The other part that he doesn’t mention is that no one wants to be the one “responsible” for the patient. If something goes wrong, all eyes go to the primary care doctor or attending (if in the hospital). Either the wrong orthopedist was called, or the cardiologist wasn’t called soon enough.
The current climate has made being the quarterback such a distasteful thing, no one wants to do it. There is no one specifically to blame, but that is the situation. b