- The Washington Times - Tuesday, September 18, 2007

On top of his 10- to 12-hour workday, Dr. Phillip Proctor rotates being on call to cover his surgical specialty in the emergency room at Providence Hospital in Northeast.

“I might have to cancel patient hours if I have to go into surgery, depending on when the surgery takes place,” says Dr. Proctor, a urologist in private practice in the physicians building at Providence and chairman of the hospital’s Operating Room Committee. “It does impact your daily business.”

This impact comes, in part, from a shortage of surgeons faced by hospitals and emergency facilities nationwide. To address this shortage, hospitals such as Providence are paying physicians who serve on the on-call panel, says Dr. William Strudwick, emergency room medical director at Providence Hospital.

Fifteen years ago, physicians who took call duty could expect to build their practice from patients they served in the emergency department and to get paid for their services, Dr. Strudwick says.

“The chance they would get the type of customers to help them build a practice has become less and less,” he says. “The underinsured and the uninsured, who do not have access to primary care, are sicker when they get to the emergency department. They are harder to take care of, and it’s more of a liability to care for them.”

The American College of Surgeons (ACS), a scientific and educational organization of surgeons that is based in Chicago, is concerned about the shortage of surgeons, particularly in emergency surgical care.

“There’s no question that we clearly see a shortage of on-call specialists that we need to provide the best possible care for our patients,” says Dr. Brian Keaton, president of the American College of Emergency Physicians, a national association for emergency physicians that is based in Irving, Texas. He is an attending physician at the Department of Emergency Medicine at Summa Health System in Akron, Ohio.

Surgeons who take call — such as trauma or general surgeons and the subspecialists of neurosurgeons, orthopedic surgeons, otolaryngologists, oral surgeons and plastic surgeons — agree to be available on an emergency call schedule and to come in when their services are needed by trauma patients. Trauma centers that do not use on-call surgeons have a 24/7 staff, as do hospitals that use surgical hospitalists (doctors who provide inpatient care) to handle trauma surgical care.

“Sometimes surgeons have to make the decision to not take call simply because they can’t afford it,” Dr. Proctor says.

Taking call presents conflicts for surgeons who hold office hours and work a full schedule to care for patients who contract with them for their services, says Dr. Gerald Bechamps, Virginia governor for the ACS and general surgeon at the Winchester Medical Center in Winchester.

“Physicians who are up all night who are providing emergency services then face the difficulty of giving quality care to their patients the following day,” Dr. Bechamps says, adding that fatigue, patient safety and providing the best care for their patients are of particular concern.

As such, covering the call panel in the surgical specialties is a problem, Dr. Strudwick says.

“At Providence Hospital, we’ve been fortunate that we have been able to get most of the subspecialty coverage. If we can’t, there are subspecialties at other facilities,” he says.

One of the subspecialties, thoracic surgery, is expected to see a shortage in the next five years when a quarter of the work force (now age 70 and older) retires. There are few medical students filling the training slots, says Dr. M. Blair Marshall, thoracic surgeon and chief of thoracic surgery at Georgetown University Hospital in Northwest. There are 140 training slots each year, but the number of applicants has dropped to the point where one-third of the positions are filled, she says.

“The complexity of what we do has increased and requires more training,” Dr. Marshall says. “We used to hire the best of the best. Now there is no competition for the positions.”

The decline in on-call specialists is a result of several factors, including a decrease in reimbursement rates from insurance companies and Medicare and an increase in the number of uninsured patients requiring emergency surgical care, Dr. Keaton says.

There are 46 million uninsured in the United States and another 30 to 40 million people who do not have adequate insurance, Dr. Keaton says. Hospitals and other facilities that provide medical services used to charge more for patients who could pay to cover those who could not through cost shifting, he says. However, in the past one to two decades, the government and insurance companies began paying only the cost of services, he says.

“We have ratcheted down and tightened up the payment system to the point that all physicians are working in a way that they have more and more demands on their time and less reimbursements from patients and less capacity to do charity care,” Dr. Keaton says.

Statistics show that patients who are unable to pay for emergency services are more likely to sue, compounding the problem for surgeons, Dr. Keaton says.

“Lots of suits are based on expectations and outcomes,” he says, adding that the circumstances of an emergency may be uncontrollable and generate outcomes that are not ideal for the patient or family. “When people don’t get what they expect or want, they tend to translate that into a lawsuit,” he says.

Another cause of the surgeon shortage is seen at the medical school level.

The number of medical doctors trained through medical schools has remained fairly static for the past 25 years, but the patient population is growing, Dr. Bechamps says. Contributing to the static number is decreased funding for medical education and the opening of only one medical school during that time period, he says.

If the trend continues, fewer new physicians will be available to fill the slots left open by the third of the surgical work force expected to retire in the next 12 to 15 years, Dr. Keaton says.

“The surgeons in training see that it’s not the greatest lifestyle and not the best paying job in the surgical field,” he says.

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