Get Me a Neurosurgeon, Stat

When I first returned to the States I didn't see what the big deal was with regard to taking emergency call. Although as a retina specialist, I thought that we should be on a separate call schedule as general ophthalmologists, since we are in essence always on call as many retina patients are emergencies. In fact, I think that we should append the moniker to "emergency" to the practice name, given how many urgent or emergent patients get added on to our schedule on a daily basis.

But this article makes some valid points that resonate with my concerns about taking call as an ophthalmologist: namely the local monopolistic hospital has decided that only some specialities deserve to be paid for taking emergency call, and ophthalmology is not among them. Second, in this litiginous society, taking call is a huge risk for any doctor...

Modern maladies. So where have all the specialists gone? They've been driven away, observers say, by three modern maladies of American healthcare: too much work, too little pay, and the fear of malpractice lawsuits. "Put all those things together, and who would want to be in this business?" asks Todd Taylor, who teaches emergency medicine at Vanderbilt University in Tennessee.

And it doesn't pay. The federal Emergency Medical Treatment and Active Labor Act, enacted in 1986 to prevent discrimination against the poor, requires that emergency departments screen all patients and ensure they are not in an immediate medical crisis, regardless of their ability to pay. That means hospitals need to maintain a roster of on-call specialists. But the law has also pushed hospitals to pressure doctors to provide on-call services for nothing in return for hospital affiliation. Doctors used to agree to this deal because they needed hospitals as places to perform surgery, and the workload wasn't too heavy. But as the workload spiraled up, surgeons spent more time answering ER calls and less time dealing with their own practices and paying patients. If they were affiliated with more than one hospital, as many doctors are, both hospitals made demands.

Recently, "office-based surgery and free-standing surgical clinics have given orthopedists and plastic surgeons and others a way out," says Rick Cameron, project manager of the Emergency Department Management Group in Palm Beach County, Fla., a partnership of county hospitals trying to solve the specialist shortage that has dogged that region. "Many don't need to be affiliated with hospitals to do their jobs."

Finally, there's fear of being sued. On-call surgeons worry there's more chance of getting sued by a stranger whom they rush to treat in an ER than by an established patient having elective surgery. "Anything can happen in an ER," says Jose Arrascue, a kidney specialist in Boynton Beach, Fla."If you have no rapport with the family, they may conclude you did something wrong, and you are wide open for a suit. That really concerns me." There have been calls for legislation exempting doctors on ER duty from lawsuits, but the idea of immunity from malpractice hasn't appealed to federal or state lawmakers.

To minimize risk, many doctors stop taking ER calls. Or, Valadka says, surgeons may limit the types of operations they do in regular practice, which means they won't be called in for emergencies that are beyond those limits. For example, some neurosurgeons—ironically—have stopped doing brain surgery and focus only on the spine.