Get Me a Neurosurgeon, Stat!

By Josh Fischman
http://www.usnews.com

Elsie Bishop didn’t expect to die in New Mexico. The 74-year-old left her Arkansas home in the summer of 2004 on a driving vacation with a friend and reached Santa Fe in early September. After dinner one night, she complained of extreme nausea, and an ambulance took her to a local hospital. “They did a brain scan, which showed a bleeding aneurysm,” says Jim McKenzie, her longtime fiancé, who got a call from the hospital later that night. “And the poor doctor in the emergency department was beside himself. He tried to call a neurosurgeon, but there was no one around.” It took hours, but the doctor finally found one in Albuquerque, more than 60 miles away, and arranged a helicopter evacuation. “The whole left side of her brain was filled with blood by the time I got there on Friday morning,” McKenzie says. “There was nothing to be done. She died on Sunday. I don’t know for sure, but if they’d had a neurosurgeon in Santa Fe, things might have been different.”

It’s not just Santa Fe that’s scrambling. Across the country, three quarters of emergency departments report a shortage of specialists like neurosurgeons and orthopedists, according to a 2006 survey by the American College of Emergency Physicians. That’s up from two thirds when the survey was done in 2004. “This is the weak link in the chain of survival,” says Loren Johnson, the emergency department director at Sutter Davis Hospital in Davis, Calif., and a researcher on medical staffing shortages. 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 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.

These delays hurt, and sometimes kill. 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.

Modern maladies. So where have all the specialists gone? They’ve been driven away, observers say, by three modern maladies of American healthcare: too much work, too little pay, and the fear of malpractice lawsuits. “Put all those things together, and who would want to be in this business?” asks Todd Taylor, who teaches emergency medicine at Vanderbilt University in Tennessee.

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. That means more people jamming into fewer emergency rooms, with no extra doctors around to treat them. “When I started working at a hospital in Houston, we would be on call for the emergency department for a month at a time, and it wouldn’t be that much of a burden,” says Alex Valadka, vice chair of neurosurgery at the University of Texas Medical School in Houston, adding that a week might go by without his pager waking him. “By the time I left that hospital, a few years ago, I’d take call for a week, and it would be really heavy, with cases on many of those nights,” he says. “The volume of ER work has become ridiculous.”

And it doesn’t pay. The federal Emergency Medical Treatment and Active Labor Act, enacted in 1986 to prevent discrimination against the poor, requires that emergency departments screen all patients and ensure they are not in an immediate medical crisis, regardless of their ability to pay. That means hospitals need to maintain a roster of on-call specialists. But the law has also pushed hospitals to pressure doctors to provide on-call services for nothing in return for hospital affiliation. Doctors used to agree to this deal because they needed hospitals as places to perform surgery, and the workload wasn’t too heavy. But as the workload spiraled up, surgeons spent more time answering ER calls and less time dealing with their own practices and paying patients. If they were affiliated with more than one hospital, as many doctors are, both hospitals made demands.

Recently, “office-based surgery and free-standing surgical clinics have given orthopedists and plastic surgeons and others a way out,” says Rick Cameron, project manager of the Emergency Department Management Group in Palm Beach County, Fla., a partnership of county hospitals trying to solve the specialist shortage that has dogged that region. “Many don’t need to be affiliated with hospitals to do their jobs.”

Finally, there’s fear of being sued. On-call surgeons worry there’s more chance of getting sued by a stranger whom they rush to treat in an ER than by an established patient having elective surgery. “Anything can happen in an ER,” says Jose Arrascue, a kidney specialist in Boynton Beach, Fla.”If you have no rapport with the family, they may conclude you did something wrong, and you are wide open for a suit. That really concerns me.” There have been calls for legislation exempting doctors on ER duty from lawsuits, but the idea of immunity from malpractice hasn’t appealed to federal or state lawmakers.

To minimize risk, many doctors stop taking ER calls. Or, Valadka says, surgeons may limit the types of operations they do in regular practice, which means they won’t be called in for emergencies that are beyond those limits. For example, some neurosurgeons—ironically—have stopped doing brain surgery and focus only on the spine.

Hospitals have attempted to counter this reluctance by paying specialists extra money—$1,000 per night, say—to be on call. But that adds up: California hospitals paid an estimated $300 million in such stipends in 2005, up from $200 million a few years earlier. And they can’t raise prices to cover these fees, since hospital services are tied to Medicare, Medicaid, and insurance reimbursement schedules. To make matters worse, hospitals now often need three specialists where one used to do. Microspecialization in orthopedics, for instance, means some docs work only on knees, some on backs, some on hips. So a hospital would have to pay several surgeons to stay on call to maintain complete orthopedics coverage.

Doctor pool. With so many causes for the shortfall, hard-hit Palm Beach is trying to put together a multipronged solution. Last month, Cameron’s group submitted a plan to the county health district that would regionalize certain critical on-call services, allowing several hospitals to pool their on-call doctors to make sure these specialties are covered at any given time. Hospitals would also pay for liability insurance just for on-call cases.

There’s no guarantee the complicated plan will work. And it’s not going to solve problems like the workforce shortage. It may even entice hospitals in neighboring counties without specialists to send their patients to Palm Beach, increasing ER workloads.

Experts believe things are likely to get worse before they get better, with emergency docs continuing to scramble—they grimly call it “dialing for doctors”—to find specialists to help people like Elsie Bishop. Says Taylor: “The American public has no idea how dangerous it has become to get sick or injured at the wrong time.”
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