On-Call Crisis Fuels Debate Among Surgical Professionals

By Sarah Pressman Lovinger

CHICAGO -- Is opting out of emergency department call an abrogation of duty or a choice that every surgeon has the right to make?

Fellows at the annual clinical congress of the American College of Surgeons vigorously debated that question, and they used several case studies as examples of the complex issues involved in making such a decision.

"There is a growing shortage of surgeons in the United States today who provide emergency care," according to Dr. Mary McGrath of the University of California, San Francisco, who moderated the forum.

Emergency department visits have increased by 26% in the past 10 years, with half of all hospital emergency departments exceeding their capacity to care for patients.

Declining reimbursement rates, increased numbers of uninsured patients requiring emergency surgical care, and the trend toward specialization have all contributed to the on-call specialist crisis, Dr. McGrath said.

Surgeons who take emergency department call are exposed to additional liability, said Dr. Edward Laws. Other health care professionals may incorrectly triage a patient before the surgeon arrives, or a hospital may lack the optimal resources, forcing surgeons to face unacceptably high liability.

"You may not be able at that particular emergency department to do a CT or an MRI," said Dr. Laws.

"We really need to make sure that places that are taking care of emergency patients have optimal resources," he added.

The current practice environment puts surgeons at odds with the financial goals of many hospitals.

Although it is certainly desirable for hospitals to establish and maintain trauma centers, which can generate a lot of income, those surgeons who take trauma call face higher malpractice premiums, according to Dr. Laws.

"If we're going to be asked to cover emergency department patients, then the hospitals need to provide liability protection to prevent the surgeon from being sued for adverse outcomes," Dr. Laws contended.

While Dr. F. Dean Griffen did not deny the existence of a liability crisis, citing a 23% increase in liability insurance premiums for general surgeons between 2000 and 2002, he stated that taking call was not one of the things that contributed to these higher rates.

He also noted that uninsured patients are no more likely than other patients are to sue doctors. In addition, Dr. Griffen pointed out that most surgeons who opt out of call do not have lower malpractice rates than those who do take call.

"What we have to do at this point in our lives is to analyze our opinions about emergency department care using data that validates our opinions," he said.

'IS IT UNREASONABLE TO GIVE BACK TO A SOCIETY THAT HAS PROVIDED EACH OF US WITH THE BEST MEDICAL TRAINING IN THE WORLD?'

In addition to liability issues, financial compensation is an important consideration, especially for general surgeons.

"I would agree that physicians, like all professionals, have an obligation to provide some amount of charitable service to the community.

"Still, it is not reasonable that surgeons and other specialists should bear the consequences of a failed public health system," Dr. Bruce Gewirtz added.

He also pointed out that uncompensated care is the most serious issue put forward in 65% of trauma centers, according to a survey taken by the National Foundation for Trauma Care.

Even though surgeons are generally well paid, salaries overall have declined.

"Our satisfaction with our job is influenced by our compensation, which is now absolutely at a lower level," he said.

"Physicians routinely exceed societal expectations for charitable services, and reasonable compensation for the stress and inconvenience of ER call is both affordable and rational," he added.

Dr. Dana Launer is well aware of the conflict presented by feeling obliged to help people who are sick and accepting the challenges imposed by taking call.

While admitting that "it is no longer financially worthwhile to drag yourself out of bed at 2 a.m.," he argued that surgeons have a moral and ethical obligation to provide care for all who need it.

"Is it unreasonable to give back to a society that has provided each of us with the best medical training in the world?" he asked.

Dr. Alex Valadka and Dr. Kim Kirkwood took opposing views of the lifestyle choices involved in taking call. Dr. Valadka argued that surgeons have the right to make choices that suit their personal needs.

Many surgeons feel burdened by the demands of their profession, he said; general surgeons have the second highest divorce rate of all medical specialties, and female surgeons not only have high divorce and suicide rates, they are also less likely to marry. By refusing to take call, surgeons can spend more time with their families and achieve a better balance, he argued.

Dr. Kirkwood agreed that it is important to enjoy family life but said that taking on extra hours is an inherent part of the practice of surgery.

Surgeons take on additional responsibility, she said, because "surgery is a profession, and as a profession, we take very carefully and very seriously our responsibility to deliver high quality care."

Furthermore, she said, surgeons have an obligation to provide care as part of their social contract and that taking call is "a way to give back" to Medicare and the federal government, which currently pay two-thirds of the cost of medical education.

"Society places its trust in us," she concluded.