By Marc Fisher
Tuesday, January 10, 2006

At Washington Hospital Center's emergency room, the city's largest and busiest at 70,000 cases a year, it's easy to get the impression that the District is in dire need of more hospitals. Stretchers line the hallways; walk-ins sit in makeshift queues in every available corner. Some patients may spend 24 to 36 hours waiting in an open, chilly hallway. The scene is demeaning, depressing, depersonalizing.

But the problem is not too few hospitals, said the ER's associate medical director, Dr. Sunil Madan. The problem is poor people showing up at emergency rooms for routine matters that a primary care doctor could handle in a few minutes: a bruised finger, a prescription that should have been filled long ago, a follow-up question.

"They don't have a relationship with a doctor; they don't have anyone to call; they don't have insurance," Madan says. "They have us."

Seventy percent of those who walk into the ER go home the same day; they don't need hospitalization. (Deep down, most patients know they don't really need emergency care: On the evening of the 9/11 attacks, Madan was working at the Georgetown ER, where not a single person came in the door for eight hours. Not one.)

The D.C. government -- the folks who brought you the $1 billion baseball stadium that the politicians wanted, then didn't want, and now don't know what to do about -- is poised to push through a new, $400 million hospital that virtually no one wants.

The mayor contends that the neighborhoods east of the Anacostia River need a hospital to replace D.C. General Hospital, which he closed because it provided lousy, inadequate services at an exorbitant price. Doctors say they don't need it. Other hospitals say it's destined to be a financial failure. Even the city sees it as a sure loser: Both the District and Howard University, partners in the proposed deal, are shouting from the rooftops that they won't cover the inevitable cost overruns and operating losses. Who will?

You, of course. As soon as losses swamp revenues, which they will, the most likely scenarios are a government bailout or a takeover by a sleazy private operator, followed by a government bailout. In either event, the taxpayers lose.

This city does not lack for hospitals. The District is blessed like few other places on the planet with an embarrassment of high-end specialists and world-class facilities.

At the Hospital Center, which is licensed for more than 900 beds and has a dazzling suite of 21 operating rooms, the surgeons' locker room bustles with activity as doctors suit up for the day's action, a continuing cavalcade of hearts, backs and stomachs; tumors, replacement parts and gunshot wounds.

The Hospital Center medical staff president, Dr. Fred Finelli, walked me through half-a-dozen open-heart surgeries going on at once; the docs hunched over the gaping chest cavities had among them done more than 10,000 such operations. In another part of the same building, Dr. Nancy Davenport analyzed 350 electrocardiograms in a marathon session, talking students from Georgetown and George Washington medical schools through each step of her reasoning.

If you're in very bad shape, this is a very good place to live.

Yet the District's poor have just about the worst health in the nation, suffering record rates of diabetes, high blood pressure and other chronic conditions. The gap that produces those awful statistics is a primary care problem, not a hospital shortage.

The closing of the city's public hospital in 2001 did create longer drives for ambulances that serve the poorer eastern part of town. But despite some hysterical political rhetoric, geography is not an issue except in the most desperate emergencies. In fact, D.C. General's old emergency room remains in operation, though it cannot handle the most severe emergencies.

What many doctors say the city needs is a full-service, free-standing ER at the old D.C. General site. Such facilities thrive in the suburbs, including Inova's Emergency Care Centers in Reston and Fairfax, and Fort Washington Medical Center in Prince George's County.

The closing of D.C. General enraged many Washingtonians, as much because of what it seemed to say about government's attitude toward the poor as because of any lost medical care. After all, few would argue that D.C. General provided top-notch service. But the place did serve a purpose: "D.C. General picked off a disproportionate number of very difficult cases socially," including disruptive patients, says Dr. Mark Smith, chairman of emergency medicine at the Hospital Center.

The crunch at ERs around town stems in good part from having to take cases that used to go to D.C. General, where the staff was accustomed to dealing with drug abuse and emotional dysfunction.

But the Howard-D.C. proposal commits the hospital to donate only a fraction of its care -- about 3 percent of operating costs -- to those who have no means to pay for services.

The hospital Mayor Tony Williams proposes to leave along with a baseball stadium as his legacy gifts to Washington is not a medical solution, but a political salve and a real estate deal.

Next week: Who wants the hospital and why.

E-mail:marcfisher@washpost.com