Primary vs. Tertiary care

Medpundit addresses the fall-out when all the high-tech treatments at a famous referral center is for naught and the patient ends up. Often these patients end up dying at community hospitals nearer to home:

But even worse, is the tendency of the tertiary care centers to leave their failures on the doorsteps of others....

But, I do know that all too often, when the treatment has been exhausted and the patient ends up in the closer hospital in extremis, the miracle-working specialists are nowhere to be found.

I'm sure this is frustrating from the local doctors perspective, but I'm not so sure it serves the patient poorly. If I found out I had pancreatic cancer, say, I'd want to go see the best surgeon to have a Whipple (surgery to try to excise the cancer) and even go wherever they had a new chemotherapy trial; basically do everything I could to maximize my chance of cure.

But if the surgery wasn't curative and the chemo didn't work, I'd want to die (and get palliative care) close to home. For me that might be a tertiary care center, but if I lived out in the burbs or a rural area it would be a community hospital. This paradigm may suck for the community docs, but it does a pretty good job of satisfying the patients desires.