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The on-call dilemma: Crisis in the ER
During the American Academy of Orthopaedic Surgeons fall leadership meeting in 2004 and the National Orthopaedic Leadership Conference meeting in 2005, there was discussion regarding the growing awareness of a nationwide problem with surgical specialist coverage of emergency departments.
In response, the AAOS Board of Directors created a project team on trauma care and on call issues, led by James Beaty, MD, then the 2nd vice president of the academy. The project team reported back to the board in December 2005 that there was indeed a problem with emergency department on-call coverage, and termed this problem a “crisis.” They noted that many factors came together to create an unfavorable environment for taking call, including decreasing reimbursement, increasing practice costs, increasing uncompensated care, worsening paperwork and the medical liability climate. For orthopedic surgeons, taking call had become, in their words, “ a point of contention.”
It concluded that the orthopedic community, as a whole, had a responsibility to ensure that emergency patients with musculoskeletal conditions received necessary emergency care services for those conditions; and that hospitals, payers, governments and society should improve the conditions in which surgeons provide those services. The team report recommended that the AAOS should, develop position statements, study the effects of the resident 80-hour work week, produce a manual to help orthopedic surgeons negotiate with hospitals, and oppose the creation of the acute care surgery specialist.
In the 2 years since that report, the AAOS and the Orthopaedic Trauma Association have created and released position statements on this crisis. In addition, the Institute of Medicine of the National Academy of Sciences has released a report on the crisis in emergency care entitled “Hospital based Emergency Care – At the Breaking Point.” In it, they state “One of the most troubling trends is the increasing difficulty of finding specialists to take emergency call. Providing emergency call has become unattractive to many specialists in critical fields, such as … orthopaedics.”
There is a widespread impression that this problem has persisted and worsened. We addressed this at the OTA annual meeting in Boston last October. The OTA has proposed that the AAOS adopt a Standard of Professionalism to demonstrate the willingness of our profession to address this issue. To date, we have not been successful in convincing the leadership of the AAOS to support the measure.
Jeffrey O. Anglen, MD
Moderator
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Jeffrey O. Anglen, MD
Mitchel Harris, MD, FACS
Michael J. Bosse, MD
William M. Ricci, MDJeffrey O. Anglen, MD: From your perspective, is there a problem with orthopedic on call coverage?
Michael J. Bosse, MD: There is undeniable evidence that we’re in a crisis. The 2006 Institute of Medicine report publicized what all providers of emergency care already knew: emergency room (ER) and trauma centers are overcrowded. The safety net expected by the public is at risk of failure. Over 500,000 ER diversions occur each year related to system capacity/coverage issues. Demand for ER care has increased more than 26% in the last decade. In the same period, 425 ERs closed. More orthopedic surgeons are opting out of community ER call coverage, increasing the burden of call on the surgeons who continue to support the system. Surgeons who remain on the ER call roster are often overworked, undercompensated and are subject to higher malpractice risk and premiums. Lastly, participation in the community ER coverage stresses the lifestyle desires of the surgeon.
What is clear in all discussions on this topic is that there is a misunderstanding and misrepresentation of the on-call issues. Too many orthopedic leaders continue to refer to emergency department (ED) patients as “trauma” patients. In fact, over 80% of patients presenting to our ERs have uncomplicated conditions that fall within the expected scope of practice of a board-certified orthopedic surgeon. This is not an orthopedic trauma problem, this is an orthopedic professional problem. The tertiary hospitals and trauma centers, however, often serve as final common pathways for the patient.
Mitchel Harris, MD, FACS: There is an increasing awareness of the existence of a deficiency of available orthopedists for on-call. In a 2004 American College of Emergency Physicians survey, three-quarters of the ED medical directors reported that their hospitals had inadequate on-call coverage. An additional survey indicated that 42% of ED administrators felt that the lack of specialty coverage in the EDs posed a significant risk to patients.
Increasingly, graduating orthopedic residents are participating in subspecialty fellowships prior to entering practice. Upon completion of their fellowship they may join practices that are centered on ambulatory surgical centers (ASCs) or specialty hospitals. This obviates the need for general hospital privileges and thus avoids the obligatory on-call responsibilities. The ASCs do not have ERs so some graduating fellows do not enter the pool of community doctors responsible for on-call coverage.
Similarly, many fellowship-trained orthopedic surgeons in subspecialties such as sports medicine, spine, hand/upper extremity, pediatrics and even foot and ankle describe a “lack of comfort” in caring for orthopedic emergencies once they become immersed in their subspecialty practices.
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William M. Ricci, MD: There are definitely problems with orthopedic on-call coverage in this country. For instance, there are fewer orthopedists interested in taking call, and there are fewer and fewer general orthopedic surgeons who maintain a comfort level for treating the variety of injuries seen on-call. Furthermore, with more orthopedic surgeons practicing primarily at surgical centers, there are fewer orthopedic surgeons that rely on in-patient hospitals for their practice.
The pool of orthopedic surgeons available to take call at full-service hospitals continues to dwindle. With these reduced numbers, individual surgeons are asked to take more call. Whereas 1 or 2 call days a month is well tolerated by most surgeons regardless of reimbursement, as a public service to the community, 3 or 4 call days per month tip the scales towards intolerability.
Paradoxically, the maturation of orthopedic trauma as a subspecialty may also contribute to problems with caring for orthopedic trauma patients at community hospitals. Prior to having traumatologists at most Level I and teaching institutions, community surgeons felt compelled to tackle moderately complex cases because there was no one else to do it. Now these cases routinely get transferred to traumatologists. This further dilutes the community surgeon’s experience with trauma, making it less and less likely that orthopedic trauma will be performed at the community level.
Anglen: Does the on-call crisis affect your community, your patients or trauma center?
Bosse: Absolutely. Patients with relatively simple but urgent musculoskeletal conditions are routinely transferred from distant sites for evaluation and care at the tertiary care centers (trauma centers). The trauma centers, already at or over capacity, are forced to absorb the care of patients with routine hip, tibia and femur fractures, soft tissue infections and compartment syndromes. Many of the cases sent under the EMTALA (Emergency Medical Treatment and Active Labor Act) umbrella are well within the expected skill set of the orthopedic surgeon at the referring center.
Many orthopedic surgeons ignore the fact that, at present, all patients with urgent musculoskeletal conditions eventually receive care. Not participating in the ER call system or participating , but not performing, simply shifts the burden of care to another orthopedic surgeon.
Harris: No, our community has several large academic medical centers (AMCs) and residency teaching programs, so this has not emerged as an issue. In fact, the trauma centers actively communicate with the community hospitals and try to establish easy referral practices into the AMC and its ER.
Ricci: The on-call crisis definitely affects our community, our patients and our trauma center. For example, one neighboring county is exceptionally litigious. This has driven out a large number of orthopedic surgeons. The end result is fewer orthopedic surgeons who are available to adequately cover ED call. Those who do cover call, due to their medical legal concerns, are less willing to assume care of trauma patients. This leads to potential problems for both the local community and trauma center. Patients who are best served with treatment in their local community for relatively straightforward problems cannot get it there. They are forced to tertiary centers, often many miles away and inconvenient for them to visit. This, in turn, potentially overloads the tertiary care center with patients who have straightforward problems that normally could be dealt with in the community setting which, in turn, makes access to tertiary care for patients with more complex needs more difficult.
Anglen: How have EMTALA and other government responses affected the problem?
Bosse: The government hasn’t responded in a manner to improve the availability or improve the access to acute musculoskeletal care. EMTALA has had an impact the opposite of the intent and, at present, facilitates bad physician behavior and inappropriate patient transfer. The 2004 AAOS compendium EMTALA and the Orthopaedic Surgeon basically served as a playbook to the orthopedic surgeon on how to avoid care of the emergency room patient.
Harris: EMTALA has enabled physicians to transfer patients who are judged to be “too complicated” to facilities that are labeled as trauma centers (ACS or state designation). Recent publications (Goldfarb et al. 2006; Koval et al 2006; Archdeacon et al. 2007) have examined the reasons leading to patient transfers to designated trauma centers. In each of these articles, injury severity was identified as a primary determinant for patient transfers. However, insurance status and availability of orthopedic on-call coverage were also identified as major contributing factors. In Goldfarb’s study, it was identified that often times the orthopedic surgeon on call does not even have the opportunity to assess the patient before the transfer process is underway. In Koval’s study, nonclinical factors such as gender, age, race, insurance status and time of day all proved to be significant risk factors for hospital transfer, even after controlling for injury severity.
As pay-for-performance initiatives come into play and the new Medicare initiatives placing the burden of future care costs on the institution after a complication occurs during the initial treatment, the trend to refer “challenging cases” to designated AMCs is bound to accelerate. This additionally overloads already burdened centers and could make it difficult for the AMCs to continue their open-arms approach to accepting all transfers regardless of actual medical complexity.
Ricci: Dr. Harris mentioned a study from our institution, (Goldfarb et al. 2006). In it, we found that an orthopedic surgeon was the transferring physician in only 25% of the cases. An ED physician was by far the most common transferring physician (69% of cases). When there was an orthopedic surgeon on call, that physician examined the patient in only 42% of the cases prior to transfer.
In helping to construct the standards of professionalism, we had several discussions regarding whether an orthopedic surgeon should routinely evaluate patients prior to transfer. The utility that is debatable. I think that this should not be an absolute necessity. Patients with complex injury patterns who clearly deserve transfer to a tertiary care center are unlikely to benefit from routine evaluation by an on-call orthopedist. Such an evaluation would only delay the inevitable and therefore, would not be in the patient’s best interest.
The Standards of Professionalism (SOP) document currently states that “The orthopaedic surgeon ‘on-call’ at the referring hospital must actively participate in the decision making for the transfer of the patient to a ‘higher-level of care’ regarding musculoskeletal conditions.” Also, “The blind transfer of patients for a higher level of care without the active participation of the on-call orthopaedic surgeon should only be permissible under medical circumstances necessitating expedited transfer for the welfare of the patient.” These guidelines must be, and we believe are, designed to best serve patients.
Anglen: How should we address this problem through our organizations — the AAOS, American Board of Orthopaedic Surgery (ABOS), specialty society, or others?
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Bosse: Waiting for a worsening crisis to pressure a system repair or naively expecting that market forces will adjust manpower needs is an abdication of our professional responsibilities and a betrayal of our patients. At present, we have a failure of initiative and leadership in our orthopedic associations to recognize and respond to the crisis. In all arenas for the last 4 years, we’ve discussed the access to urgent musculoskeletal care, but have developed no clear strategy nor implemented a fix. At the same time, our organizations have worked to restrict podiatrists from providing emergent lower extremity care, argued against the expansion of practice by the physical therapists and blocked the development of the new general surgery “acute care specialty” from including ER-based orthopedic care – including the fixation of fractures – in their curriculum.
Orthopedic surgery can’t have it both ways. We either have to reverse the orthopedic evolution that is moving us away from the core competencies of the profession and the ownership of emergent musculoskeletal care, or recognize the public’s need for this care and work to educate and monitor other interested specialties.
Clear and decisive action can and should be taken now to re-define the orthopedic profession and to hold those who elect to serve in the profession accountable to the expectations of their communities and fellow orthopedic surgeons.
The ABOS is first in line to effect change. To complete an orthopedic program, core competencies/skills need to be clearly defined. To obtain and maintain board certification, the orthopedic surgeon must maintain proficiency in the core competencies and participate, in a reasonable fashion, in the ER coverage of the community. This requirement should be expected through the first re-certification process. Core competencies would include the debridement and provisional external fixation (if needed) of open fractures, the reduction and splinting of fractures and dislocations, repair of hip, tibia, femur, ankle and forearm fractures, and the treatment of compartment syndromes and soft tissue/joint infections. Future orthopedic surgeons incapable of this care should not be certified by the board!
The AAOS is next. Rather than exhausting efforts to limit access of others to the care of extremity injuries and/or musculoskeletal conditions and supporting the efforts of orthopedic surgeons who abandon ER care obligations, the AAOS needs to support those who continue to provide care and develop clear standards of professionalism that would allow regional surgeons to police their own behavior. Refusal to provide reasonable ER coverage and “dumping” of patients to other centers or surgeons should be violations of the SOP.
An Emergency Care SOP has languished in AAOS committee for more than a year and recently, failed to obtain the support of the AAOS board of directors.
The “community of leaders” in the American Orthopaedic Association (AOA) likely will not have an impact. The AOA chose to address the topic with a symposium in two of the last three meetings. The AOA board failed to respond to an Acute Care Resolution in 2005. Meanwhile, the problem increases.
The subspecialty societies can have a significant impact. They need to pressure their members to locally address the ER on-call crisis and pressure both the AAOS and the ABOS to develop a long-range strategy to address the future musculoskeletal specialist needs of the emergency care system. Of importance, the ABOS unanimously supported the draft On-Call SOP at the 2005 Spring NOLC meeting and forwarded it to the AAOS SOP pipeline.
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Most importantly, resident mentors (faculty) and orthopedic leaders need to step up and lead by taking call and fixing the problems in their own communities. Residents should not be exposed to faculty who can’t find the ER or who haven’t maintained basic core competencies. They may graduate and emulate their “no-call” faculty mentor. Senior orthopedic leaders can’t effectively address this issue — inside or outside of the specialty — if they lack credibility. They can’t negotiate a solution to the on-call crisis if they don’t take call! Perhaps participation in an on-call panel should be a requirement to serve in a board-level position.
Medical students considering an orthopedic career, and residents training for one need to be continually and clearly educated regarding the professional expectations, specifically related to access to urgent musculoskeletal care. If properly selected, appropriately educated and mentored, and held to a reasonable level of professional compliance by the ABOS and the AAOS, future surgeons will graduate knowing that they can’t opt out of the emergency medical care system.
Harris: There are a couple of initiatives that are being discussed. One proposal is to include as an initial obligation of board certification: the necessity to participate in orthopedic on-call coverage for X number of years. This would be consistent with the concept that upon graduation from an accredited orthopedic residency program and before being allowed to take the ABOS part I exam, all trainees must demonstrate a level of core competencies in the care of urgent and emergent musculoskeletal conditions. This should eliminate the objection of subspecialty-trained orthopedists that they “don’t feel comfortable managing orthopedic on-call issues.”
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The AOA has created a committee/task force through its Orthopaedic Institute of Medicine to further study this issue. First, we have to acknowledge that the problem exists in certain communities. We then have to quantify the magnitude of the problem. Currently, the Health Care Policy Committee of the OTA, which has representatives from many different geographical locations, is informally tracking the volume and stated reasons for the inappropriate transfers. This information will be reviewed and compared to the articles cited to see if this is, in fact, a national trend or more specific to particular health care networks.
Ricci: Our orthopedic organizations must take a proactive leadership role in dealing with on call and access to care issues. If we don’t, we run the risk of having these issues decided for us rather than by us. We must step up to the plate, be true professionals, and deal with this crisis effectively by ourselves. The OTA has developed an SOP that sets very realistic standards that every orthopedist should easily be able to live by. The next step to have broader acceptance of these standards by the AAOS.
For more information:References:
- Jeffrey O. Anglen, MD, can be reached at 541 Clinical Drive, Suite 600, Indianapolis, IN 46202; 317-274-7913; e-mail: janglen@iupui.edu.
- Michael J. Bosse, MD, can be reached at Medical Education. Bldg. #306, 1000 Blythe Blvd., Charlotte, NC 28203; 704-355-6046; e-mail: mbosse@carolinas.org.
- Mitchel Harris, MD, FACS, can be reached at 75 Francis St., Boston, MA 02115: 617-732-5322.
- William M. Ricci, MD, can be reached at 660 South Euclid Ave., Campus Box 8233, St Louis, MO 63110; 314-747-2811.
- AAOS Position Statement: http://www.aaos.org/about/papers/position/1157.asp.
- American College of Emergency Physicians Survey: www.acep.org/WorkArea/downloadasset.aspx?id=8974.
- Archdeacon MT, Simon PM, Wyrick JD. The influence of insurance status on the transfer of femoral fracture patients to a level-1 trauma center. J Bone Joint Surg (Am). 2007;89:2625-2631.
- Bosse MJ. CAQ: Orthopaedic Trauma – “Damage Control”. Journal of Orthopaedic Trauma. 21(1):1-4,2007.
- Goldfarb CA, Borrelli J Jr, Lu M, Ricci WM. A prospective evaluation of patients with isolated orthopedic injuries transferred to a level I trauma center. J Orthop Trauma. 2006;20(9):613-617.
- Bosse MJ, Henley MB, Bray T ad Vrahas M. An AOA Critical issue: Access to emergent musculoskeletal care: resuscitating orthopaedic emergency-department coverage. J Bone Joint Surg(Am),2006; 88:1385-1394.
- Institute of Medicine Report: http://www.iom.edu/CMS/3809/16107/35007.aspx.
- Koval KJ, Tingey CW, Spratt KF. Are patients being transferred to level-I trauma centers for reasons other than medical necessity? J Bone Joint Surg (Am). 2006;88(10):2124-213.
- OTA Position Statement: http://www.ota.org/downloads/PositionStatement12-05.pdf.
- OTA Presidential Address: http://www.ota.org/meetings/Presidential%20AddressAM07.pdf.