Jobseekers would pass on this depressing pitch: Looking for physician specialists who are willing to be rousted out of bed, yanked from their office schedules or hustled away from Junior's soccer games at a moment's notice. Failure to respond promptly may result in federal fines of up to $50,000 per violation. The salary is not commensurate with experience or practice overhead, and your compensation is not guaranteed.
"Who would take that job?" asks Robert McNamara, M.D., chairman of emergency medicine at Temple University Hospital in Philadelphia and president of the American Academy of Emergency Medicine, a Milwaukee-based alliance representing 3,000 emergency physicians. "It's perfectly understandable what's going on."
What's going on is that specialists--citing reasons ranging from lifestyle considerations to outpatient surgery centers rendering hospital affiliations moot--are pulling their names from on-call panels and resigning from hospital staffs to avoid the perceived risks and dwindling benefits of seeing patients in emergency departments.
While rural areas have long suffered a dearth of specialists taking call, the problem is now bedeviling even urban ERs.
Nancy Ferguson, M.D., an emergency physician at St. Francis Medical Center in Trenton, N.J., says she routinely sacrifices an hour from patient care either trying to persuade a specialist to come in or attempting to transfer a patient to another facility for specialized care.
"It gives me less time to spend with patients and more anxiety about how I'm going to provide them with optimal medical care," says Ferguson, board chair of the New Lenox, Ill.-based Association of Emergency Physicians, a national coalition of 2,000 ER doctors. Ferguson says the trend frustrates not only emergency physicians and specialists but also consumers. "What about the family that sits here--after you've told them their relative is critical and needs immediate care--and an hour and a half later you still don't have a place to send them?"
That scenario is being played out in ERs from California to Florida, but the problem is particularly acute in western cities with greater concentrations of uninsured people, says Michael Williams of The Abaris Group, a Walnut Creek, Calif.-based emergency care consulting firm.
McNamara says that while Philadelphia has been spared thus far, the crisis likely will move eastward in a path carved by other healthcare trends and concerns. "It's migrating closer."
ERs in Los Angeles and other cities are already hitting a wall, says Williams. "In Phoenix, the entire trauma system is falling apart."
Emergency physician John Shufeldt, M.D., has seen both sides of the dilemma. Shufeldt, who has served as director of two rural emergency departments, is CEO of NextCare Urgent & Family Care centers and is on staff at the Level I trauma center at St. Joseph Hospital & Medical Center in Phoenix.
Shufeldt says he has frequently scrambled to find placement for outlying patients requiring specialty care and daily fields similarly frantic calls from other hospitals and clinics looking for help from St. Joe's 1,527 providers.
"It's definitely a crisis," he says.
Many on-call specialists express fear of violating the Emergency Medical Treatment and Active Labor Act (EMTALA), a 1986 federal law to curb patient dumping.
But physicians tend to overestimate their own "negligible" risk of EMTALA fines, Williams says.
According to a General Accounting Office report released June 22, a total of 28 physicians have been assessed a collective $412,500 in civil penalties by the Office of the Inspector General since inception of the act 15 years ago.
Still, the report states, "(The OIG) generally does not pursue a physician unless clearly culpable behavior is involved, such as an on-call physician refusing to come to the hospital to treat a patient when asked by the hospital."
Physicians and hospitals are unclear about their obligations under EMTALA, according to the report. For example, while hospitals must keep a list of specialty physicians on call to stabilize emergency patients, they are not required--as commonly believed--to provide "full-time coverage of a specialty if the hospital staff includes three or more physicians in that specialty." In fact, there is no such rule, nor are "physicians . . . required to be on call at all times," says the GAO.
St. Joseph CMO Michael Coyle, M.D., a pulmonary and intensive care physician, says, "EMTALA is not the reason for the erosion of on-call but has catalyzed and accelerated the problem."
Family and lifestyle issues also contribute to the problem. Orthopedic surgeon Brad Bruns, M.D., of Arizona Bone & Joint Specialists in Phoenix, and three of his four partners are fathers who say they are trimming call to coach sports teams or attend school activities.
"It's no longer accepted that physicians have to dedicate their entire life's energies to their profession," Bruns says. "It's not all push, push, push."
Coyle says younger physicians like Bruns commonly cite lifestyle choices for cutting back or eliminating call. That leaves older doctors to carry a disproportionate load of the "community service," which, he says, bodes ill for the future.
St. Joseph's still has full coverage across specialties most days but is paying for the privilege out of a pot that could fund extra nurses, says Coyle. "We're having to pay them to take call, and that's an extra, unbudgeted expense."
Some hospitals are responding by making call compulsory. But with more procedures being performed in outpatient settings, other hospitals are losing leverage with specialists. As providers lose motivation to build up a patient base due to managed care, a hard-line approach by hospitals has been known to backfire.
Such is the case at Littleton (Colo.) Adventist Hospital, a not-for-profit, 140-bed institution in metropolitan Denver-an area hard-hit by specialists abandoning ER call, says ED director Mark Elliott, M.D.
In July, Littleton suffered physician backlash when it expanded existing on-call compensation to include more staff doctors and also dictated compulsory call for its affiliated physicians, says Elliott. "We've already had many neurosurgeons and ENT docs resign from staff, just to get out of taking calls."
Williams, the California consultant, says the solution to the on-call problem is complex. More funding by hospitals would help; so would improved billing systems to recoup higher percentages of accounts receivable, as would reducing patient volume through an expanded urgent care system and better education for those with chronic illnesses such as diabetes, asthma or psychiatric ills.
Emergency departments are a bellwether for the entire healthcare system and must be fixed to avert disaster, Williams says. "ERs tend to feel the wind before the hurricane hits."
Linda Boone Hunt is a Prescott, Ariz.-based investigative reporter and feature writer.