Deciding whether to take call in the ED

Specialists in private practice increasingly limit their work exclusively to outpatient care in private offices, leaving patients' hospital care to others still at the hospital. What is the impact?

Response

When colleagues stop taking emergency department and hospital call and expect people like me to take care of their patients who get sick, I feel abused. Even though their patients get the care they need, are free to change physicians and aren't subject to unfair discrimination, it's not as if nobody gets hurt. I do. And so do others like me.

Doctors who leave hospital and ED care to others violate the cardinal rule learned early in internship: One never, never, dumps dirty work on a colleague. Being a physician implies an obligation not only to our patients, but to each other. We must share the pain if we are to be permitted to share the rewards. We are not a fraternity, but a community. I believed it when I learned it, and I believe it still.

It's not so simple, you say. You're right. I understand the other side of the story, and it deserves to be heard.

Nobody I know went into medicine for the money. Sure, people get caught up in it, but that wasn't the point for any doctor I know. It's just that matters get complicated in a system that keeps demanding that we change how we do things, for reasons only rarely having to do with helping patients.

I'm not old enough to have traded my services for chickens, but I know a few rural Canadian docs who found themselves awash in cash and short of fresh eggs when national health insurance arrived in the '70s. And I know American docs who quit because they couldn't stay afloat seeing fewer than 25 patients an hour. They were internists, family physicians -- the kinds of people writers wax rhapsodic about -- who would check your prostate, your dad's lumbago, your kid's earache and your neighbor's chilblains before and after they went on hospital rounds six or seven days a week.

It's not just the pressure to produce that's the problem. It's the insult to injury that's the worst. It's the administrator who says you have to join this group or you'll lose your referral base and go belly up. It's the agency that says -- under threat of ruinous fine or imprisonment for "fraud and abuse" -- you have to chart things just this way and not another, primarily to enable a kid to read it and know what you billed for (which, face it, ain't necessarily exactly what you did, since half the codes don't fit and the other half don't make any sense). It's the personal injury lawyers who solicit reports of your supposed malfeasance loudly on the air, for lots of money.

It's when you have the audacity to ask your bookkeeper how much you get paid for something you do pretty routinely, and she says, "It depends on which insurance."

And you say something like, "Oh, I don't know. Say, InsurerX."

And she says, "It depends."

And you say, "On what?"

And she says, "Well, who does the patient work for?"

And you say, "I don't know. Say, SnapitBuzzComm."

And she says, "Which policy?"

And you say, "What?"

And she says, "They have a dozen of them. They're all different. I can't tell you without knowing which policy."

And you say, "Well, give me an average. Just give me an average."

And she says, "For InsurerX, or InsurerXPlus, or for everybody except Medicare and Medicaid?"

And you say, "I don't know, whatever you want."

And she says, "Well, there are differences of at least 10% to 15% among them; there are too many anyway."

And you say, "How many am I contracted with?"

And she says, "About 500."

So you make the mistake of taking the bull by the horns (just as they told you in that practice seminar) and you phone "provider services" at InsurerX. After 20 minutes on hold in voice-mail hell, the brief conversation is too painful to reproduce. The lady on the phone is allowed to look up only 10 codes at a time for any given "provider," because "anything more would keep us from providing excellent services to all our subscribers."

So you give up. Heck, you never thought of yourself as a "provider," at least not to anybody but your family.

So you go back to slogging away at the work you love. You learn to accept reproach slung casually in your direction by people who have no idea what you do for a living. They don't see the holes in your schedule last week. They don't see your bills; they don't see your payroll. They see only your busy, thriving practice. They don't notice the tremor, the sweat, the sheer terror as you dash from room to room, hoping you won't miss anything big enough to do anybody any real harm, trying to keep up, to stay afloat, to stay alive. They don't see the desperation.

It might be easier if all your colleagues were as understanding as they ought to be: self-righteous curmudgeons like me, or virtuous academicians who don't know what it's like to meet a payroll, or salaried people in group practices whose guaranteed referrals and permanent waiting lists eliminate anxiety over anything more than the bills at home and the number of hours in a day. They don't really understand, either.

No, when you make the decision not to go to the ED anymore, it has nothing to do with money. It's not a decision about "efficient use of time" or "lifestyle," nor is it necessarily a matter of expertise (at least not that you'd care to admit). It's not a "choice," but a moment of existential reckoning, a confrontation with reality. You do it for yourself, your family, your employees, your patients. You abandon the hospital -- the scariest, most dangerous, thrilling and rewarding work, the kind of work for which you were originally trained -- neither to shield your coronary arteries nor to pad your coffers, though doing so may or may not accomplish either. You do it to contract your world to a livable size.

Sometimes I'm not sure why I don't do the same. I wonder when I'm finally going to catch on, when I'm going to realize it really doesn't make any sense to keep punishing yourself with unpaid late night calls about things you can't do anything about. Nobody's going to thank you, and nobody will remember it when you're in your grave.

And then I realize that it isn't a question of punishment or sacrifice. It's not a question of "ethics." It's simply what I do. It's how I conceive my vocation, and I have no desire to conceive it otherwise. It's why I became a physician. It's why I feel kinship with my colleagues -- even those I chide here -- and it's the last thing I can hang onto when I feel the rest slipping away, when I mourn a professionalism so impoverished that we now believe it has to be taught.

So when somebody accuses you of dumping on colleagues, don't imagine I don't know how you feel. Don't think me unsympathetic. Think of me as somebody who, after 20 years, isn't there yet and doesn't want to be, a physician-dinosaur who still hopes to find a way to survive with equanimity in the world in which he was born. Maybe I'll come around someday, but not yet. I hope never. Or at least not until that meteor comes along.

James Gordon, MD , neurologist, Seattle, Wash.; clinical associate professor of neurology at the University of Washington; vice chair, Ethics, Law and Humanities Committee of the American Academy of Neurology; chair, Ethics Committee of Health Resources Northwest

The views expressed are his and do not represent these organizations.