Emergency Departments Face Shortage of Specialty Care : Obstetricians are among the specialists who don't want to take call because of the liability risks that are involved.


Most hospital officials are having trouble getting specialists to take emergency department call, according to a national survey of physician executives.

About 64% of physician executives surveyed reported having a problem getting specialists to take call at their hospitals. Many of them—about 47%—report that their hospitals are coping with this problem by paying specialists to take call.

Of those whose hospitals were not offering payments, 46.4% said the idea has been considered.

The survey, conducted by the American College of Physician Executives, was sent to 3,000 physician executives in hospitals and group practices around the country.

The poll had 814 responses, or a 27% response rate.

Obstetricians are among the specialists who are reluctant to take call because of the liability risks involved, said Damian Alagia, M.D., vice chair of the department of ob.gyn. at the Virginia Hospital Center, Arl- ington, and president-elect of the Medical Society of the District of Columbia.

“It's a horrible situation because we're talking about the life of a baby,” he said.

While physicians recognize their obligation to take call in the emergency department, Dr. Alagia said the economic realities are different.

Obstetricians are walking into a situation where they haven't managed the pregnancy and they have no relationship with the patient. And many of the women who present in the emergency department have had little or no prenatal care, which obviously increases their risk of complications, he said.

“We're talking about the poorly insured or uninsured,” he said.

Even if physicians are compensated for taking call, it's not enough to cover the related malpractice insurance costs. The risks incurred far exceed any payment provided, Dr. Alagia said.

The answer is to provide some type of legal protection for physicians, he said. Obstetricians need to know that if they provide their best care to patients in the emergency department, they will be protected from being sued, Dr. Alagia said.

The high cost of professional liability insurance also is forcing some neurosurgeons to stop or cut back on emergency call, said Alex Valadka, M.D., chairman of the Joint Section of Neurotrauma and Critical Care for the American Association of Neurological Surgeons (AANS) and the Congress of Neurological Surgeons. Some insurance carriers offer discounts to physicians who cut back on these services, he said.

In the past, physicians may have had enough of a profit margin to cover the cost to them of taking emergency call, he said, but declining reimbursements have mostly eliminated that margin.

“Like any other service, nothing is for free,” said Dr. Valadka, who also is a professor of neurosurgery at Baylor College of Medicine in Houston.

But even with stipends for taking call, some neurosurgeons still won't do it, he said. “I think the money will help, but it's not going to solve all the problems,” he said.

These financial incentives need to be coupled with federal medical liability reform to ease the strain of the high cost of premiums, Dr. Valadka said.

Paying specialists to take call helps to offset their costs, but it is only a stopgap solution, said James Bean, M.D., AANS treasurer and a neurosurgeon in private practice in Lexington, Ky.

In the short term, hospitals should create more incentives for physicians to take call. “You've got to create a carrot, not a stick,” Dr. Bean said.

Over the long term, physicians and hospitals should consider the idea of a regional trauma system with a large staff of rotating specialists to handle cases.

“Clearly, the community needs physicians to take call,” said Andrew Pollak, M.D., associate professor of orthopedics at the University of Maryland in Baltimore and a member of the board of directors of the American Academy of Orthopaedic Surgeons.

Hospitals and physicians need to work together to provide reasonable ways to manage call, he said. For example, hospitals should provide stipends to help offset physician costs. In addition, hospitals need to provide physicians with the right resources to work in the emergency department, such as having an adequate level of ancillary staff to assist physicians, Dr. Pollak said.

Emergency physicians have a different take on the issue, however. It's often the hospitals with the highest number of uninsured patients that face shortages in specialist care in the emergency department, said Wesley Fields, M.D., who is the immediate past president of the California chapter of the American College of Emergency Physicians and an emergency physician in Laguna Hills, Calif. But those are also the hospitals that are least able to provide stipends to physicians.

“This really just reflects the weakness of the hospital safety net,” Dr. Fields said.


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