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Most U.S. Hospital ERs Lack Specialists
TUESDAY, May 2 (HealthDay News) -- Three-fourths of U.S. emergency department medical directors say they have too few on-call neurologists, plastic surgeons and other specialists to cover the emergencies they handle each day, a new survey finds. That''s a significant increase from 2004, when the last report was issued. Back then, two-thirds of emergency department directors reported difficulty getting specialists to treat patients in the emergency department. "The main reason for this problem is [inadequate] compensation" for staff, said lead author Dr. Benjamin D. Vanlandingham, an emergency physician at St. Joseph Medical Center, in Baltimore. "That''s what specialists tell us." The surveys were conducted to study the potential unintended consequences of changes made in 2003 to the Emergency Medical Treatment and Labor Act (EMTALA). Changes include permitting specialists to be on-call at more than one hospital at the same time and limiting the amount of call time. The report, titled On-Call Specialist Coverage in U.S. Emergency Departments, was released Tuesday and prepared by the American College of Emergency Physicians'' and the Emergency Medicine Foundation. In the past, specialists used the emergency department as a way to build their practice, Vanlandingham explained. But today, insurance companies dictate which doctors will provide continuing care. "Many times, specialists are called to the emergency room to treat patients who don''t have insurance," Vanlandingham said. "Those patients are there exactly because there is no other place they could find a specialist." Orthopedists, plastic surgeons, hand surgeons and neurologists are the most common specialists in short supply, Vanlandingham said. In addition, it appears that urban hospitals have a more severe problem compared with rural hospitals, who don''t feel the need to provide specialist services. Although many physicians feel a responsibility to provide care in the emergency department, issues of compensation and legal liability can deter them. Improving compensation and offering liability protection might improve the situation, Vanlandingham said. "If that were done, then more people out there would want to help." One expert agrees that compensation is the primary problem. "Physicians are neither compensated for being on call nor compensated for many of the patients they are called in to see," said Dr. Ron M. Walls, chairman of the Department of Emergency Medicine at Brigham and Women''s Hospital and an associate professor of emergency medicine at Harvard Medical School. "I''m not saying that it''s right or wrong that physicians feel that way, but it''s understandable." Walls lays part of the blame on the recent changes to the law. "EMTALA is an unfunded mandate that requires physicians to care for patients without any promise of compensation," he said. "In addition, most payment schemas do not allow any compensation for physicians to be on call." "It''s not a greed issue," Walls said. "It''s just a concept of fair compensation for services that are commanded, not asked." The rest of the problem, according to Walls, is that many specialists are moving their practice away from the hospital and doing more procedures in their office or in same-day surgery centers. A lack of liability insurance for their work in the emergency department also factors in decisions not to be on call for emergencies. While teaching hospitals have full-time, round-the-clock staff in most specialties, they are being strained as more and more patients are transferred for treatment that they should have been able to get at the emergency department where they were initially taken, Walls noted. Another expert agreed that the lack of specialty care is putting pressure on teaching hospitals. "It is harder and harder for emergency physicians, particularly in community hospitals, to get specialists to come in to take care of patients who need specialty care," said Dr. Marshall Morgan, chief of emergency medicine at the University of California, Los Angeles Medical Center. "In an academic hospital like mine, this means that we are getting more transfers from outside hospitals." Some people believe that transferring patients is a way of dumping cases that hospitals don''t want under the guise of not being able to treat them, Morgan said. The combination of EMTALA and insurance companies that balk at payment causes many of these transfers, Morgan said. "Some of these practices the insurance companies engage in are illegal, but they do it anyway, and they generally don''t get called on it," Morgan said. "But I also think it''s scurrilous for the federal government to impose an obligation for a segment of the work force to work for nothing." More information For more on problems facing emergency medicine, head to the American College of Emergency Physicians.
Last Updated: May 3, 2006 |