films after 5 p.m. on weekdays.

    Still, I continue to scratch my head about why only three of seven community pediatricians take call, forcing family ­physicians to admit their patients. I was bumfuzzled that our neurologists were previously going to require us to use telemedicine for stroke evaluation, although their offices were close to the hospital — in the same year each neurologist was called in three times for urgent stroke evaluation. That ­problem was resolved, thank goodness.

    Now I find that the problem has returned — and grown. We will very soon have no ophthalmologist on call, despite the fact that we have three in the community and they are contacted with remarkable rarity to deal with on-call emergencies. Soon, we will have no neurologist on weekends. And the pediatric problem remains.

    Of course, I'm using my local experience to highlight ­something that isn't a local problem at all. All over America, specialists are relinquishing their hospital privileges and staying in the office. Proceduralists are opening surgery centers that are free from the burdens of indigent care. Primary care physicians are allowing hospitalists to do all of their admissions.

    In the process, not only are patients losing out, but referral centers are being absolutely overwhelmed. The cities and counties that lie around teaching hospitals are sending steady streams of patients because they have fewer and fewer ­specialists. Those referral and teaching centers want patients, but they can't take all of the nonpaying patients, all of the ­complicated or even all of the mundane patients with no local coverage. Those facilities, for all their shiny billboards and “center of excellence” marketing, will collapse.

    They will collapse financially and from the sheer exhaustion that will crush their staff physicians and residents. I already hear it in their voices. “Am I on call for your hospital? Where's your doctor? Fine, send them. We'll figure something out.” Many of those docs will ultimately join the exodus as well, simply to keep their sanity.

    My partners and I understand everyone's frustration. We face some of the same struggles: too many patients, too little reimbursement, overwhelming rules and regulations. I think the federal government has made our jobs inefficient, unpleasant, and in many instances, unsustainable. Laws like EMTALA and quasi-governmental regulatory bodies with their endless rules make physicians crazy. And they certainly explain why owning and practicing in a surgery center or the act of simply abandoning call duties is preferable to working in a hospital. I also know that lifestyle matters. I still work evening shifts that keep me out until 2 a.m. I occasionally work nights, as do many of my partners. Fatigue is miserable.

    Maybe the combination of regulations, financial constraints, and weariness is driving physicians away from what they once loved. Despite those issues, physicians are choosing to make themselves unavailable and ultimately perhaps irrelevant. And they are depriving patients of their amazing, critical skills.

    I implore physicians across the country to think a little before leaving. To think about the fact that their absence only passes the patient, the responsibility, and the opportunity down the line, to a colleague in another town. To consider the fact that patients, real patients with real illnesses and real injuries, desperately need their abilities. And equally important, to remember that emergency physicians can't do it all, not nearly as well as their specialist co-workers.

    I beg administrators and government agencies to observe this migration, from hospital to office, and ultimately from office to early retirement, and ask how it can be reversed. I hope that both groups will not ask, “What's wrong with those doctors?” but “How did we contribute to the problem?”

    Many of us, our children, or our grandchildren may one day end up in a hospital with a genuine, urgent need for some specialty intervention. And because it is after 5 p.m. or a weekend, because no one is available or is available only 100 miles away, they may suffer or die.

    If nothing else, that's worth serious consideration all around by a profession and a government ­purportedly dedicated to the well-being and health of real human beings.

    Dr. Leap is a member of Blue Ridge Emergency ­Physicians, an emergency physician at Oconee Memorial Hospital in Seneca, SC, and an op-ed columnist for the Greenville News. He is also the author of three books, Working Knights, Cats Don't Hike, and The Practice Test, all available He welcomes comments about his observations, and readers may write to him atemn@lww.comor visit his web site and blog This article first appeared in his blog on Jan. 28.

    © 2011 Lippincott Williams & Wilkins, Inc.