One of the most nagging challenges for ED physicians in recent years has been the inability to find specialists and sub-specialists to take call. The specialists argue that the increased liability risks are not merited by the pay they receive, and many are simply no longer willing to tolerate the lifestyle disruptions. The situation has gotten so bad that newspaper headlines are now telling of patients who died because it took too long to find a specialist to care for a critically ill patient.
Unfortunately, say the experts, things do not look as though they will be getting better anytime soon. Even the recent ruling by the Centers for Medicare & Medicaid Services (CMS) to allow the creation of community call panels, they say, may not be the answer EDs are looking for.
"In my perception, I think the situation is getting worse – that's unquestionably true," says Dave
Ross, DO, an emergency physician at Penrose Hospital in Colorado Springs, CO, and a spokesperson for the American College of Emergency Physicians (ACEP). "In our area, in Colorado Springs, we've been fortunate for the most part but we are starting to see problems with certain surgical sub-specialties we can't get on the call panel any more. Specifically for us it's been hand specialists and often facial plastics specialists."
The most chronic problem in his area, says Ross, is the hand specialty. "As you can imagine, there are a lot of people with significant hand injuries of one kind or another," he says. "Orthopedic surgeons who've been used as backup are usually not comfortable taking care of almost anything below the elbow; they're worried about the liability."
"Things are getting progressively worse every year," adds Paul
Kivela, MD, MBA, FACEP, an attending ED physician at Queen of the Valley Hospital in Napa, CA. "The issue here is multi-factorial; there have been some solutions over time — some that work for some EDs but not so well for others."
"It's certainly not improved; it's a little like the stock market — up, down, all over the place," says Todd
B. Taylor, MD, FACEP, a physician executive with the Microsoft Health Solutions Group. "I don't see anything that has substantively been done that would fundamentally improve the situation."
Taylor, a veteran ED physician and an active member of ACEP, left clinical medicine two years ago. "One of the primary reasons I decided to leave was because of this issue," he says. "I was frustrated at not being able to deliver the kind of care our patients should come to expect."
Physicians pay a price, too
Clearly, the patients who fail to receive adequate care because of this problem pay the highest price of all, but ED physicians pay dearly as well in the form of stress and even burnout, as Taylor's experience indicates.
"The fundamental problem with on-call specialist coverage in America is that nobody owns it, so the ED physician now owns it one patient at a time in the middle of the night on holidays and weekends," says Taylor. "There's no doubt that the lack of specialty on-call backup has created additional stress on ED physicians. In many respects you are being forced to do things you are not comfortable with; sometimes you can muddle through, but there are times when you don't have the services at all that you need. It takes forever to find the appropriate services, and it takes time away from what you should really be doing — taking care of the next guy in the waiting room."
"When you can't get coverage, it jams up your ED, so it affects your ability to turn around patients," adds Kivela. "That can make for a long and stressful day — especially when there's a specialty case you can't do anything about. You can spend hours calling people, trying to convince them to come in or trying to transfer patients to another hospital."
Kivela says he's even heard a story about an ED physician in San Francisco who had a patient with a GI bleed who took money out of his own pocket to pay a doctor to come in. "We in emergency medicine with a patient in front of us feel compelled to do whatever we need to in order to take care of the patient," he explains. "I've heard stories of doctors and nurses taking collections among themselves to pay for an ambulance to take a patient over to a county hospital."
The situation is clearly a source of stress, and in some cases, burnout, says Kivela. "We are ‘savers,'" he explains. "When this begins to potentially affect the disposition and care of the patient, it becomes particularly frustrating. You go home and you don't forget; you pray the same thing will not happen on the next shift."
No panacea seen
ED observers agree that there is no silver bullet to solve the call panel problem, but there are some strategies that have helped.
"We have entered into direct pay agreements with neurosurgeons, trauma surgeons, and orthopedic surgeons," says Ross. "If we did not have our hospital pay our primary surgical specialists to take call, we wouldn't be able to meet the criteria for a trauma center. They can bill for their services, but that typically has not been enough of a draw for specialists since they deal with people with no insurance or who are under-insured."
When a particular specialist is not on call, he continues, you may call someone in town to see if they would be willing to take the patient, but what often happens is that they are transferred up to Denver.
"We also have plans to look at regionalization in care, so perhaps all the surgical patients can go to one facility without needing three hours of phone calls," he continues. "In the future that will hopefully help with this problem."
This is a model, he notes, that already works with trauma centers. "Maybe there will one day be orthopedic centers and oral surgery centers," he posits.
Taylor is less sanguine. "It's hard to develop a ‘vaccine,' because the situation keeps changing as soon as you apply a solution," he asserts. "It's bad, and it's getting worse."
Isn't there anything ED physicians can do? "One of the most important things you can do is support the people who can get their arms around the problem," Taylor says. "I was a leader in ACEP; people complain about the situation, but they are not supporting an organization that is able have that effect; you should get in the game."
Finally, he says, most on-call solutions at this point are local. "Do not wait for the government to come in and solve it," he advises. "The problem is there is no single — or even group of solutions — that can be applied universally to correct the situation. Do what you think is going to work, and six months later figure out if it has or not."
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