Refusing ER call

Wow, I didn’t know I was salaried! I need to talk to administration about some back pay.

Well, here’s the thing. Our ER is staffed by nine physicians, all board certified by the American Board of Emergency Medicine. In fact, until recently, we were the only hospital in SC that could make that claim. I don’t consider us poorly-staffed.

Our hospital has struggled with specialty staffing, as many rural facilities do. We only have one ENT now, though we’ve recruited another. That one ENT doesn’t have to be on call every day. In fact, he only has to be on call every third day.

We have arrangements with other facilities, but I assume that since this was a child my partner tried to send him to our pediatric referral center. But even those places where we have arrangements are often hesitant to take transfers. I understand; they’re already overworked. But this wasn’t just any situation.

It wasn’t a dump, anonymous, it was a child who may have lost an airway and died, and who needed surgical involvement. We try to keep everything in house, since transfers are difficult, dangerous and often met with unprofessional, angry attitudes.

I have done this for almost 15 years, and one thing I’m not is naive. The real world is very clear to me, since I bill my patients and have never worked at our hospital for salary. In fact, our uninsured patient population is about 30%, much higher than most places. And if you think a non-profit, private hospital in a rural area is an ivory tower, then maybe you need a class on ivory, or towers, or something.

Sincerely,

Edwin Leap, MD, FACEP

So it’s OK that your tertiary referral center is too overworked to take the child, but it’s not OK for the overworked private guy in the neighboring hospital to refuse?? It’s OK for your hospital not to have in place a contingency plan for these emegencies, but it’s OK to dump that responsibility on a private consultant who doesn’t attend at your hospital? BTW where was YOUR ENT in all of this? How is it that the child fared alright inspite of not having your needed consultant after all?

Sorry I din’t know your weren’t salaried. But answer the questions please.

Edwin Leap MD, FACEP:

You are glossing over the fact that your hospital is unprepared to deal with after-hours emergency specialist call. Why is there only one ENT? Why haven’t they successfully recruited more? Why didn’t you call the ENT from your hospital, even if he wasn’t on call that night? What could it have hurt? He must be getting your regular referrals, so it would have been reasonable for him to bend a little to take this one. Or does your ER have a practice of sending the good referrals one way and other things another way when your staff specialty docs aren’t on call? If that is the case, then you were dumping, plain and simple. You really have no right to expect staff specialists at other hospitals but not your own to play the patsy for you. And holding up the patient like a hostage is, child or not, the last refuge of a scoundrel.

Most specialists get difficult about accepting out of area transfers out of miserable experience and abuse. Hospitals that treat local specialists who generate surgery billings at the local hospital preferentially but are quick to dump uninsured patients out the door on other ERs and their covering specialists with the argument that they don’t have coverage quickly get known for their practices.

I am a specialist surgeon and I get calls from ERs in other states wanting to send me patients (some who have not even been properly stabilized) because their specialists who are on call just don’t answer their phone. The problem I have with those EDs is that they never send me patients otherwise, it is only when they need to dump someone when their own docs aren’t answering. Sorry, but you can’t play things like that both ways. So I really don’t feel I owe it to them to bail them out when I realize I am only a chump to them.

–A Specialty Surgeon, FAAO, FACS

it seems best if we decide that getting sick at night should be a never event.

i am a 24/7 specialist in a rural area. it sucks covering my own area, let alone someone else’s. it only takes a few calls to really ruin a weeks sleep and make your life miserable. it is not so easy to recruit specialists into rural areas. i would dearly love to have more, but there is no business for it.
i’m not even sure how long i can last here, because i got busier and busier. eventually something is going to have to give.

How often do you read the flip answers from non-physicians and a certain lawyer about how we’re poor businessmen, just drop out of the insurance contracts, and in various ways have brought our problems on ourselves?

Well, you’ve just seen what happens when the doctors are good businessmen. The doctors don’t necessarily disappear when malpractice liability is a threat. They just reorder their lives so as to minimize their exposure to risk. The neurosurgeons bring their business to non-trauma hospitals so they don’t have to do emergent intracranial neurosurgery.

The ENT surgeon gets little benefit from a business standpoint from accepting the child. Medicaid or uninsured is more likely. The patient did not necessarily need surgery, so even if insured, little monetary benefit. And a BIG litigation risk if things go wrong.

And goodwill? Sounds like the ER in question is not a significant referral source for the ENT consulted.

There are other businesses, banks, various enterprises that find certain customers are not worth having. Here’s a doctor who feels the same way.

No, I’d treat the kid. But I’m not rational. The ENT surgeon *IS* rational from a business standpoint.

Oh, and in my rural hospital, the ER docs faced with this problem try to force the child onto the FP on-call. I’ve had my share of such problems. Then it’s my problem to find the consultant.

That’s why I stopped taking ER call at my hospital. The problem rolls on.

And no, I don’t want to see tort liability reduced just for ER work. All that does is spread the liability to the primary care doctor. Tort reform for all doctors, or none.

“Remind me never to grow old or get ill.”

If you do get old or ill, make sure to avoid rural areas.

In a previous era, before Dr. Leap arrived, I was practicing in an outlying hospital in the upstate of South Carolina. I accepted any and all in my specialty for inpatient care–and soon noticed that the biggest hospital provider in the Greenville-Spartanburg area in my field was sending their uninsured patients out to our ER and telling them to ask for me. (This was pre-EMTALA).

That put me about 80% of the way to being cured of taking ER call. In this case it was a referral down the pyramid instead of up–based on who was the biggest sucker.

Maybe, the ENT, like Dr. Kranky is just a bitter self centered jerk. Or maybe he has been up with 2am cases for 3-4 nights in a row and just can’t do it any more.

I would like to be able to slam dunk a basketball. No matter how hard I try it is just not possible for me. Maybe it was just impossible to take on another charity case, not monetarily, but physically and mentally.

That said, the very first anonymous has no clue to the real world. Most ER docs are not salaried. And if the ENT doc himself needed an ENT there would not be an ENT (or plastic, neuro, hand, GI, neurosurg) at a large percentage of hospitals across AMerica.

Yep Anon 8:44, I Dr. Kranky must be a self-centered, bitter jerk because I don’t want to hang on a cross of someone else’s making.

You, like the illustrious Dr. Leap FACEP are trying to crucify me because of an erroneous assumption I made about him being a salaried physician. (Pardon me, since where I practice the majority of the ER docs ARE in fact salaried) I already addressed that, but please continue to harp on it as it allows you and Dr. Leap to continue to avoid the thorny questions posed- which have been answered effectively by all the above detractors.

Oh and if you DO happen to hear of some guy in Botswana with a compressive parotid tumor in desperate need of an ENT, please feel free to call me as I wouldn’t wish to carry the albatross of “heartlessness” any more than I might be permitted.

OK guys,

Thanks for all your comments. I think this is an intriguing line of discussion.

I get the point of being overworked. I’m not suggesting we work for free. I realize the reimbursement is miserable, especially at the Medicaid rates. I know because I, too, take care of Medicaid patients.

I don’t even know if the child in question had insurance or not. The thing is, we run into this problem with both the insured and the uninsured.

I believe in capitalism. I really do! I like making money! But the plight of people in communities all over America is like this. They need something, but no specialist is available.

It isn’t as simple as abuse of real doctors by stupid, simplistic ER doctors who just don’t get anything in their arrogance. That’s a nice, simple way to describe it, and it may be somewhat cathartic, but it’s unrealistic. We make dispositions on countless problems without any specialist help.

But what are we going to do for our children? What are you going to do for your children? I understand not wanting to be worked to death. So do we increase the number of specialists we train? In order for them to go to under-served areas?

Do we bring about the nightmare of national health care? We’ll all get paid for everyone, but not very much. Then, specialists will quit, and the same issue remains.

I wish everyone had private insurance. I wish, in fact, that insurance had never existed. Things would be cleaner, simpler and probably cheaper for everyone.

And maybe, the answer is just this. In order to preserve realistic schedules, and realistic reimbursement, we just need to let more people go without specialist coverage. There will be some disasters, but that might get people’s attention in the halls of power. Is that where we need to head?

I’ve asked for honest suggestions. All I have gotten from detractors is 1) angry personal attacks 2) angry comments about an admittedly broken system and 3) angry discussions of how we’re abusing specialists.

Please tell me what we should do? Please tell me what you would do! I’m honestly curious.

We all need to have these discussions. But name-calling isn’t going to cut it.

I’d love to never bother another specialist out of town. But we weren’t contacting a facility we don’t already refer to regularly. My partner didn’t go down a list of who he had and had not dumped on lately. And rest assured, we don’t selectively send paying patients to our own ENT, but indigents out of town. That may happen some places, but not at the hospital where I work.

My partner was just trying to find help for a situation he was unable to fix himself.

Was it unprofessional of the ENT to refuse? Maybe, in light of the comments here, it wasn’t. Maybe I misspoke. I apologize for that. I’m sure he’s oveworked, overtired, and sick of being consulted on people who aren’t his own. I’m sorry we had to call anyone, and I’m sorry that rural hospitals have to bother anyone at all. I’m sorry we don’t have a neurosurgeon, a CT surgeon, pediatric subspecialties and a full slate of ENTs.

I’d love some direction here. How do we repair this system? How do we get treated fairly, ER docs and and specialists alike?

Less anger, please, and more suggestions.

Edwin

Well said Dr. Leap.

I am waiting for the good constructive ideas.

anon 2:01,

I am all for it. it is freaking scary that the country is running after Hilary, Barack, and other politicians in just exactly the opposite direction.

Edwin:

I think the immediate answer is to do what you did, keep trying until the child gets while they need, but without wasting energy being judgmental about those who wouldn’t help. Without wearing their shoes, you can’t know if they were stretched beyond their resources and saying the right thing in saying “no” or just plain greedy. Since you can’t know, why bother thinking about it.

When I tried to say yes to all, life was unbearable and I broke eventually. People, including a few ER docs, took flagrant advantage of my willingness to help. “Broke” means that I hurt bad enough to reassess my values, shrug off the sense of responsibility for anyone who I didn’t already have a doctor patient relationship, and set up barriers to all of the other unmet needs out there, just opening the valve a little when I had the time and energy to provide good treatment to my standards.

That naturally means I don’t take ER coverage anymore.

But keep in mind, that I didn’t work in 12 or 24 hour shifts, but took call 24 hours a day for weeks at a time. There were no “turn-off” times.

On the other hand, when I got all of my barriers in place to unmanageable demands (perhaps perfectly manageable to someone made of tougher stuff–but I didn’t make myself so why should I feel guilty) I found myself enforcing my rules to not take on a child, who I probably couldn’t have helped but perhaps have given a small measure of comfort. When it was too late, I realized that I didn’t feel comfortable with that and feel guilty about that.

So now I feel free to make the rules that I need to make to have my life livable, and make it a rule to break them when my conscience compells me to do so.

But it is my conscience that must compel me, not your bind, so that doesn’t solve your problem. Perhaps accepting that everyone is trying to survive this profession in their own way (some by unbridled greed) and respecting that, even if it means that they are unavailable to help you with your patients might help you be more at peace with it.

We all accepted certain frustrations when we entered our chosen profession–although judging from the blogs, I don’t see much evidence of the acceptance part. One of the burdens you accepted by going into ER medicine was putting yourself in the peculiar position of always having to find someone to hand patients downstream to and doing this many times a day. This puts you in the position of being especially impacted by service limitations–such as one or no ENT docs who are actually obligated to be available to your patients–especially upon choosing to work in a semi-rural hospital.

Letting yourself resent that is a bit like a family physician resenting always having his skills compared to specialists, or a psychiatrist resenting his patients being nuts, or a physiatrist resenting dealing with chronic pain patients. Surely you knew it would be so?

Will someone PLEASE explain to me WHY all this moral dudgeon applies:

NOT to the ENT doctor who reasonably chooses to limit the number of days he is available….

NOT to the University ENT doctor who chooses to limit the number of patients he takes on…..

But it DOES apply to a private out-of-area ENT in a non-referral hospital who chooses to limit the number of hospitals he covers?

Correct me if I misunderstand the facts as above. The ENT is in some community setting and has arrangements to cover certain hsopitals, but no other.

You can limit the number of days you’re on, the number of patients you have, but not the geographic area you cover? If someone from New Mexico wanted to send the patient to South Carolina, would it be an EMTALA violation if the South Carolina doc declined the transfer?

For those who think that’s a reductio ad absurdem, I’d say EMTALA is a reductio ad absurdem. It’s reach extends day by day. They’d extend it to my private office if they could, and I’m sure they’re trying.

I wish Ayn Rand were alive today to write “Aesclepius Sneezed”.

To those who have read Atlas Shrugged, this would make sense. To the rest of you, I recommend strongly that you read Atlas Shrugged.