Excuse me, but what do you mean by the patient's 'attending physician'? You can't possibly mean the patient's own doctor. I think that's the guy who works in a practice where he goes home at a decent hour and another physician in the practice takes calls (the doctors in the practice rotate being 'on-call') after 5 p.m.

The best insurance in the world doesn't mean you are going to get any treatment after 5 p.m. that is different from going to the E.R. for whatever pain or symptom that seems worrisome. I am amazed that this is not the very assumption every discussion starts with - it is a fact of life in these United States and I don't know where else.

This is the reality. Let's start from there. You have a child, a relative, yourself - with a pain in their abdomen. You call 'your doctor' - and because it's after 5, you get the 'physician on-call' who says, 'Go to the E.R. Without an examination, abdominal pain is difficult if not impossible to diagnose.' So you go to the E.R. because no doctor wants to say, 'Call tomorrow for an appointment and I'll look at it.' They don't want to risk it being a burst appendix, and the lawsuit that would follow.

So you HAVE to go to the E.R. In the case of a child who has chronic constipation (as was my experience), you make several trips throughout a certain year when the child is particularly troubled by this condition ((while you try to handle the cause of the problem, using food and drink and cajoling him to use the bathroom, as a parent you do this) and each trip is at odd hours, waiting for several hours in the E.R. to be seen by a physician. That physician pokes and prods the tummy and then pronounces: 'constipation' but at least you have acted in your child's best interest. The child's doctor wasn't disturbed by pesky phone calls. The doctor 'on-call' checked you off his list. The E.R. physician did his job. All proceeded in accordance with the laws of the jungle-hospital. It was only 5 hours out of your life that night.

That's with the best insurance and a good suburban hospital and a simple ailment. What in the world are you talking about - having the patient's physician involved? The guy has a social life and a home life and that's why he's in a practice. That's his reasoning and he will tell you that up-front. Nothing more.