The Case

St. Elsewhere is a 130-bed hospital with a catchment area of 50,000 people, providing all basic services (medicine, surgery, obstetrics, complex care and emergency medicine) to its surrounding community. Until 1999, all in-patient care was provided by a group of 20 family physicians who maintained a full spectrum of practice, with specialists playing a supportive role. However, by the end of 1999, five physicians had retired from active practice. While the community was able to recruit new family doctors, all new recruits had young families and preferred to limit their practices to ambulatory care. As a result, the remaining physicians created a "doctor of the day" program to provide care for their patients and for a growing number of "unattached" patients. The program was largely successful for the first few years of its operation; but by 2005, three more physicians had either retired or limited their practices to outpatient settings. With a complex patient population, the remaining 12 family physicians found it increasingly difficult to maintain the program. The hospital tried to enhance support for physicians by recruiting more specialists, but these efforts were by and large unsuccessful. By 2006, the impending resignation of half of the group had resulted in a crisis of in-patient care delivery for the organization.