Commercial features of placebo and therapeutic efficacy.

of general surgery “at the feet of primary care.” Having been involved in an effort to undo the flawed sustainable growth rate system for the past decade, I know that the system is broken. In a rational world, specialties would unite to correct this flawed system, which seems cynically designed to pit specialties against each other. The calculations for physician compensation used in the cited study of internal medicine reimbursement cut off in 2004 while the increases in evaluation and management codes took place in 2004 through 2007. For example, evaluation and management codes increased in work relative value units from 2006 to 2007 (code 99213: increase from 0.67 to 0.92 [37%]; code 99214: 1.10 to 1.42 [29%]; and code 99215: 1.77 to 2.00 [12.9%]). Furthermore, this article has been rebutted. The primary care–specialty income gap has largely been corrected, at an estimated cost of $4 billion. I appreciate the enthusiasm of Dr Maa and colleagues for the surgical hospitalist, particularly in emergency and trauma care. However, I do not believe this is the answer to the shortage of general surgeons, who not only do emergency and trauma care but often perform endoscopy and other general surgical operations in critical access hospitals. Philosophically, I have difficulty with medical or surgical hospitalists. My objection to the medical hospitalist system is that patients may perceive that they are being abandoned by their primary care physician at a time of their most dire need—when they are sufficiently ill to require hospitalization. I would hope that this sense of abandonment is not present in a surgical hospitalist system. When we train “physicians who operate,” we try to instill judgment about the need for surgery. But if operation is required, the operator must be thoroughly competent. I believe that such decisions are more informed when the physician/surgeon is familiar with the patient. The surgical hospitalist system may aid trauma and emergency care in urban centers but will not solve the access problem in small rural hospitals.