When the privileged are the underdogs

I was recently called in to see a patient in the emergency room. The woman from Newfoundland had developed rectal bleeding but could not be seen locally by a gastroenterologist for six months. In desperation, she came to Ottawa where she was seen by her daughter's family doctor. She was referred to a gastroenterologist who performed an urgent sigmoidoscopy; she was diagnosed with inflammatory bowel disease, and placed on oral prednisone therapy.

She began suffering severe abdominal pain, couldn't eat or sleep, and had almost constant diarrhea. However the gastroenterologist who diagnosed her not only did not have admitting privileges, but wasn't available outside 'regular business hours.' The woman ended up in the ER. The emergency room physician rehydrated her and I admitted her for further care.

This case illustrates the need for government to establish a relative values scale to acknowledge and support physicians who choose to be affiliated with hospitals and provide inpatient care for patients � as opposed to those who refuse to commit to patients outside 'regular business hours.' Is my outpatient consultation worth more than that of my non-admitting colleague? Frankly, I believe it is.

When I see a patient, I'm making a commitment � spoken or unspoken. I will take care of her through thick and thin, on a 24-hour seven-days-a-week basis. I will certainly not desert her after I hang up my lab coat for the day.

I'm part of a team of like-minded specialists who will maintain that commitment if I'm away on vacation. Moreover, as a part of an organization (the hospital) that's continuously reviewing my competence, I'm also presenting myself to my patient as a qualified physician.

Obtaining admitting privileges as a specialist at a hospital is just that � a privilege. It requires references, training and certification from the Royal College of Physicians and Surgeons of Canada. Opening an outpatient clinic without hospital affiliation, by contrast, requires only a license issued by a provincial College and adequate financial resources.

I suggest that any relative values scale should not only apply to gastroenterologists but all specialists who shirk the responsibility of maintaining hospital privileges.

Is there merit to my argument? Certainly the patient I just admitted would think so.
� Dr Robert J Fingerote is a consultant in gastroenterology and hepatology in Ottawa

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