Who Is Your Doctor?

• Position: MEDICINE & HEALTH - Government as the authority on health care

People used to know who their doctor was. His name and phone number were on the wall or the refrigerator next to the telephone. He was there for you and could manage most of your problems.

When I was about 13, my mom took me to our pediatrician for stomach pain. He was on his way out the door, but he stopped to take care of me. He diagnosed appendicitis based on history and physical examination. He called his favorite surgeon ("Billy," a Tucson legend), who came from the golf course to meet me in the emergency room. Within hours, my red-hot appendix was in a jar. My parents paid the hospital bill ($150, 10 days' pay for a construction laborer), and I was discharged a few days later.

Today, the patient with abdominal pain could wait for hours to see the ER provider--possibly a nurse practitioner or physician assistant who never has seen a case of acute appendicitis. She probably will get a CT scan, after another wait. Eventually, Dr. On-Call may take her to the operating room, hopefully before the appendix ruptures--and the bill will be beyond the means of ordinary people.

I used to be able to direct-admit patients from my office and send them with a set of orders to the hospital admitting office. For years, this has been impossible. The hospital is decidedly unfriendly to independent physicians. There now is a gatekeeper in the emergency room, and most patients are under the control of a hospitalist.

This hospital, still Catholic (at least in name) now is owned by a huge national conglomerate. Recently, it thwarted all efforts to keep it from dehydrating a patient to death despite lack of an advance directive or permission from next of kin. The patient's mother disputed the diagnosis of brain death. The gastroenterologist of her choice was willing and able to place a feeding tube, needed in order to transfer the patient to a skilled nursing facility, but the hospital would not permit it. An outside physician whom the mother had called on was removed from the patient's room by security, when she merely was praying with the mother. The mother could not get a phone call returned from an attending physician. Who was the doctor? Apparently, the hospital system.

Recently, a physician called me about her mother, who seemingly was a captive in a world-renowned hospital. She was concerned about her...