By Christopher Lee
Washington Post Staff Writer
Friday, December 21, 2007
Hospital emergency departments across the United States, already struggling with overcrowding and growing patient loads, are increasingly unable to find specialists to help treat seriously injured and ill patients, according to medical experts.
Crucial minutes, hours and even days can go by as patients suffering from trauma, strokes, broken bones and other maladies await evaluations by neurologists, orthopedic surgeons and other specialists because hospitals are having difficulty getting them to serve 24-hour emergency "on-call" shifts.
"It can mean death," said Linda Lawrence, president of the American College of Emergency Physicians and a practicing emergency department doctor in California. "Patients have died in transport, or waiting to find a neurosurgeon, or getting to a heart center for a cardiologist."
A nationwide survey by the American College of Emergency Physicians in 2005, the most recent available, found that of the 1,328 emergency department directors who responded, 73 percent said they had a problem with inadequate on-call coverage by specialists, including neurosurgeons, orthopedic surgeons and obstetrician/gynecologists. That was up from 67 percent in 2004.
The shortage comes at a time when emergency rooms at many hospitals are routinely stretched to the breaking point. The annual number of visits to emergency departments rose 18 percent, to 110 million, from 1994 to 2004, according to the Centers for Disease Control and Prevention. At the same time, the number of hospitals operating 24-hour emergency departments fell by 12 percent.
The shortage of specialists is the result of a fear of malpractice lawsuits, a reluctance to go without pay when seeing uninsured patients, and a growing intolerance for the disruption in their personal lives and private practices, the experts say. Many specialists are also decreasing their work for general hospitals.
Retiree Mary Jo McClure, 74, experienced the problem firsthand one Friday afternoon in January when she fell down some concrete steps, tearing large chunks of flesh from one leg. The plastic surgeon on call for Tucson Medical Center refused to leave her private-practice patients to come to the emergency department to treat McClure, who has health insurance. The doctor said instead she would see the injured woman in her office the next Monday.
But over the weekend, the specialist telephoned the family to say that she could not treat McClure after all because she performs only cosmetic procedures and is not trained to handle severe wounds, McClure said.
"What was she doing on the roster?" asked McClure, who searched for six days before finding a plastic surgeon at another hospital who would see her. "Do they expect you to walk in for a face-lift? . . . That was a very bad day, because you are hurt and you're in pain, and you always feel like the hospital will help you."
Judy Rich, the hospital's executive vice president and administrator, said the plastic surgeon later acknowledged that she should have seen McClure.
"It's a constant issue, our emergency room coverage," Rich said. "We count on the medical staff to come in when they are called. . . . There's too many patients and not enough specialists many times in communities, and Tucson, I think, is pretty typical of the kind of dilemma that we have."
In the Washington area, specialists are generally available, but emergency room patients sometimes must be transferred to get the expert care they need, said Eric Glasser, assistant chief of the emergency department at Georgetown University Hospital.
"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."