Emergency on-call coverage from specialist physicians is “unraveling” at hospitals across the country, resulting in delayed treatment, patient transfers, permanent injuries, and even death, according to a study from the Center for Studying Health System Change, a nonpartisan policy research group in Washington.
While the problem is predominantly an issue for hospital emergency departments, it also is becoming increasingly problematic for inpatients who need urgent specialty care, according to the report. The findings are based on 2007 data from 12 nationally representative communities: Boston; Cleveland; Greenville, S.C.; Indianapolis; Lansing, Mich.; Little Rock, Ark.; Miami; Northern New Jersey; Orange County, Calif; Phoenix; Seattle; and Syracuse, N.Y.
The picture is particularly grim because overall ED utilization rates have risen by 7% in the past decade, from 36.9 to 39.6 visits per 100 people, according to the report. While insured people account for the vast majority of ED visits, “the proportion of visits by uninsured people is rising at a relatively higher rate,” the researchers wrote.
Citing a 2006 paper from the American College of Emergency Physicians, the study reported that 73% of emergency departments in the United States report inadequate on-call coverage by specialist physicians. In particularly short supply are neurologists, neurosurgeons, orthopedic surgeons, plastic surgeons, trauma surgeons, hand surgeons, obstetrician-gynecologists, ophthalmologists, and dermatologists. While an actual shortage of such physicians may sometimes be to blame, “physician unwillingness to take call appears to be a more pressing issue for many hospitals,” the authors said.
Although unwillingness to accept on-call duty is largely influenced by quality of life issues, the requirement to provide on-call coverage has traditionally been mandated by hospitals under the Emergency Medical Treatment and Labor Act. However, many specialists are now shifting their practices away from the hospital, and are no longer obligated by medical staff privileges, noted the report's authors.
Many physicians also believe payment for on-call care is inadequate, especially when caring for the uninsured. Specialists also worry that providing emergency care may increase their exposure to medical liability and drive up the cost of their malpractice premiums, the report stated.
One study found 21% of patient deaths or permanent injuries related to ED treatment delays are attributed to lack of specialists' availability. Complete lack of access to specialty care in some EDs is forcing either travel or transfer of patients. And for the physicians who continue to provide on-call coverage, increasing workload and decreasing morale may put patients further at risk.
Crisis May Drive Physicians Away
“It's not a surprise that we're having this problem—it's a surprise to me that we have any on-call specialists at all,” Dr. Todd Taylor, previously an emergency physician and speaker for the ACEP Council, said in an interview. Dr. Taylor left clinical medicine last summer to work in the computer industry because of the risks of liability.
“The liability issue has become the overriding barrier to physicians being willing to put themselves at risk,” he said. “Unless you solve the liability crisis in emergency care and health care in general, nothing else you do matters.”
More troubling than the lack of emergency on-call specialists, he added, is the lack of emergency physicians in general—a newer phenomenon reported earlier this year in the 2007 Daniel Stern & Associates Emergency Medicine Compensation and Benefits Survey.
“This has applied to on-call specialists for years, but the phenomenon is now spreading to core emergency physicians, who are increasingly seeking alternative careers,” Dr. Taylor said, noting 30% of study respondents were considering leaving medicine because of the malpractice climate.
Most on-call specialists have a private practice outside of the emergency department—they don't need the ED—so it's not suprising that they were first to leave, he explained. “But now that core emergency physicians, who were trained to practice only emergency medicine, are making the same choices, that should be a wake-up call,” Dr. Taylor said. “That's what's different now compared to 2 or 3 years ago.”
On-Call Shortage Cripples Trauma Care
Lack of optimal on-call coverage is what will ultimately “cripple” trauma and emergency care, agreed Dr. L.D. Britt, professor of surgery at the Eastern Virginia Medical School in Norfolk. “Some of the specialists are asking for unbelievably exorbitant fees to provide coverage, and hospitals are being held hostage. That's unsustainable for many hospitals—it's a major crisis,” he said in an interview.
While Dr. Britt sympathizes with physicians' struggles with payment and liability issues, he believes the true bottom line is simply that obligations are being overlooked.
“It cannot be everyone saying, 'I can't do this.' Something has to give,” Dr. Britt said. “I consider it my obligation to provide emergency coverage if I am on call. I know that's my responsibility—and I'm a chairman of a department. Some people can find ways out of it, but I'm saying we cannot have all those options out there.”