It all started with the neurosurgeons. “I was in situations in El Paso where we had no neurosurgery, and we had to ship patients out to other cities,” recalled Dr. Juan Fitz, an emergency physician with Covenant Medical Group in Lubbock, Tex. “Now we're finding it here in Lubbock: With maxillofacial, we have no call; [with] neurology, we have no call.”
It's a problem hospitals and emergency departments across the country are facing more often.
Many are finding it difficult to find physicians willing to accept emergency calls, forcing emergency departments to find nearby cities where patients can see specialists. “There is a tremendous crisis developing on the surgical side to staff the in-house care that must take place after the emergency department,” Dr. C. William Schwab recently told the U.S. House Committee on Oversight and Government Reform.
Hospitals are already experiencing a shortage of physicians, specifically surgeons, willing to be on call for the emergency department. That is a problem that will become even more profound as the nation's 80 million baby boomers age, said Dr. Schwab, chief of the division of trauma and surgical critical care at the University of Pennsylvania Medical Center in Philadelphia.
Dr. Schwab cited the findings of an Institute of Medicine panel on which he served. That panel warned that the increasing difficulty of finding specialists to take emergency calls is one of the most troubling trends faced by U.S. emergency departments.
“Providing emergency call has become unattractive to many specialists in critical fields such as neurosurgery and orthopedics,” according to the institute's June 2006 report, “Hospital-Based Emergency Care: At the Breaking Point.”
There are several factors involved, such as the difficulty specialists face in trying to collect payment for on-call services, especially from uninsured patients. There are also liability concerns unique to the emergency department.
“Patients are often sicker, and emergency procedures are frequently performed, in the middle of the night or on weekends, when the hospital's staffing and capabilities are not at their peak. A national survey of neurosurgeons found that 36% had been sued by patients seen through the ED,” the report continues.
And the problem is getting worse, Dr. Ramon W. Johnson, an emergency physician at Mission Hospital, Mission Viejo, Calif., and a member of the American College of Emergency Physicians board of directors, said at the House hearing.
Dr. Johnson cited the results of a national survey of emergency department directors conducted in the spring of 2004 and again in the summer of 2005. The ACEP survey found that access to specialists deteriorated over the year. In 2004, 67% of the departments reported having too few specialists on call, while by the next year the number had risen to 73%. More than half said the problem was due to physicians leaving the hospital to practice elsewhere.
The survey found that the top five specialists in short supply were orthopedists, plastic surgeons, neurosurgeons, otolaryngologists, and hand surgeons. Many of those who are still willing to take emergency calls have agreed to fewer on-call coverage hours.
In the past few years, physicians have found they have much more say over whether they accept emergency calls. Although taking emergency calls was once a requirement to maintain hospital privileges, physicians now have a greater ability to perform outpatient procedures in their offices, at ambulatory centers, or elsewhere besides the hospital, explained Dr. Robert Berenson at a recent forum held by the Center for Studying Health System Change.
“This is a big issue. Hospitals are working very hard to try to draw lines as to which physicians they are going to compensate for taking call or for caring for uninsured patients,” said Dr. Berenson, a senior fellow at the Urban Institute, Washington. “It has not yet become standard that all docs are getting paid by the hospital for ER call, but it is increasingly a cost of business.”
Given that choice, specialists may prefer not to take emergency calls, in part because of the impact it has on their lifestyles and in part because being on call all night can cut into their ability to keep regular office hours, said Dr. Fitz. “Unfortunately, it is a problem across the country that has been around for some time, at least for the past 5 years, and it has just gotten worse [over time],” he said.
Recently, the emergency department in Lubbock has found itself with a shortage of on-call neurologists. Within only a couple of months, the number of neurologists willing to take emergency calls dropped from half a dozen to none. “If somebody comes in with a stroke, there's nobody to call,” said Dr. Fitz.