Study: Shortage of On-Call Specialists Spreads Nationally (American College of Emergency Physicians News, Jan 2008)

It ain't rocket surgery. My crystal ball rocks. This was predicted by yours truly. Why be a doctor?

Could 'cripple' emergency, trauma care.
ACEP News
January 2008

By Kate Johnson
Elsevier Global Medical News

Emergency on-call coverage from specialist physicians is "unraveling" at hospitals across the country, according to a new study--and the crisis may be pushing beleaguered physicians out of emergency medicine and into alternative careers, some observers warned.

The on-call specialist shortage is resulting in delayed treatment, patient transfers, permanent injuries, and even death, cautions 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 a challenge 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 especially grim given the fact that 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 study's authors 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 orthopedic surgeons, neurosurgeons, plastic surgeons, trauma surgeons, hand surgeons, obstetrician-gynecologists, neurologists, and ophthalmologists. 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 study authors stated.

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 setting, 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 they are caring for uninsured patients. Specialists are also concerned that providing emergency care may increase their exposure to medical liability and drive up the cost of their malpractice premiums, according to the report.

Adverse patient outcomes may be the result of a lack of timely specialty care. One study found that 21% of patient deaths or permanent injuries related to ED treatment delays are attributed to lack of specialists' availability, noted the report. 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.

"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, he said, because the risks of liability were more than he could justify.

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. "Speaking for myself, 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."

In addition, high fees charged by specialists and paid by hospitals for on-call coverage are not justified based on the premise that on-call coverage increases a physician's liability exposure, he said. "Being on call doesn't give you more litigation than being in general surgery--that's well documented," he said.

Dr. Taylor disagreed.

"The literature is very clear that emergency care is one of the highest liability environments in health care," he said. "You only have to look at what's happened to emergency physician malpractice premiums relative to others not involved in emergency care. Mine almost doubled the last 3 years I worked."

For Dr. Taylor, it is these very liability risks that are at the root of the current on-call crisis. "The liability issue has become the overriding barrier to physicians being willing to put themselves at risk," he said. "Until and 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, Dr. Taylor added, is a shortage of emergency physicians. This newer phenomenon was reported last 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 that 30% of the study's respondents said they 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 a big surprise they were the first to leave, he explained.

"But now that core emergency physicians, who were trained only to practice 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."