Staffing Issues
On-call? No thanks.Specialty physicians cite any number of reasons to refuse ED assignments, and hospitals search for ways to fill the void
Juan Fitz, M.D., a Lubbock, Texas, emergency physician, has become accustomed to working the phones in recent months, trying to find a neurologist to help out in the emergency department. Some local neurologists do take call, but troubling gaps persist, he says.
“Sometimes we have to beg or coerce to try to get them to come in,” says Fitz, associate medical director of emergency services at Covenant Medical Center in Lubbock. “Sometimes they will and sometimes they won’t. Sometimes they’ll never return phone calls.”
Fitz, also a board member of the Texas chapter of the American College of Emergency Physicians, says his colleagues in Texas and elsewhere share similar stories. Patients are boarded for hours in the emergency department, waiting for a specialist to arrive. Or they are transferred to another hospital, potentially one hundreds of miles away.
From 1995 to 2005, emergency department visits increased 7 percent, reaching 39.6 million annually, according to the most recent Centers for Disease Control and Prevention data, released in June. By several recent measures, though, specialty coverage remains inconsistent.
More than half—55 percent—of 840 hospital administrators surveyed by the American Hospital Association in early 2007 reported specialty coverage difficulties. In Oregon alone, 48 percent of hospitals couldn’t provide continuous coverage for at least one specialty and 13 percent said their trauma designation had been affected, according to a 2005 survey of 54 hospitals published in the June issue of the Annals of Emergency Medicine.
“Some hospital directors have said this is the No. 1 issue on their agenda,” says K. John McConnell, an author of the Annals research report and assistant professor at the Center for Policy and Research in Emergency Medicine at Oregon Health & Science University in Portland. “It takes the most time and pain to deal with. And it’s causing the most strife between the hospitals and the physicians.”
Potential solutions, meanwhile, remain as complex as they are costly. For hospitals and physicians alike, reducing liability exposure remains front and center. So does better reimbursement, given the stresses and unusual hours involved in taking call. Federal legislation introduced earlier this year—the Access to Emergency Medical Services Act of 2007—proposes establishing an additional Medicare payment for care related to the Emergency Medical Treatment and Labor Act, including care provided by on-call specialists. Another big-picture proposal, discussed in a 2006 Institute of Medicine report, involves the regionalization of emergency treatment, similar to the existing system for trauma care.
“It will take a whole range of strategies to really address this issue,” says Caroline Steinberg, vice president for trends analysis at the AHA. “It will take both community solutions and policy solutions.”
Already, some hospitals and physician leaders are proposing steps to at least plug part of the specialist gap. Nationally, several surgical groups have teamed up to develop a training fellowship in acute care surgery, with the goal of producing specialists—sometimes dubbed surgical hospitalists—to cover general surgery needs in the emergency department.
Telemedicine and robotic devices also may play a role, both in limiting late-night trips to the hospital and in providing access to vital specialists. This summer, Covenant Medical Center added a robotic device to provide real-time video communication with a long-distance neurologist when one isn’t available locally. “Necessity,” Fitz says, “is the mother of invention.”
A Regional Focus?
In the short term, payment for on-call coverage continues to be the most common default solution. According to the 2007 AHA survey, more than one-third of hospitals reported paying for at least some specialty coverage. General surgeons and neurosurgeons were most likely to be compensated. In the Annals study, about 40 percent of Oregon hospitals paid for coverage in at least one specialty; the per-diem median stipend ran about $1,000.
Payment for coverage remains controversial, driven in part by a generational split, says Gabe Heckt, vice president of recruiting at Martin, Fletcher, a health care recruiting firm near Dallas. “It’s a very hot topic with a lot of physicians,” he says. Older surgeons, to some degree, have more traditionally viewed call coverage as intrinsic to medical practice, as well as a boost to building their practice, he says. Younger doctors have other surgical alternatives, such as outpatient centers and specialty hospitals, and perhaps a greater interest in work-life balance.
But payment—controversial or not—can only achieve so much, as Tenna Wiles can attest. In Palm Beach, Fla., an increasing number of hospitals are paying at least some specialists, says Wiles, executive director of the Palm Beach County Medical Society.
Even so, less than one-fourth of the county’s active physicians—883 out of nearly 3,700—take call, according to a survey that the medical society released in March.
Several years ago, the medical society launched an effort to regionalize specialty coverage, beginning with hand surgery and neurosurgery. The approach, which essentially steers patients to the best-staffed facility for their particular diagnosis, was touted in a 2006 Institute of Medicine report as a strategy to pool specialty resources. The Palm Beach effort, now led by an emergency management group comprising the local health taxing authority, physicians and hospitals, is making some headway, Wiles says.
Still, a number of key details remain unresolved. The cost has yet to be determined, as does the network’s structure. It may be that a single hospital will be the designated recipient for say, neurosurgery patients, or that the specialty will be rotated among several facilities over the course of each week, she says. Participation by the county’s 14 hospitals is voluntary.
Wiles commends the hospitals for cooperating amid a competitive local market. “Hopefully this [regionalization] will be a model for others in the future,” she says. “But we still have a long way to go.”
Beyond South Florida, such efforts appear more concept than reality. Wiles couldn’t cite any other emerging efforts; neither could McConnell. “There hasn’t been much traction there,” McConnell says, adding that competition is a major obstacle. Hospitals may be more willing to relinquish the bulk of trauma patients than more profitable specialties, such as orthopedics or cardiac surgery, he says.
Creating On-Site Specialists
More promising, at least at this point, is the development of on-site acute care surgeons, McConnell says. “Instead of having five different specialties on call, you would have one surgical hospitalist to deal with emergency patients,” he says.
To this end, several groups, including the American College of Surgeons and the American Association for the Surgery of Trauma, have developed a fellowship in acute care surgery. The surgeon will be trained to stabilize trauma and other emergency patients prior to other specialists’ arrival, says J. Wayne Meredith, M.D., medical director of trauma programs at the American College of Surgeons.
But the approach won’t be a cure-all, Meredith cautions. Only large urban areas treat a sufficient number of patients to support an acute care surgeon. And training efforts, he says, will take a while to catch up with demand.
In the meantime, a few hospitals are already employing their own on-site surgeons, says Ron Greeno, M.D., chief medical officer of Nashville, Tenn.-based Cogent Healthcare, which manages hospitalist programs. Even more, he says, “are talking about it.” The concept, albeit intriguing, is not without some competitive risk. “The hospital could have some fallout, with general surgeons taking their cases elsewhere,” he says.
Road Testing Robotic Support
Where human coverage lags, telemedicine and robots may provide part of the solution.
In 2006, the not-for-profit hospital chain Trinity Health based in Novi, Mich., launched the Michigan Stroke Network, which relies in part on robots to assess potential stroke patients at far-flung facilities. By mid-summer, 30 hospitals were already participating.
With the help of the mobile robotic devices, made by InTouch Health, physicians at the 30 facilities can consult a neurologist and other relevant specialists through the stroke command center at St. Joseph Mercy Oakland in Pontiac, Mich. Imaging scans can be reviewed. The patient can be examined, with the assistance of the on-site physician. In the first seven months, 600 calls were made to the stroke center and about 150 patients were transferred, says Jack Weiner, the hospital’s CEO.
Outcomes won’t be analyzed until after the first 12 months, but Weiner estimated that two to three dozen patients have already benefited from the stroke network, which includes air ambulance transfer for surgery.
“The anecdotal cases almost bring tears to your eyes,” he says. Now the 428-bed community hospital is starting to pioneer a similar approach for cardiology.
But robotic support, despite its high-tech pizzazz, doesn’t address the nub of the on-call problem: surgical coverage. In the AHA survey, surgeons dominated the top 11 specialties that hospitals were paying cash to cover: general surgery, neurosurgery, orthopedics, hand surgery and plastic surgery, among others. Neither can obstetrics be handled remotely. “Ultimately, to do the procedure, someone has to show up,” says Todd Taylor, M.D., an ACEP officer.
Making Call Palatable
Taylor, who recently stopped practicing emergency medicine because of the liability climate, argues that specialists won’t return to the call schedule in substantial numbers until that pressure is eased. “How much money do you have to pay a bomb technician to defuse a bomb without protection?” he asks.
In the interim, though, hospital administrators can take some steps to make call responsibilities more palatable. They can provide conciergelike services to gather resources—the operating room, nursing staff and equipment—to fast track any procedure, thus limiting specialists’ time away from their families or practices. Physicians who take call also could be given priority when booking time on the coveted operating room schedule, Taylor says. “It’s like being a frequent flier—you get to board first,” he says.
Robotic technology also can play a hand in improving quality of work life, Weiner says. By checking on the patient and imaging tests from home, for example, an orthopedic surgeon could separate pressing crises from those that can wait until morning.
A little creativity can only help, when it comes to on-call coverage challenges, Weiner says. “If we can reduce the hassle factor, maybe we’ll make it more acceptable,” he says.—Charlotte Huff is freelance writer in Fort Worth, Texas.
This article 1st appeared in the August 2007 issue of HHN Magazine.
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