Get Me a Neurosurgeon, Stat!
As fewer doctors sign up for on-call emergency room duty, patients suffer
And it doesn't pay. The federal Emergency Medical Treatment and Active Labor Act, enacted in 1986 to prevent discrimination against the poor, requires that emergency departments screen all patients and ensure they are not in an immediate medical crisis, regardless of their ability to pay. That means hospitals need to maintain a roster of on-call specialists. But the law has also pushed hospitals to pressure doctors to provide on-call services for nothing in return for hospital affiliation. Doctors used to agree to this deal because they needed hospitals as places to perform surgery, and the workload wasn't too heavy. But as the workload spiraled up, surgeons spent more time answering ER calls and less time dealing with their own practices and paying patients. If they were affiliated with more than one hospital, as many doctors are, both hospitals made demands.
Recently, "office-based surgery and free-standing surgical clinics have given orthopedists and plastic surgeons and others a way out," says Rick Cameron, project manager of the Emergency Department Management Group in Palm Beach County, Fla., a partnership of county hospitals trying to solve the specialist shortage that has dogged that region. "Many don't need to be affiliated with hospitals to do their jobs."
Finally, there's fear of being sued. On-call surgeons worry there's more chance of getting sued by a stranger whom they rush to treat in an ER than by an established patient having elective surgery. "Anything can happen in an ER," says Jose Arrascue, a kidney specialist in Boynton Beach, Fla."If you have no rapport with the family, they may conclude you did something wrong, and you are wide open for a suit. That really concerns me." There have been calls for legislation exempting doctors on ER duty from lawsuits, but the idea of immunity from malpractice hasn't appealed to federal or state lawmakers.
To minimize risk, many doctors stop taking ER calls. Or, Valadka says, surgeons may limit the types of operations they do in regular practice, which means they won't be called in for emergencies that are beyond those limits. For example, some neurosurgeons—ironically—have stopped doing brain surgery and focus only on the spine.
Hospitals have attempted to counter this reluctance by paying specialists extra money—$1,000 per night, say—to be on call. But that adds up: California hospitals paid an estimated $300 million in such stipends in 2005, up from $200 million a few years earlier. And they can't raise prices to cover these fees, since hospital services are tied to Medicare, Medicaid, and insurance reimbursement schedules. To make matters worse, hospitals now often need three specialists where one used to do. Microspecialization in orthopedics, for instance, means some docs work only on knees, some on backs, some on hips. So a hospital would have to pay several surgeons to stay on call to maintain complete orthopedics coverage.
Doctor pool. With so many causes for the shortfall, hard-hit Palm Beach is trying to put together a multipronged solution. Last month, Cameron's group submitted a plan to the county health district that would regionalize certain critical on-call services, allowing several hospitals to pool their on-call doctors to make sure these specialties are covered at any given time. Hospitals would also pay for liability insurance just for on-call cases.
There's no guarantee the complicated plan will work. And it's not going to solve problems like the workforce shortage. It may even entice hospitals in neighboring counties without specialists to send their patients to Palm Beach, increasing ER workloads.
Experts believe things are likely to get worse before they get better, with emergency docs continuing to scramble—they grimly call it "dialing for doctors"—to find specialists to help people like Elsie Bishop. Says Taylor: "The American public has no idea how dangerous it has become to get sick or injured at the wrong time."
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