Physicians cut back emergency on-call shifts, study finds

At one time, being on-call for emergencies was a way to build up a patient base. It also was a sign of dedication to the profession.

But some physicians say a professional approach to on-call coverage is being overshadowed by other problems that are making it less desirable to doctors. Rising medical liability premiums have made some high-risk specialists less willing to take call. More physicians are embracing lifestyles that allow additional time for family and outside activities and less time for 24-7 schedules. Low reimbursements also make on-call duty unattractive.

"A lot [of doctors] would like to be professional about it. But there are real economic issues for them if they are not being paid," said Brad Zlotnick, MD, a San Diego emergency physician and director of strategic development for Emergency and Acute Care Medical Corp., an on-call specialty physician management organization. "It used to be you'd compete to be on-call because that's how you'd get new patients. Not anymore."

The woes of on-call coverage also have pitted some emergency physicians against specialists.

"On some nights, they might yell at you and say, 'I'm not on-call for your hospital,' " said Ben Vanlandingham, MD, who worked in emergency departments in Arizona.

A new survey of 1,427 hospital emergency departments found that emergency physicians were spending more time seeking specialists for consultation and admission of emergency patients. The survey by the American College of Emergency Physicians also found that 16% of emergency directors said some specialists were negotiating with their hospitals for fewer on-call coverage hours.

Two in three emergency directors reported shortages of on-call specialists such as neurosurgeons and orthopedists. Directors said the most significant consequences of the shortages are risk or harm to patients who need specialist care, delays in patient care and an increase of patients transferred between emergency departments.

Physicians partially blame the Emergency Medical Treatment and Active Labor Act for chasing specialists away.

Since EMTALA, some say physicians balk at taking calls from emergency departments because many patients are not insured and physicians struggle to get any payment.

"We have this progression of undesirable factors that have been piled on over and over and over again," said Todd Taylor, MD, vice speaker of the ACEP and an emergency physician in Phoenix. "From a practical perspective, who wants that business?"

AMA policy says all physicians and health care facilities have an ethical obligation and moral responsibility to provide needed emergency services to all patients, regardless of their ability to pay.

Despite problems that doctors face with on-call issues, some simply overlook the difficulties and don't hesitate to answer an emergency call.

"There are still a lot of heroes out there who will take care of a patient when you really need them to," said Loren Johnson, MD, chief medical officer for Sutter Emergency Medical Associates in Davis, Calif., and past president of ACEP's California chapter.

Emergency departments in crisis

An article in the May 2001 Annals of Emergency Medicine said emergency departments were not receiving the specialty assistance they needed, and the matter was getting worse.

Anecdotal evidence suggested a nationwide problem that involved all specialties, with primary care physicians having excessive workloads and some surgical specialists complaining their work force was insufficient to provide continuous coverage.

The most common grievance cited by on-call doctors: lack of payment, according to the article.

Other factors that played a role included an aging work force, changing physician lifestyles and excessive professional demands.

"It's horrible. I live in a well-to-do community and I can't get coverage now. That's increasingly the case all over California," said Dr. Johnson, co-author of the 2001 article.

Nationwide, the ACEP survey paints a grim picture.

One in three survey respondents said their emergency physicians spent more time calling specialists since regulatory changes to EMTALA in November 2003 eased obligations of specialists to take calls from emergency departments.

"The decrease in the number of medical specialists willing to be on-call in the nation's emergency departments is a looming national health care crisis," ACEP president J. Brian Hancock, MD, said in a statement.

Hospitals are providing some incentives to specialists to take call, said the ACEP study, released in September. About 8% of hospitals paid stipends, while 14% provided some medical liability coverage for on-call commitments.

The study said 15% of hospitals were guaranteeing certain levels of payment for services.

"In some hospitals, that has been enough to bring specialists back on board," said Dr. Vanlandingham, the study's principal investigator and a Robert Wood Johnson Clinical Scholar at Johns Hopkins University.