On-Call Specialists At Emergency Rooms Harder to Find, Keep

"At Georgetown, we take referrals from the whole region, because some hospitals can't find a neurosurgeon," said Glasser, president of the D.C. chapter of the emergency physicians' group. "They have to be transported long distances when minutes count. And that, in turn, impacts overcrowding in our hospitals."

For the most part, the dearth of specialists nationally arises not from a numerical shortage but from the growing unwillingness of many specialists to take on-call duty, said Ann S. O'Malley, a physician and senior researcher who co-authored a new study of the issue for the District-based Center for Studying Health System Change.

Traditionally, many specialists agreed to pull on-call duty in exchange for admitting privileges and use of a general hospital's facilities to perform operations and other procedures as part of their regular practice, O'Malley said. But the rise of physician-owned specialty hospitals and outpatient surgical centers over the past 15 years has reduced doctors' reliance on the general hospital.

"The historic relationship between physicians and hospitals is unraveling," O'Malley said.

Another factor is the rising number of the uninsured, with specialists complaining that they often do not get paid for treating patients they see in the emergency room. Moreover, rising malpractice insurance costs and the threat of lawsuits have made more physicians reluctant to see such patients, with whom they have no established professional relationship. Because taking on-call duty can require trips to the emergency department at any hour, it can disrupt doctors' personal lives and force them to reschedule appointments or elective surgeries for their regular, paying patients.

"It's our responsibility to take care of these patients, because that's what we do. That's part of our inherent fiber of being an orthopedic surgeon," said Leon S. Benson, a hand surgeon near Chicago who is active in the American Academy of Orthopaedic Surgeons, a professional association. "But there's no question that as the inconvenience and fatigue and poor compensation and difficulty in having appropriate resources to take care of patients build up, you get this perfect-storm effect where more and more people are thinking, 'Gee, I don't know if I want to do that anymore.' "

Benson, 47, an associate professor of clinical orthopedic surgery at Northwestern University, takes emergency department on-call duty every other day, but he acknowledged that he is the exception these days.

"I can understand nationally why this is becoming a bigger issue, because the system is being pressured," he said. "More volume is getting through a pipe that's getting smaller in diameter. And then what you actually do while you're on call gets to be more and more painful."

Some hospitals have taken steps such as hiring specialists full time or on contract, covering professional fees for doctors who see uninsured patients, and paying physicians daily or monthly stipends for on-call duty, said O'Malley, the analyst. That helps, Benson said, but hospitals might impress physicians more by setting aside trauma rooms and teams of people to assist the on-call specialist in a timely, efficient way when an emergency arises.

The shortage of on-call specialists is so dire at Covenant Medical Center in Lubbock, Tex., that the hospital sometimes has to haul out telemedicine equipment that enables neurologists in faraway cities such as San Antonio to evaluate possible stroke victims through a video link, said Juan Fitz, associate director of the emergency department.

Sarah Thompson, 29, an emergency medical technician at Covenant, said she had to be admitted to the hospital for six days in September before doctors could find an oral surgeon to evaluate a swelling in her jaw and neck. It turned out to be cat-scratch fever that caused swollen lymph nodes and a secondary infection, not an abscessed tooth, as doctors first suspected, she said.

"They had an oral surgeon on call, but he wouldn't come to see me," said Thompson, who was pregnant. "He was supposed to be taking call. And then they called him, and they said he was out of town. It was a big mess-up. . . . All of our doctors were very frustrated with the situation. They tried their best."

Lawrence, the president of the emergency physicians' group, said that legislation introduced this year on Capitol Hill -- but not yet considered in committee -- would create a bipartisan national commission to study challenges related to the provision of emergency medical services, including the on-call specialist problem.

"Something people don't understand is that even if you have insurance, if I don't have an on-call orthopedic surgeon, I can't help you," Lawrence said. "It's an issue that affects everybody, insured and uninsured. If there's no bed available, there's no bed available."