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.


Rob

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There is a real crisis bubbling up through the American health care system in re. to how the Emergency Room is covered by surgical specialists. In 2006 the Institute of Medicine issued a report "Emergency Medical Services at the Crossroads" which highlighted this growing problem. I've been thinking about how to talk about this for months, but a few snap shots from articles in print this week speak louder then my words.

From US News & World Report comes "E.R. Help Needed Stat!" which gives some context to the problem. As the burden and liability of ER coverage by Doctors goes up while reimbursement has plummeted, you're seeing a predictable withdrawal of physicians willing to provide coverage. Most notably neurosurgery, orthopedics, and plastic surgery coverage is getting harder and harder to maintain for many hospitals.

"Emergency rooms depend on specialists to come in at any hour, any day, to, say, treat stroke victims or reattach fingers severed in an accident. But "specialists just don't want to cover emergency rooms anymore," says Dr. Loren Johnson. Earlier this month, he coauthored a study published in the online edition of the Annals of Internal Medicine reporting that nearly half of Oregon's hospitals cannot provide emergency on-call treatment around-the-clock in at least one specialty. A recent survey of emergency departments throughout the Southeast showed that 54 percent had to divert patients to another hospital because they didn't have the appropriate specialist on call....The Joint Commission, hospitals' major credentialing body, has cited lack of specialists as the cause of 21 percent of emergency department "sentinel events"—unexpected deaths or serious injuries due to slow treatment.

There were about 114 million visits to ERs in 2003, a 26 percent increase over the previous decade. During that same period, about 700 hospitals closed. But the number of surgeons in the country remained the same. "

These pressures have led to many specialists excluding areas involving trauma or emergent care from their practice to focus on elective surgical practices. These aren't "greedy" doctors, but they're frustrated caregivers who've watched the for-profit insurance industry strip-mine health care while recording record profits while simultaneously being squeezed by the feds who seek to contain health care cost with persist ant cuts in medicare fees. An AMA survey, released last week, showed that most doctors -- up to 77 percent -- would limit the number of new or existing Medicare patients they would accept if the cuts are made. The double whammy here is that private insurers, never one to leave money on the table, adjust their rates down to index medicare. You've also got the spectre of the malpractice free-for-all which affects both the economic & psychologic practices of medicine.

In Plastic Surgery the recusal from uncompensated ER call this has been facilitated by the increase in outpatient surgery which is flourishing outside of hospitals (which usually require some kind of obligation for ER call if you want to operate there. )

From the editorial page of the June 11,2007 Tampa Tribune titled "Running Doctors Out of the Emergency Room" which is discussing a recent med-mal case there when a woman who had a tummy-tuck nearly a month before, showed up with a late infection to the ER in septic shock which eventually required amputation of multiple extremities. A Plastic Surgeon (who wasn't her doctor) who was covering the ER and came in to drain her abdomen while calling in multiple specialists to try and save her life, got dragged into a $30 million plus malpractice verdict. Every report on this suggests appropriate care was given, but Florida's most notorious and successful ambulance chaser persuaded a jury that someone must pay for this unfortunate event, even when no clear malpractice is present.

I am writing this as a warning to readers who may at some time seek emergency medical care at one of our area hospitals. You may find that there are no doctors to treat your injuries from a car or motorcycle accident, a burn injury, head trauma or severe medical illness. Just as 'video killed the radio star,' plaintiffs' lawsuits filed when there are bad outcomes, rather than true malpractice, will keep qualified specialists from taking 'call' in emergency rooms.

My case in point is the recent decision by a jury to award Sally Lucia $30 million for the loss of her legs and fingers. Tragic, yes. A result of malpractice? I don't think so. I admit that I don't have all the facts presented by both sides, but I have spoken to Dr. George Haedicke, the surgeon on call, who was found to be 20 percent liable for a total of $6 million. Mrs. Lucia had a tummy tuck in early 2001 and had problems following surgery. Apparently, the plastic surgeon who did the original abdominal surgery told her to go to the emergency room if she had problems, which she did on Super Bowl Sunday in 2001.

The surgeon also happened to be in South Florida at the time she went to the ER.Dr. Haedicke was on call for Memorial Hospital and came in to see her. He evaluated her, drained her abdomen, ordered antibiotics and consulted four other physicians (who were also sued) to evaluate her condition. Her own surgeon returned to Tampa later that afternoon to assume care. Dr. Haedicke had seen her for a total of five hours.

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