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Survey: On-call surgical specialists hard to find; lack of incentives may be a root case
EDs wrestle with shortages; make greater use of mid-levels
With all the talk about the shortage of primary care physicians, one would think there is an abundance of surgical specialty care providers ready and willing to answer the call. However, while there may be an ample supply of providers in many specialty areas, that doesn't necessarily mean they are readily available to emergency departments (EDs). To the contrary, a new survey of a national sample of ED directors suggests that problems with on-call coverage are widespread.1
In fact, the authors report that inadequate on-call coverage of specialty surgical providers is linked with 21% of the deaths and permanent injuries that occur in the ED. They're stressing that the issue needs to be dealt with as policy makers wrestle with issues of quality and the implications of health care reform.
Dearth of specialty providers a widespread concern
Mitesh Rao, MD, MHS, a physician in the department of emergency medicine at Yale University in New Haven, CT, and the lead author of the study, explains that while he is fortunate to work in a Level 1 trauma center where there is access to just about every type of specialist, his colleagues who work at community hospitals frequently comment on the enormous amounts of time and effort required to get appropriate care for their patients.
"Almost everybody has an interesting story about a patient who they would try to get care provided for at another hospital, but that patient would usually have to travel long distances and wait a long time in order to get approval from that other hospital for the transport," says Rao. However, Rao observed that aside from a handful of state-level studies and a few commentaries, there wasn't anything in the literature that captured the scope of this problem on a national level. "I thought that at this stage, we didn't have the most up-to-date data on what is going on [with on-call coverage], so I decided to see if I could collect it."
Using a survey that was reviewed by emergency medicine experts and pilot tested for content and readability, Rao and his coauthors surveyed a national sample of ED directors at 715 hospitals that offer a full range of emergency care services; specialty providers such as women's or children's EDs were excluded. More than half of those surveyed responded, for a response rate of 62%, and the results were sobering.
Nearly three-quarters (74%) of the respondents reported problems with on-call coverage of specialty physicians, and 60% said they had lost 24/7 coverage of at least one specialty in the last four years. Further, 26% reported some unreliability in their on-call coverage, and 23% noted that their trauma center designation had been impacted by their on-call coverage difficulties. A number of survey respondents (22%) also reported that problems with on-call coverage had caused an increase in their leave-without-being-seen (LWBS) rates.
Broken down by specific specialty, the most widespread problems with on-call coverage pertained to plastic surgery coverage (81%), hand surgery coverage (80%) and neurosurgery coverage (75%). However, 35% of respondents reported they had difficulty maintaining adequate coverage for general surgery, and 6.5% reported having no on-call coverage for general surgery.
Teaching hospitals appeared to be somewhat better off than non-teaching facilities with respect to on-call coverage in their EDs; 68% of respondents from teaching hospitals reported problems, as opposed to 78% of respondents from non-teaching hospitals. And problems appeared to be more widespread in the South than other areas: 81% of respondents from Southern hospitals reported problems with on-call coverage, as compared to 62% reporting problems from hospitals in the Midwest.
While the numbers suggest there is a shortage of specialty providers in some areas, such as neurosurgery, for example, Rao emphasizes the root cause of on-call coverage problems may have more to do with a lack of incentives for specialty providers to accept on-call coverage responsibilities.
"Once upon a time it was the norm that specialty physicians would come out of their training and take call in the hospital. That would be how they would develop their practices," explains Rao. "But now these physicians graduate with specialty surgery fellowships, and they join group practices, so there is no practice development [needed]."
Further, Rao points out that there are actually disincentives to coming into the hospital in the middle of the night to provide care. Not only does it take physicians away from their families and make it difficult to resume their normal schedule the following morning, there is also a higher risk of liability. "Treating patients who you don't have an established relationship with can translate into increased malpractice costs," says Rao. "And there is also always the risk that you come in the middle of the night [to treat a patient] and there is no reimbursement. For physicians in private practice, that is not a plus."
While there are no easy answers to the on-call coverage dilemma, Rao explains that some hospitals are having some success with the use of specialty mid-level providers. "Having an orthopedic physician's assistant in-house who can come in and see patients alleviates a lot of the issues with on-call coverage," he explains.
Other solutions include better management of resources so that patients with specific needs are immediately routed not to the nearest hospital necessarily, but to the hospital that has the specialty care that will be needed for that patient's care, adds Rao.
"That has to do with the regionalization of care so that we organize our resources so that we know where specialty physicians are available, and we can get patients to the right place as opposed to getting them to the first place and then having delays in care that can lead to morbidity and mortality."
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