Crucial minutes go by without ER on-call specialists

Many hospitals struggle to fill void

The shortage of on-call specialists comes at a time when emergency rooms are stretched to the breaking point. (John Bazemore/associated press/file)

WASHINGTON - Hospital emergency departments across the United States, already struggling with crowding and growing patient loads, are increasingly unable to find specialists to help treat seriously injured and ill patients, according to medical analysts.

Crucial minutes, hours, and even days can go by as patients suffering from trauma, strokes, broken bones, and other maladies await evaluations by neurologists, orthopedic surgeons, and other specialists because hospitals are having difficulty getting them to serve 24-hour emergency "on-call" shifts.

"It can mean death," said Linda Lawrence, president of the American College of Emergency Physicians and a practicing emergency department doctor in California. "Patients have died in transport, or waiting to find a neurosurgeon, or getting to a heart center for a cardiologist."

A nationwide survey by the American College of Emergency Physicians in 2005, the most recent available, found that of the 1,328 emergency department directors who responded, 73 percent said they had a problem with inadequate on-call coverage by specialists, including neurosurgeons, orthopedic surgeons and obstetrician/gynecologists. That was up from 67 percent in 2004.

The shortage comes at a time when emergency rooms at many hospitals are routinely stretched to the breaking point.

The annual number of visits to emergency departments rose 18 percent, to 110 million, from 1994 to 2004, according to the Centers for Disease Control and Prevention.

At the same time, the number of hospitals operating 24-hour emergency departments fell by 12 percent.

The shortage of specialists is the result of a fear of malpractice lawsuits, a reluctance to go without pay when seeing uninsured patients and a growing intolerance for the disruption in their personal lives and private practices, the analysts say. Many specialists are also decreasing their work for general hospitals.

Retiree Mary Jo McClure, 74, experienced the problem firsthand one Friday afternoon in January when she fell down some concrete steps, tearing large chunks of flesh from one leg. The plastic surgeon on call for Tucson Medical Center refused to leave her private-practice patients to come to the emergency department to treat McClure, who has health insurance. The doctor said instead she would see the injured woman in her office the next Monday.

But over the weekend, the specialist telephoned the family to say that she could not treat McClure after all because she only performed only cosmetic procedures and was not trained to handle severe wounds, McClure said.

"What was she doing on the roster?" said McClure, who searched for six days before finding a plastic surgeon at another hospital who would see her. "Do they expect you to walk in for a face-lift? . . . That was a very bad day, because you are hurt and you're in pain, and you always feel like the hospital will help you."

Judy Rich, the hospital's executive vice president and administrator, said the plastic surgeon later acknowledged that she should have seen McClure.

"It's a constant issue, our emergency room coverage," Rich said. "We count on the medical staff to come in when they are called. . . . There's too many patients and not enough specialists many times in communities, and Tucson, I think, is pretty typical of the kind of dilemma that we have."

For the most part, the dearth of specialists nationally arises not from a numerical shortage but from the growing unwillingness of many specialists to take on-call duty, said Ann O'Malley, a physician and senior researcher who co-authored a new study of the issue for the Washington-based Center for Studying Health System Change.

Traditionally, many specialists agreed to pull on-call duty in exchange for admitting privileges and use of a general hospital's facilities to perform operations and other procedures as part of their regular practice, O'Malley said. But the rise of physician-owned specialty hospitals and outpatient surgical centers over the past 15 years has reduced doctors' reliance on the general hospital.

"The historic relationship between physicians and hospitals is unraveling," O'Malley said.

Another factor is the rising number of the uninsured, with specialists complaining that they often do not get paid for treating patients they see in the emergency room. Moreover, rising malpractice insurance costs and the threat of lawsuits have made more physicians reluctant to see such patients, with whom they have no established professional rela- tionship.