Fewer physicians are taking call in rural emergency rooms

My partners and I have long struggled with the lack of specialty back-up at our hospital. Semi-rural hospitals, out of the way facilities, just can’t always attract specialists. So, we’re happy to have cardiologists every night, but understand that we only have an ENT every third night. We’re thankful to have neurologists, even if they don’t admit anyone. We’re glad to have radiologists, even if they don’t read plain films after 5PM on weekdays.

Still, I continue to scratch my head about why only three of seven community pediatricians take call, such that family physicians have to admit their patients. I was bumfuzzled that our neurologists were previously going to require us to use telemedicine for stroke evaluation, when their offices were close by the hospital. (In the same year they were called in roughly three times per neurologist for urgent stroke evaluation.) That problem was resolved, thank goodness.

Now, I find that the problem has returned and grown. We will, very soon, have no ophthalmologist on call, despite the fact that we have three in the community and that they are contacted with remarkable rarity to deal with on-call emergencies. Soon, we will have no neurologist on the weekend. And the pediatric problem remains.

Of course, I’m using my local experience to highlight something that isn’t a local problem at all. It’s a national problem. All over America, specialists are relinquishing their hospital priveleges and staying in the office. Proceduralists are opening surgery centers that are free from the burdens of indigent care. Primary care physicians are allowing hospitalists to do all of their admissions.

In the process, not only are patients losing out, but referral centers are being absolutely overwhelmed. The cities and counties that lie around teaching hospitals are sending steady streams of patients, since they have fewer and fewer specialists. Those referral and teaching centers want patients, but they can’t take all of the non-paying patients, all of the complicated, or even all of the mundane patients with no local coverage. Those facilities, for all their shiny billboards and ‘center of excellence’ marketing, will collapse.

They will collapse both financially and from the shear exhaustion that will crush their staff physicians and residents. I already hear it in their voices. ‘Am I on call for your hospital? Where’s your doctor? Fine, send them. We’ll figure something out.’ Many of those docs will ultimately join the exodus as well, simply to keep their sanity.

My partners and I understand everyone’s frustration. We face some of the same struggles; too many patients, too little reimbursement, overwhelming rules and regulations. I think that the federal government has made our jobs inefficient, unpleasant and in many instances unsustainable. Laws like EMTALA, and quasi-governmental regulatory bodies with their endless rules, make physicians go crazy. And they certainly explain why owning and practicing in a surgery center, or the act of simply abandoning call duties, is preferable to working in a hospital. I also know that lifestyle matters. I still work evening shifts that keep me out until 2 am. I occasionally work nights, as do many of my partners. Fatigue is miserable.

Maybe the combination of regulations, financial constraints and weariness is driving physicians away from what they once loved. However, despite those issues, physicians are choosing to make themselves unavailable and ultimately perhaps irrelevant. And they are taking the amazing, critical skills they have and depriving patients of them.

So I implore physicians across the country to think a little before leaving. To think about the fact that their absence only passes the patient, the responsibility, the opportunity, down the line, to a colleague in another town. To consider the fact that patients, real patients with real illnesses and injuries, desperately need their abilities. And equally important, to remember that emergency physicians can’t do it all, not nearly as well as their specialist co-workers.

I also beg administrators and government agencies to observe this migration, from hospital to office, and ultimately from office to early retirement, and ask how it can be reversed. I hope that both groups will not ask, ‘what’s wrong with those doctors,’ but will ask, ‘how did we contribute to the problem?’

Many of us, our children or grandchildren, may one day end up in a hospital with a genuine, urgent need for some speciality intervention. And because it is after 5PM, or because it is a weekend, because no one is available or only available 100 miles away, they may suffer or die.

If nothing else, that’s worth serious consideration all around by a profession, and a government, purportedly dedicated to the well-being and health of real human beings.

Edwin Leap is an emergency physician who blogs at edwinleap.com and is the author of The Practice Test.

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  • PAULMD

    Good piece. We are OBLIGATED to cover the ER and inpatient consults in return for privileges. Our group is one of the few privates left in our town. What galls us is that the expanding entrepreneurial business practices of our local hospital OBLIGATES us to cover patients outside of our usual catchment area.

    These areas already have practicing docs in our specialty seeing these patients at their leisure during the day and enjoying our MANDATED night and weekend coverage for their patients.

    This helps contribute and feed the animosity between hospital and docs. We just want to maintain ourselves and our autonomy without threats and mandates from a hospital whose “OWNED” docs vote that we private docs must contribute to their medical company without fair representation. Hospitals, you reap what you sew.

    • Michael

      I agree with PAul MD. Here is the problem—-most specialists are INDEPENDENT CONTRACTORS and not employees. Most hospitals are CORPORATIONS and not charities. Many physicians are NOT fairly compensated for their sacrifice and service which DEFIES employment laws of any kind——yet there seems to be an attached guilt trip on physicians who feel they need to provide endless supplies of free care at their expense. Our hospitals TAKE ADVANTAGE of our provisions by accepting, WITHOUT our permission, patients who are from areas over 100 miles away. JCAHO, EMTALA, and CMS have created a HOSTILE ENVIRONMENT with hospital work, which is COMPENSATED LESS versus at-office care. At office care is CMS DRIVEN, as consultation reimbursements under CMS have been eliminated.

  • Greg

    Good post highlighting a problem that most of the public has no idea exists.

    Part of the problem for specialists taking call is that providing pro-bono care isn’t free. Even if a specialist is willing to give up his/her sleep night after night, and is willing to work without pay (already a combination most non-doctor workers in America would refuse outright), he/she is still liable for any litigation which results from their services. So even if they spend a sleepless night working for free, they may still lose their shirt if sued for malpractice. It’s difficult to be altruistic to those who may harm you; it’s possible, but takes a Dalai Lama-esqe sense of compassion to pull off, and is therefore pretty rare. As a result, even altruistic specialists are turned off from night call, and the problem only gets worse.

    • imdoc

      And, of course, if an untoward event does occur after many hours of work doing your duty to cover the ER, the plaintiff attorney will use it against you to imply that fatigue undermined your abilities at the time.

      • Smart Doc

        Yup, the lawyers will 100% attack you on that basis.

        No liabilty for ER slave duty. Emergent care must be made exempt from liabilty charges.

  • Guest

    Anybody who takes ER call who doesn’t have to should have a psychiatric evaluation: You get called in the middle of the night, to come see a patient who probably won’t pay you, and is more likely to sue you for your trouble.

    Sounds like an enticing proposition, doesn’t it?

  • Jack

    Every doctor is turned off by evening and weekend calls. It’s the most tiring portion of our work. It’s no wonder physicians stopped taking calls if they have that option.

    Which profession/job do people enjoy getting awaken in the middle of the night and sometimes even have to go into work. Not to mention it doesn’t pay and potential liability involved. Take away the “medicine” title and ask if anyone is willing to do it!

    Honestly I still remember 20 years ago I needed to see a doctor and was charged extra for “after hour visit”. My parents thought it was “normal”. Now the public just expect physicians to be there regardless of time. In fact, I get phone calls for absolutely trivial issues after hours. People simply have lost respect for other people’s time.

    If I could, I would stop taking calls.

  • Nancy

    In the title of this article, please change the word “Less” to “Fewer” so as to be grammatically correct.

    • Kevin

      Will do, thanks for correcting the oversight.

      Kevin

  • http://www.hopestreetgroup.org/index.jspa Joy Twesigye

    This is interesting as it cause me to rethink some of the conversations I had last fall while working on a project. I was hearing that the current trend is for new physicians to choose hospital employment over hanging their own shingle in addition to a trend that hospitals were buying specialty practices in their catchment area. I assumed that to mean that these new hires took call….it seems as though “access to care” could use a definition that balances both the expectations of providers and potential patients.
    http://www.hopestreetgroup.org/community/healthcare

  • doc99

    What if they gave an Emergency Department and Nobody Came?

  • ninguem

    They have long ceased to be hospital PRIVILEGES.

    They are hospital BURDENS.

  • paul

    pretty tough to change this course without some kind of emtala reform. my shop is not all that rural and has basically the same specialty coverage you describe.

  • soloFP

    Around five years ago primary care call coverage was so hated in my area that the local hospitals each form hospitalists to take unassigned adult ER admissions for call. Admissions per call night ranged from 3-7 patients, with the majority of them as self pay or medicaid with lots of acute concerns. Around 75% of the primaries now use hospitalists for their call. It is not worth being awakend and taken many hours away from private practice to deal with alcoholics, drug users, car accidents, prisoners, and overdoses, suicide attempts, etc that make the call unpleasant. Even worse is that about 10% of the on call patients would leave AMA but likely weren’t competent when drunk to sign the AMA papers. Call in my area used to be nothing but liability headaches. Also annoying was doing full H&Ps like a med student for free. Now I am only on call for my own patients, and I enjoy seeing my own people in their times of need.

  • Smart Doc

    EMTALA is an unfunded federal mandate utterly destroying emergent care in America.

    There needs to be another unfunded federal mandate to counteract the toxic effects of EMTALA: Make ER care exempt from the medical liability jackpot lottery. No liability for work done in America’s emergency rooms.

  • Vox Rusticus

    In my town, half of the practicing ophthalmologists no longer cover the ED. They have either hit age 60, or they have the requisite 25 years on staff to be exempt. They still are very busy otherwise, in the office and in surgery. The rest of the ophthalmologists share the call coverage schedule.

    If I was the only ophthalmologist on staff, knowing that most of the ED calls would be unpaid and at late hours, I would probably be looking for a way off regular staff also. Being the only eye surgeon on call in the present practice climate would be a nightmare, and surely a ticket to professional burnout.

    I submit that the broader community of citizens has not done its part in trying to fix this situation. I think that specialists who cover EDs ought to have complete and total immunity from malpractice claims arising from services provided in the EDs or that arise from ED admissions, not limits, or coverage from the state, but outright immunity. That kind of immunity will be resisted by the entitlement parasites who think forcing work from doctors is OK, but i think is the only right and fair condition to recognize the compulsory nature and value of on-call coverage. The other requirement I see unmet is for CMS to pay every claim for services mandated under EMTALA not covered by private insurance at the local Medicare participating rate and at 100% of that rate rather than at the usual 80%, regardless whether the patient is a Medicare beneficiary or not. Let the federal government and the IRS go after the patients for the recoupment; they have more than adequate means to do so.

    There are solutions to these problems, and they do not really have to cost that much, but they will require political and moral courage and an understanding that the solution cannot just be the burden of the doctors.

  • pcp

    If doctors are not treated like professionals, they don’t act like professionals.

  • soloFP

    I am still on call for assigned outpatients from ER call. At least 80% of them are self pay or Medicaid. The rest are noncompliant insured patients. Many of them fail to show up for the follow up visit and about 5-10% of them have abnormal labs that need follow up. I then have to look up the demographics at the hospital, attempt tocal the person and send a certified letter with the abnormal information. I have to recommend that they follow up with a physician somewhere, just to lower my liability risks. It gets old dealing with abnormal glucose, STDs, + drug screens, abnormal CTs or CXRs. It actually costs me money and time to deal with these free follow up patients.

  • docguy

    We don’t seem to have this problem in the suburbs where I practice but I can see it getting worse.

    The ER docs at the hospital where I work get a stipend from the hospital, how many specialists get a stipend from the hospital for taking call?

  • jsmith

    Simple really. It’s all about incentives. Given current incentives, sloughing off hospital work=less work and more money. Add that to radical American individualism and lack of social and professional constraints and you have current reality.
    If it becomes financially beneficial to not slough off work, then work will not be sloughed off. Jawboning this issue will be ineffectual.

  • Goodenyou

    To ignore the eroding largesse of physicians due to decline reimbursements and overregulation is folly. Just “suck it up” and rise above it ain’t cutting it anymore. Communities should be put on notice that their assumptions of a doctor on call at any given hospital is erroneous. There once was a billboard on a highway in Dupage County, Illinois that read “Drive Safely, there are no neurosurgeons on call in Dupage County” If communities want 24/7 coverage, than have a 911-like fee on phone bills that provide the coverage. After all, it is the community at-large that benefits from it. Let the market dictate what a physician would cost to provide life-saving care.

  • PAULMD

    @ninguem

    Sums it up perfectly.

  • Goodenyou

    Are there any other businesses (hospitals) that are built around a model of depending on free labor (physicians)? The system is broken. Hospital “privileges” is an antiquated model from a time past. The solution is either push or pull. The push model has not worked yet. Make the physician more desperate, and you will get desperate physicians. Hence, a decline in quality. Working harder to keep your practice afloat in an environment of declining reimbursements, while donating free care, is unsustainable.

    • ninguem

      Goodenyou – “….Are there any other businesses that are built around a model of depending on free labor?….”

      The agriculture of cotton in the early to mid 19th-century America comes to mind.

  • Dr. Dredd

    “So I implore physicians across the country to think a little before leaving. To think about the fact that their absence only passes the patient, the responsibility, the opportunity, down the line, to a colleague in another town.”

    Sure, I’ll think about it. For about a minute, until I remember how how internship almost killed me. Hospitalist medicine would be like repeating residency for me, albeit with with better pay. Not worth the hassle.

  • Primary Care Internist

    The difference between being an ER doc and a primary care doc (or especially a pediatrician) is SHIFT WORK. Yes, you may have the same issues with bad payer mix, liability, lack of negotiating power with hospita/insurers, etc. but after your shift is over, you go home and are not interrupted. Then 12 or 24 or 36hrs later you go back to the ER, having gotten a true break to sleep or spend time with your family or whatever.

    In pediatrics (my wife was a practicing pediatrician once) you are woken up EVERY NIGHT by entitled parents with crappy insurance when their infant has the sniffles, this after having seen their EOB from blue cross that denied 4 of the 5 vaccines you gave them last week (and prepaid for), and only paid you $36 for the office visit. Then you get to wake up again in the morning to go into the office.

    So it is not surprising at all that pediatricians, otherwise the most altruistic group of people in the world i think, burn out quicker than the rest of us.

    As an internist myself, i felt quite enlightened to learn that the ENT who sublet space from me and set foot in the hospital once/year was getting paid to take service call one week a month. While for myself and my internist colleagues, NADA ZIP ZILCH. Nope, that was the cost of having hospital “privileges”. Needless to say, i gave up hospital privileges and now admit to “service” ie. some other sucker who hasn’t realized yet that the hospital needs him more than vice versa.

  • Goodenyou

    ninguem: “The agriculture of cotton in the early to mid 19th-century America comes to mind.”

    LOL. Actually, food and housing was covered in that arrangement.

  • Muddy Waters

    Appropriately, this problem will continue to get worse until the current system of entitlement and liability collapses. Our ideology as Americans has mutated into a cesspool of apathy and selfishness. Whether we like it or not, the lack of common resources will eventually FORCE people to take responsibility for their lives and be held accountable for their actions. Only then can we reset this country back to some of its FORMER glory.

  • Goodenyou

    “So I implore physicians across the country to think a little before leaving. To think about the fact that their absence only passes the patient, the responsibility, the opportunity, down the line, to a colleague in another town.”

    Yea, for those patients you lose money on, make up for the loss in volume. Just see more and more money losers and you are on the road to success. Good luck.

  • gjpearce

    Rural ophthalmologist here.
    This is a no-brainer. If there is any way to get out of call, why would you want to deal with calls from ER docs that have minimal ophthalmologic education (but are scared of missing a serious injury), go to an ER with poor equipment, be paid less for a service than if performed at your office (for some reason the medicare payment formula assumes there are lower expenses to you the physician if you provide care in a hospital-discounting commuting time,charting time, etc.), deal with a typically inebriated and self pay car accident/fight/etc., and then screw the next day when you need to be at your best for your paying customers. I know hospitals have a lot of money! Let them pay us to take call and attend meetings and we can decide if we want to!

    • ninguem

      Sorry gjpearce, the hospitals need that money to pay millions to their administrators.

  • PAULMD

    Whenever the president/CEO of our local hospital is asked about payment for mandated call services or for caring for the uninsured he has the same predicatable answers.
    We don’t have the money
    It would be a slippery slope and we would have to pay everyone
    It’s not being done in our area
    You must take call as it is in the staff bylaws that was approved by the medical staff in exchange for priviliges
    IT IS A COST OF DOING BUSINESS THAT YOU ARE JUST GOING TO HAVE TO ACCEPT

    I am not hopeful that the tables will turn but the sweetness of potentially getting to say to such a person, “Sorry pal, it’s the cost of doing business that YOU are going to have to accept” …is at the top of my wishlist.

    • ninguem

      Go to guidestar.org and look up your hospital’s form 990 filed with the IRS. See what that hospital CEO is paid annually.

    • neurojim

      Our hospital couldn’t afford to pay us to be on call so we told them that if no one wanted to pay for a service then we shouldn’t supply it. We sent a letter terminiating our privilegs and within one day they found $500/day for being on call.

  • Goodenyou

    “Our hospital couldn’t afford to pay us to be on call so we told them that if no one wanted to pay for a service then we shouldn’t supply it. We sent a letter terminiating our privilegs and within one day they found $500/day for being on call.”

    While this is a good (small) gesture, what typically happens is that some physicians opt out (after all… $300 after taxes…I’d rather not be woken up to operate on a disaster), and the whole thing breaks down again. The hospital then hopes the agreeing physicians “convince” the others to “do their part” and take call. More call at $500 per night is not more attractive to the ones who agree to it. Seen it happen many times before.

  • PAULMD

    @neurojim,
    You must have admitting privileges with some other hospital then, yes?

  • Jone

    AEM recently published a national study on this issue:

    http://onlinelibrary.wiley.com/doi/10.1111/j.1553-2712.2010.00927.x/abstract