Shortage of specialists worsens, ACEP says

75% of ED directors report inadequate coverage

Almost three-quarters of ED medical directors responding to a survey reported inadequate on-call specialist coverage, compared with two-thirds in 2004, according to a new report released by the American College of Emergency Physicians (ACEP).

The new survey was conducted from August 2005 to November 2005. It was released by ACEP with researchers from Johns Hopkins University and funded by a grant from the Robert Wood Johnson Foundation. The top five shortages were among the specialties of orthopedics; plastic surgery; neurosurgery; ear, nose, and throat; and hand surgery. A total of 73% of ED directors reported problems with inadequate specialist coverage, compared with 67% in the 2004 survey.

"There are several factors involved," says Angela Gardner, MD, FACEP, a board member of ACEP and a professor of emergency medicine at the University of Texas Medical Branch in Galveston. The most recent problem occurred with interpretation of Emergency Medical Treatment and Labor Act (EMTALA) guidelines, Gardner says. "EMTALA had previously been interpreted to mean that hospitals had an obligation to provide on-call physicians," she says. "But CMS [the Centers for Medicare & Medicaid Services] clarified that interpretation, saying they never meant the hospitals had to provide on-call physicians — just that they had to provide information about who was on call and when."

This clarification specifically allowed for physicians to be on call at more than one facility, Gardner explains. Thus, if there is only one ear, nose, and throat physician in town, he or she is not required to be on-call 24/7 at a given facility, she says.

In addition, she says, there simply aren't enough specialists available to answer the calls. "Especially in big cities, in order to cover call obligations, groups were assigning one person to answer all calls," Gardner notes. "That one person may be in surgery for four or five hours; meanwhile, new patients are waiting in the ED, not getting admitted, and things back up."

Not all ED managers believe things will get better. "I have only bad news," laments Todd B. Taylor, MD, FACEP, who co-authored a paper on the topic in Annals of Emergency Medicine1 and is a board member of ACEP.

In Taylor's article, three strategies were recommended:

  • Pay physicians by stipend.
  • Implement fee-for-service programs.
  • Establish regional calls panels.

But, says Taylor, none of these has truly been successful. "As it turns out, if you don't address the liability issue, almost nothing else matters," he says. "It comes to the point where almost no amount of money is enough."

Taylor compares on-call specialists to bomb technicians. "How much will they take to defuse a bomb if you do not give them protection?" he poses. "You can give money and incentives, but one of two things happens: One, it's not enough because of the risk; or two, the hospitals don't have enough money."

Gardner agrees. "I've seen a number of strategies used across the country," she says. "But one that has not been very successful is having the hospital pay people to take calls. It doesn't solve the problem because physicians are still reluctant to come in, and it causes resentment among other members of the medical staff."

Try this strategy

One strategy that has worked fairly well, Gardner says, is the on-call specialty physician management company model, which guarantees payment to the physicians. She points to Emergency and Acute Care Medical Corp. in Rancho Santa Fe, CA, as an example of this model. "Unfortunately, they are not big enough yet to solve the problem across the nation, and there have not been a lot of companies getting on the bandwagon." says Gardner.

A new concept is evolving which is similar to the hospitalist model, she adds. "We're beginning to hear about people who have formed 'traumatologist' or 'surgicalist' groups — specialists whose only job is to provide acute care," says Gardner. This could be an answer, she says. "It certainly has worked for internists to get their call covered with hospitalists."

One solution that could work on a citywide basis is to coordinate emergency medical services to deliver certain types of patients to certain types of hospitals, Gardner says. "Trauma patients would be directed to trauma centers, cardiac patients to cardiac facilities, and so on," she explains. Another possibility that sounds good is a regionally directed ER call, Gardner adds. "If the region is large enough, you could designate a person to be on call for a certain region for everyone," she says. "If you had a regional on-call list, a patient could be transferred to the on-call person at another facility."

Despite these potential solutions, Gardner admits that "it will get worse before it gets better." Taylor is even less sanguine. In Arizona, the governor vetoed a bill that Taylor had worked on for years. The bill would have raised the burden of proof from "a preponderance of evidence" to "clear and convincing evidence" for civil claims against physicians and other health care providers who render emergency services required under EMTALA or following a disaster.

Taylor says he chose to leave clinical medicine and Arizona. "I've had it," he says. "And I'm not alone; four other emergency physicians I know are doing this in the wake of the veto."

Reference

  1. Johnson LA, Taylor TB, Lev R. The emergency department on-call backup crisis: Finding remedies for a serious public health problem. Ann Emerg Med May 2001; 37:495-499.

Source

For more information on ED call panel strategies, contact:

  • Angela Gardner, MD, FACEP, Professor, Department of Emergency Medicine, University of Texas Medical Branch, 301 University Blvd., No. 604, Galveston, TX 77555. Phone: (817) 455-5757.
  • Todd B. Taylor, MD, FACEP, Board of Directors, American College of Emergency Physicians, 2714 Westwood Ave., Nashville, TN 37212-5218. Phone: (480) 731-4665. E-mail: ttaylor@acep.org.