My partners and I have long struggled with the lack of specialty back-up at our hospital. Semi-rural hospitals, out of the way facilities, just can’t always attract specialists. So, 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 5PM on weekdays.

Still, I continue to scratch my head about why only three of seven community pediatricians take call, such that family physicians have to admit their patients. I was bumfuzzled that our neurologists were previously going to require us to use telemedicine for stroke evaluation, when their offices were close by the hospital. (In the same year they were called in roughly three times per neurologist 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 that they are contacted with remarkable rarity to deal with on-call emergencies. Soon, we will have no neurologist on the weekend. And the pediatric problem remains.

Of course, I’m using my local experience to highlight something that isn’t a local problem at all. It’s a national problem. All over America, specialists are relinquishing their hospital priveleges 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, since they have fewer and fewer specialists. Those referral and teaching centers want patients, but they can’t take all of the non-paying 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 both financially and from the shear 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 that 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 go 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 am. 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. However, despite those issues, physicians are choosing to make themselves unavailable and ultimately perhaps irrelevant. And they are taking the amazing, critical skills they have and depriving patients of them.

So 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, the opportunity, down the line, to a colleague in another town. To consider the fact that patients, real patients with real illnesses and 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 also 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 will ask, ‘how did we contribute to the problem?’

Many of us, our children or grandchildren, may one day end up in a hospital with a genuine, urgent need for some speciality intervention. And because it is after 5PM, or because it is a weekend, because no one is available or only available 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.

Edwin Leap is an emergency physician who blogs at edwinleap.com and is the author of The Practice Test.

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