Friday, December 21, 2007

Emergency Room coverage by surgical specialties continues to worsen

Last summer I wrote a post "What's going to happen when you need a plastic surgeon in the E.R.?" about the worsening crisis in E.R. coverage among many specialists including Plastic Surgeons.

As we end the year, I've been seeing a number of articles referring to this come up again in our professional journals and on the news wires. MSNBC today highlights this again in a story "Emergency rooms find on-call specialists rare: Seriously ill suffer as relationship between physician and hospital unravels." Surveys of Emergency Room around the country have reported that as many as 75% have had issues about coverage for services like Orthopedics, Neurosurgery, Obstetrics, Hand Surgery, Oral Surgery, and Plastic Surgery.

In the MSNBC story, they profiled a patient who had trouble finding treatment from a plastic surgeon

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 performs only cosmetic procedures and is not trained to handle severe wounds, McClure said.

I can remember seeing this scenario multiple times during residency, and in this instance it is B.S.. This doctor may not want to or like to treat wounds but she is certainly over-qualified to. After examining it, she may determine that the extent of it requires surgical techniques she is no longer proficient in (eg. microsurgical techniques). This particular doctor is going to have to decide if staying on staff at that hospital is worth it to her for exposure to these issues from the ER. She may choose not to, but it looks real bad to behave like she did in this instance. Now for patients who present with hand issues, complex facial fractures, and mangled extremities I do feel it is more appropriate to defer treating if you don't do those types of procedures as the skill sets for treatment are more advanced and the resources required for their global care do not always exist at all hospitals.

I, for example, do not do any hand surgery (beyond smaller burns and occasional peripheral nerve procedures) in my elective practice and I do not take ER call for hand. Out of the nearly 40 Plastic Surgeons in my city, maybe 5 do any amount of hand surgery with most of those working at the University-affiliated level I trauma center. Outside the University, you may be SOL if you're trying to find a plastic surgeon doing hand injuries. As many orthopedic surgeons are following plastic surgeons out of the hand business, we're reaching critical mass for coverage of that specialty.

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.

I think that last sentence says it all. Surgeons en mass have reached a breaking point about being bullied by hospitals and insurers and now have some opportunities to walk away from uncompensated and unreasonable demands for ER coverage. In years past, the ER was a reliable practice builder for many plastic surgeons but in many instances it's now a reservoir of uninsured patients and offers less then cost reimbursement on insured patients with significant exposure of malpractice liability. What's not to like?

Much like I suggested when talking about specialty hospitals, the relationships between doctors and hospital ER's is going to have to be renegotiated. It's clear that hospitals will be having to pay stipends for ER coverage (which is perfectly reasonable to me) and that there will have to be increased medical malpractice tort reform for ER coverage to halt (if not reverse) this trend.



Anonymous said...

I know it's a bit off-topic, but do you think its ever justified for an ER to make someone in pain lie on the floor when there are beds available? Just curious about my own recent treatment, and the hospital's indifferent response. Should I forget about it, or make a fuss?

Anonymous said...

this particular dr. does not take call at that hospital and was not on call. and if you read the rest of this story, you will see that she made a formal apology to the patient:
just because an ER doc calls a physician does not make that physician responsible until they agree to accept the patient. it sounds like there was some confusion in this case.

Dr. Rob Oliver said...

The link to that story is

In point of fact, I think the doctor even comes off worse as she tries to explain herself

Anonymous said...

As a surgical resident myself (found my way here from SDN), I think stipends for each night on call should have been here a long time ago. Even if you don't get called, you are committing yourself to not go out of town, to not drink any alcohol at dinner, and to not plan anything with family or friends. It definately affects lifestyle.

Thomas Fiala, MD said...

As a practicing plastic surgeon, I also felt troubled by the surgeon-on-call's refusal to see the patient and subsequent excuses. If the patient needed an exotic surgical procedure, sure, it could have been referred out to a tertiary center - but at least a basic evaluation of the patient's problem should have been performed by the surgeon on call. A wound evaluation is something that all plastic surgeons are quite capable of doing, even if you have a 100% cosmetic practice.

Keep up the great work on the blog!

T. Fiala, MD
Orlando, FL

Dr. Rob Oliver said...


I couldn't agree more.

Anonymous said...

I've seen these same patients who fall and get a flap avulsion of the lower leg. Basic wound care could have been given by the ER and then the plastic surgeon at the minimum. As plastic surgeons, we've all seen these patients. The wound care is basic, and a skin graft could be done even weeks later with proper care. If the cosmetic surgeon is unable to do a skin graft, then arrangements could be made later after the wound is stablized. Unfortunately, it made her look like she was abandoned. If the plastic surgeon had not agreed to see the patient, and was not on call, then that is another issue. This lack of specialist availability is particularly a problem when patients need a hand specialist. The problem is multifactorial including lifestyle issues, reimbursement issues, and professional liability exposure to name just a few. Things will only get worse. Rob, I love your blog site and read it often.

Dr. Rob Oliver said...

Thanks Ray!

Again, this doctor (whom I don't know) has a choice to make if she's going to accept ER call as part of her hospital privledges. You just can't make the claim that you're unqualified to evaluate a primary soft tissue wound as she did.

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