By 8 AM, I had completed rounds on all of my hospitalized patients and stopped at the nursing home. As I settled down to paperwork before the clinic doors opened, I took a moment to organize my day. I had 2 critical patient issues that needed to be resolved as soon as possible. The solutions centered on contacting 3 different specialists and discussing the cases.

So I dialed the operator and had each physician paged. I waited 15 minutes and yet received no response. Undaunted, I called the offices individually. None of them had arrived yet, but their secretaries were kind enough to re-page them. Over the next few hours, while I ran from room to room seeing patients, my medical assistants dutifully tried to make contact with the specialists. One was out of town, the other was in the operating room, and the third had lost his pager.

At 1 PM, a full 5 hours later, I finally was able to reach all 3. Our conversations were short, but I was able to negotiate these critical care issues with little difficulty. It would have been nice if it hadn’t taken so long. Thank goodness these were issues that could wait while I spent time tracking down the right people.

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You may wonder if there is something that ties these slow responders together. Is there a sentinel characteristic that binds?

Around the country, private practitioners are closing their doors and joining hospital systems and large medical groups. The economic and regulatory climate has changed to favor such arrangements. The problem is, something can happen to physicians when they transform into company men. Sometimes they become lackadaisical. Occasionally their pagers are nonfunctional, and consults can take greater than 24 hours to attend to.

This doesn’t affect only physicians; hospital and nursing staff are adopting a similar attitude. This morning I called a medical floor to relay important information to a nurse. After waiting on hold for 5 minutes, the secretary informed me that the nurse was not available because she was in the middle of report.

Please call back in thirty minutes.

Let’s talk hypotheticals. Why is it that a pedestrian who comes upon a mugging while walking in a dark alley will call the police, yet hundreds of onlookers will do nothing while an innocent victim gets assaulted outside his or her building? Group think can lead to group paralysis. Decentralized decision-making can promote a loss of culpability.

What threatens to topple our medical system is the disappearance of individual actors. When you’re down and out, what you want is that guy standing alone in the alley—the one who thinks that if he doesn’t make the call, no one will.

I’ve been accused of practicing in a silo. But standing alone in that empty room gives me a lot of time to think. When the heart is fibrillating, the blood pressure drops, and the white count rises, you better believe that I’ll be doing my best. I’ll be making that phone call, checking those labs, and consulting the literature. Because the truth is, I take sole responsibility for each and every person who walks into my office. There is no group to lean on.

And maybe, just maybe, that isn’t so bad.