Covering the emergency department: Not everyone wants that assignment

Finding a way to negotiate with your hospital is essential.

Issue: July 2004

ByDouglas W. Jackson, MD

Douglas W. Jackson, MD [photo] --- Douglas W. Jackson, Chief Medical Editor

Serving as medical editor, I receive letters from readers who ask my advice on different issues related to orthopedics. As I try to think through the specific questions and issues they raise related to the professional and personal lives of practicing orthopedic surgeons, these letters often serve as the stimulus for my writing a particular editorial.

This month’s column is the result of inquiries from three orthopedic surgeons about the same topic. These surgeons, all in their 50s, have received letters from their hospitals notifying them that they are now required to take emergency room call if they want to maintain their hospital privileges.

Over the years they have limited the scope of their practices to subspecialty areas and no longer feel qualified to treat more severe acute musculoskeletal trauma. Their on-going continuing education has been in areas of orthopedics related specifically to their current patient-care profiles. Only a small proportion of their surgical practice has been related to hospitalized patients, and about 85% of their surgical cases have been in a surgery center.

Their questions bring up new twists in the current medical environment to this ongoing discussion of orthopedic emergency department and/or trauma center coverage.

Medical liability an issue

The position typically has been that all orthopedists are qualified to do emergency call and that a practicing orthopedic surgeon has a responsibility to the community to help with emergency care. If they are not qualified to give definitive care they can triage the complex trauma. This answer may still pertain but some aspects are changing:

There are fewer emergency rooms now than even five years ago, and many of those that are open are busier then ever.
The hospitals sign contracts to bring in patients from outside the community of the practicing orthopedic surgeon.
Hospitals sign contracts that guarantee reimbursement for their expenses but not the treating consultant.
Public perception and expectations are changing. A 2001 survey by the University of South Carolina’s Institute of Public Affairs found that 75% of respondents incorrectly believe that all hospitals are equally staffed and equipped to care for internal injuries, head injuries, heart attacks, strokes and spinal cord injuries. Two-thirds believe that emergency surgery is available 24 hours every day at all hospitals.
More orthopedists are limiting the scope of their practices and are more specific in their ongoing education.
The large number of uninsured and underinsured trauma patients, HMO patients out of plan and restrictions on transfer (dumping) has changed emergency room reimbursement and follow-up care for surgeons treating patients.
It is much more difficult for young surgeons to start and build a practice by taking extra emergency/trauma calls compared to how effective it was in years past.
The medical liability is substantial for an orthopedist who provides care to emergency department (ED) patients.

Strict requirements for staffing

Another large change is the difference between a trauma center and hospital emergency department. Trauma centers have strict requirements for staffing, specialist availability and response times. A trauma team stands ready 24 hours a day, seven days a week to give immediate care for the seriously injured. More hospitals are paying the orthopedic surgeons for this type of trauma coverage because of the time restrictions required for immediate availability, poor reimbursement and liability issues.

There is a large difference in the role of an orthopedist depending on whether the trauma facility is Level I, II or III. A major difference between Level I and II is that the orthopedist on-call has the commitment to be in the ED within a short time after the patient arrives. This often requires changing one’s clinic and surgical schedules and leaving blocks of time open.

Orthopedists practicing in a Level III trauma center hospital do not have the same responsibilities, and often the ED physicians stabilize and transfer the complex trauma patients.

Working with hospital administration

Over the years, I have been in many meetings with my fellow orthopedists, other medical staff and the hospital administration about our department’s obligation to provide emergency and trauma coverage for our community and to service contracts the hospital signs that obligate our coverage to a larger catchment area.

Some of the changes that have emerged from these meetings include:

Bylaw changes with exclusions above a certain age (ie, 55).
Certain exclusions based on practice profile and hospital privileges (ie, the hand surgeons have a separate call panel for hand trauma).
Since the hospital contracts to increase the catchment area and bring in greater numbers of patients, their emergency room operations and trauma center are more profitable. There have been negotiated stipends for an orthopedic surgeon’s coverage time and availability, as well as some provided protection from nonreimbursement for provided medical care.
Recruitment of trauma-qualified orthopedists for immediate referral of cases and/or to assist the treating surgeon with the complex cases.
Some surgeons have dropped hospital privileges and practice in surgery centers or moved to hospitals with other coverage demands and policies.

Graying of our profession

A current problem in our hospital is associated with the graying of our members taking ED call. We are not seeing younger members wanting to replace them in the area of emergency department and trauma coverage. About every two to five years, our department has a crisis related to orthopedic coverage. Over the past 30 years each time the problem arises, our orthopedic department has been able to work out a solution that is satisfactory for patient care, our orthopedic staff and hospital administration.

By sitting down with our hospital administration, we have come to satisfactory solutions without forcing orthopedists to provide coverage that they do not want or are not qualified to do. It usually is a compromise and an effort by all to make the situation more attractive to the qualified orthopedists willing to provide this coverage. Because this has worked for us in the past is no guarantee that this approach will always work. Our charge and responsibility are to work at defining and meeting patient care needs in this area, and we will continue to do so in the future.