When You Go to an ER and There’s No One There to Take Care of You

Recently, I’ve been reading less-well known health care blogs—and finding some provocative stories.

Below, Edwin Leap–who is a physician and a blogger–tells a story about trying to find a specialist for a very sick child in the middle of the night.

Let me preface Dr. Leap’s story by explaining that, in the past, specialists who had “privileges” at a hospital (to treat patients there and to use the hospital’s very expensive equipment and operating rooms) were routinely “on call” to treat emergency patients. But these days, more and more entrepreneurial doctors are refusing to fulfill what was once seen as a traditional duty—unless they are paid.

In Money-Driven Medicine, I quote the chief operating officer of a rural community hospital who recalls a conversation with a young doctor who walked into his office and informed him that he would no longer be willing to be on call for the ER. When the doctor had signed on with the hospital, he, like all of the other physicians, had agreed to be available to treat ER patients one week a month. Typically that might mean coming into the ER two or three times during that week. But now, he explained, he wanted to spend more time at home with his children. He was not willing to continue answering the calls unless the hospital would pay him $80,000 a year.

The COO was nonplussed. He knew that an additional $80,000 would work out to $2,200-$3,300 each time the physician came in ( He did not ask how the doctor had calculated that quality time with his children was worth $80,000).

“But we have a contract,” he protested.

The doctor nodded: “Times change,” he said easily.

The COO knew that he had a legal and moral responsibility to cover his ER. He also knew that if he paid this physician, he would have to pay all of the other physicians.

But he didn’t even try to negotiate. Because he also knew that if he refused to pay the amount asked, he risked alienating not only this doctor, but all of the others who practiced at his hospital. In response, they might well begin referring some of their most profitable business to a hospital in a city just an hour and a half away. He had no choice but to agree.

This is not an uncommon situation; covering ERs has become a problem nationwide. A report by the California Senate Office of Research offers an example of what can happen, citing the case of a man suffering from internal bleeding who came into the ER of an unidentified California hospital. Over the next three hours, six gastrointestinal specialists refused to come to the hospital to treat the patient. Finally, the director of the emergency room lured a specialist to the hospital with the promise of $500 cash. The specialist then performed the needed procedure, and the bleeding was stopped.

Below, Dr. Leap’s post. I will be very interested in your comments.

You won’t help a critically ill child? Is this how low we’ve fallen?
Dr. Edwin Leap, April 4th, 2008

One of my partners recently took care of a child with a retro-pharyngeal abscess.  For the non-medical, this is a serious infection behind the throat that can easily result in loss of an airway.  The child, some 20 months of age, was obviously very ill.

We frequently don’t have an Ear Nose and Throat physician on call at our hospital, and the night that child presented was typical.  So, the only viable option was to transfer the child.  However, when my partner tried to find an ENT surgeon to care for this child in a nearby town, he was met with this response:  ‘I’m not on call for your hospital.’

Now, I understand not wanting to have ridiculous referrals.  I understand not wanting to increase your already busy workload.  I understand that being a surgeon is very time intensive already, so the doc in question probably didn’t need more work.  But the thing is, it wasn’t a drunk with a broken jaw, an elective tonsillectomy, or even a fish-bone stuck in the throat.  It was a child who might have died.

Well, I guess Hippocrates didn’t cover that scenario.  You know, sick child from another town.  After hours, and all that.

Is this how far we’ve fallen?  See, we don’t have endless options for transfer.  We practice in a semi-rural area.  It isn’t Manhattan. There aren’t surgeons on every corner.  Trust me, if we could have handled it, we would.

Is this what doctors have become?  Technicians who feel no sense of urgency or obligation to the sick, in fact, to the most vulnerable of the sick?  Is this how we want our children, or grandchildren, treated?  Dismissively?  With a ‘good luck’ and a hearty pat on the back?  With a ’sorry, but you know how business is these days?’  I hope to heaven not.

That sort of behavior makes me feel angry, and a little sick.  It makes me see how malpractice litigation could get out of hand, or how national health care might slip in the back door.  If we’re so unprofessional that we can ignore a critically ill child on a technicality, then maybe we’ll deserve whatever happens.

Fortunately, the overwhelming majority of docs I know would never behave that way.  Like the intensive care docs who ultimately accepted the child, they do the right thing at the right time, the way we were taught.

We need to call this behavior what it is; childish and unprofessional. And we need to remind ourselves, every day, of why we do our jobs.  And that we have a duty to the sick and injured, convenient or not.

Maggie Mahar is an award winning journalist and author. A frequent contributor to THCB, her work has appeared in the New York Times, Barron’s and Institutional Investor. She is the author of  “Money-Driven Medicine: The Real Reason Why Healthcare Costs So Much,” an examination of the economic forces driving the health care system. A fellow at the Century Foundation, Maggie is also the author the increasingly influential HealthBeat blog, one of our favorite health care reads, where this piece first appeared.

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4 replies »

  1. The problem, as I see it in the above child-throat infection, is that the hospital did not have proper ENT coverage arrangements. It is irresponsable for the hospital to have an emergency room, and not have coverage of all specialities … or at least a contractual agreement with nearby hospitals/doctors for cross-coverage.
    If I am an ENT specialist, does that mean I am responsable for all the emergency ENT problems in the state? That’s a lot of liability for one doctor. Is the doctor responsible for all the nearby hospitals (possibly hours away) who see emergency patients, but didn’t bother to set up specialty coverage for emergencies … instead, looking to other responsible hospitals to pick up their slack?
    You can say that the doctor was “heartless,” and perhaps he was, but I think the true blame is on the original hospital, for not having formal specialty coverage agreements.

  2. This problem has been developing for at least 5-10 years; it’s nothing new, just accelerating. I believe it will eventually backfire on the physicians because hospitals will be forced to go to a staff model similar to Kaiser in order to get coverage – and cut out the uncooperative docs who wouldn’t take their ER call. (This will become more possible as reimbursements drop and drive more docs into the arms of salary-providing hospitals). Right now many hospitals in major metro areas are coping with huge medical staffs who cause a lot of regulatory paperwork (think of maintaining databases, re-credentialing, providing clerical support for departmental activities, monitoring performance quality through peer review, etc.) but who do not support the hospital by taking call, serving on committees, providing leadership, etc. I think marrying doctors and hospitals is really the only realistic solution to many of our health care delivery problems anyway, so maybe that’s the silver lining in the cloud.

  3. An international medical device company exec (an MD) recently gave a presentation in a World Health course that I’m taking, and one of the points he emphasized was that Americans increasingly have a very ‘transactional’ perspective in their relations with doctors; much more so than any other country, and he works in all the major medical markets. The old-fashioned image of a professional, ideal-driven doctor treating a respectful, obedient patient is evolving into something resembling your everyday supplier/consumer relationship. This is surely in line with the ‘consumer driven health care’ that is a huge talking point lately.
    What caused what? Did an increasing entrepreneurial medical community erode the patient’s respect for doctors… or is the growing capitalist character among physicians a response to their lost status in the minds of their patients? Who knows? Maybe its a little bit of both. I’ve encountered doctors that fall into both categories, but it doesn’t surprise me at all that people don’t equate becoming a cardiologist earning $300K+a year to joining the Peace Corps; Primary care doctors aside.
    Unfortunately, all the nostalgia in the world won’t erase the fact that doctors increasingly worship the ‘incentives’ god just like every other profession in America. I’m not old enough to remember the good ol’ days, and I know that there are a lot of well-intentioned doctors out there, but I do know that I am much more cynical of my physician’s incentives than my mother or grandmother would be, and not entirely without reason.

  4. NEXT-GEN ER Call
    Of course, it’s getting more expensive these days to take hospital ER call as physicians are electing not to take this responsibility because of decreased reimbursement rates, etc. Other doctors opt-out because of a desire to spend more time with family, and/or scheduling conflicts. And, let’s not forget the liability concerns.
    But, back in the old days, I recall eagerly signing up for ER call to make a few extra bucks [it was a very competitive proposition back then] as I started my fledgling practice. About a decade later, I didn’t make much on-call money any more, but continued my rotation and chalked it all up to societal “pro-bono care”. And, the increased medical service visibility still garnered me a few lucrative patient referrals. Then, it became a greater financial burden, opportunity-cost and time loss; and ultimately a greater liability headache. Fortunately, I could finally afford not to do it any more; and quit. Let the younger guys and gals “pay their dues”, I reasoned.
    Now today, there is a growing revolt of specialists against hospital on-call duties that threatens to violate Federal law and lose status as trauma centers. Specialties most likely to refuse include plastic surgery, ENT, psychiatry, neuro-surgery, ophthalmology, orthopedics and other surgeon types or proceduralists.
    But, refusing to respond to assigned ER call may be a violation of Federal law and carries fines as much as $50,000 per case.
    In contrast, refusing to sign up for call does not violate the law, and more physicians are taking this option.
    The problem is especially acute in California where hospitals are combating the issues with compensation, reporting the miscreant docs to the authorities, or threatening to remove them from staff completely. In turn, doctors are fighting back with lawsuits.
    For more on modern medical risk management and related issues, try the handbook: “Risk Management and Insurance Planning for Physicians and Advisors.”
    Link: http://www.jbpub.com/catalog/9780763733421/
    Dr. David Edward Marcinko; MBA
    CEO – iMBA, Inc
    Atlanta, Georgia USA