Few physicians doubt that patients in need of neurosurgical care are best treated by neurosurgeons. Similarly, few physicians doubt that children — particularly young children — in need of neurosurgical care are best treated by pediatric neurosurgeons. However, stresses in the emergency care system and on the neurosurgical profession have created a particular threat for children who need emergency neurosurgical care.
To alleviate this situation in the short term and to resolve it in the long term will require the participation of all neurosurgeons in local or regional emergency planning as well as organized neurosurgery’s advocacy at the national level. To facilitate both processes with the goal of swift and appropriate delivery of neurosurgical care to children, a description of the current situation and short- and long-term solutions are presented.
What We Know
Neurosurgical emergency care has been explored recently in the Bulletin’s
pages in “Baseline ER Survey Explores System’s Cracks,” one
of a collection of articles on the topic in the Winter 2004 Bulletin,
and in “Completing the Picture,” a report on the AANS 2006 Workforce
survey. More information was added to the mix with the June 2006 release of
three Institute of Medicine reports evaluating the emergency medical system
in the United States. The report Emergency Care for Children: Growing Pains,
summarized in this issue, focuses on how children are faring in the nation’s
emergency care system. In short, there is great capacity for improvement, and
the same might be said with respect to the delivery of neurosurgical emergency
care to children.
The IOM report notes that 27 percent of all emergency room visits are for children, with more than 30 million children seen in emergency rooms each year. However, the report asserts that the needs of children were largely overlooked in the design of the emergency care system. It documents that only 6 percent of emergency rooms are fully equipped to handle the spectrum of pediatric emergencies and only half of hospitals that lack pediatric emergency care capabilities have formal transfer agreements. Further, it finds that few healthcare providers in the emergency system have formal training in pediatric emergency care, and that neurosurgeons are among the specialists in limited supply.
The AANS 2006 Workforce survey found that while 94 percent of neurosurgeons are taking ER call, 76 percent feel that emergency call is a problem in their areas. A most disturbing finding is that of the 94 percent of respondents taking call, only 22 percent are covering pediatric neurosurgical emergencies; this translates to about 530 survey participants. Extrapolating the percentages to the approximately 3,200 neurosurgeons certified by the American Board of Neurological Surgery—the certification for which includes the care of pediatric patients—about 662 neurosurgeons are providing neurosurgical emergency care for the nation’s children.
Given the lack of ERs adequately supplied and staffed for pediatric emergency care, it is little wonder that when faced with a pediatric neurosurgical emergency, ER staff is quick to call for transport to the nearest children’s hospital.
Children’s hospitals represent about 5 percent of the 4,908 hospitals in the United States, according to the National Association of Children’s Hospitals and Related Institutions. They include 50 to 55 freestanding general acute care children’s hospitals (20 percent); 110 to 125 non-freestanding general acute care children’s hospitals, also known as children’s hospitals within larger hospitals (44 percent); and 90 to 100 orthopedic and other specialty children’s hospitals (36 percent). The distribution in the United States of 212 NACHRI member hospitals is shown in Figure 1.
Click here for larger image (PDF 71KB)
Also shown in Figure 1 is the state-by-state distribution of 85 pediatric level 1 or level 2 trauma centers verified by the American College of Surgeons Committee on Trauma. Similarly depicted are 174 pediatric neurosurgeons certified by the American Board of Pediatric Neurological Surgery. Of the 174 pediatric neurosurgeons listed, 13 are retired and a larger number are nearing retirement. ABPNS certification for a 10-year period requires: completion of a postgraduate fellowship in pediatric neurological surgery accredited by the Accreditation Council for Pediatric Neurosurgical Fellowships Inc.; certification by the American Board of Neurological Surgery or the Royal College of Physicians and Surgeons of Canada; submission of surgical logs confirming that 75 percent of operative cases for the year preceding application were in patients age 21 and under, or that 125 operative cases were in patients age 12 and under; and a passing score on the ABPNS written examination.
With the availability of so few facilities that are tailored to emergency pediatric care, and very few pediatric neurosurgeons available across the country to care for children with neurosurgical emergencies, the trend has been toward regionalized care.
Pediatric Neurosurgery: A Model for Regionalized Care?
The IOM and others have touted regionalization as the primary
remedy for the emergency healthcare system as a whole and for pediatric emergency
care in particular. Indeed, pediatric neurosurgery is becoming a model for
regionalized care.
However, a reliably functioning system of pediatric emergency care has not yet been achieved. As the IOM report points out, the emergency care system is highly fragmented, and while some areas of the country have developed admirable systems, “a state-by-state analysis shows that many states still have not formally regionalized pediatric intensive or trauma care.”
Further, the IOM cites a 2004 study by Gauche-Hill and colleagues that puts the number of children’s ER visits to a children’s hospital at only about 7 percent. Therefore, the vast majority of children are seen at community ERs, a setting where, according to the 2006 AANS Workforce Survey, 59 percent of neurosurgeons provide care.
Everyone can agree that it is daunting to see children suffer death or permanent injury, but this is particularly true when children must bypass facilities where board-certified neurosurgeons are on call but cannot care for a child because their practices are limited to adults.
Two true-life cases illustrate this problem. TS, a 14-year old male, accidentally ran into the schoolyard wall while playing at recess. He was briefly unconscious. School personnel called an ambulance, but en route to the local hospital he began vomiting and became disoriented. An emergent CT scan showed a linear skull fracture and associated acute epidural hematoma. Even though a neurosurgeon was on call for that emergency room, he no longer cared for children and thus was not called. By the time emergency transfer to the nearest children’s hospital could occur, the child had herniated and, despite emergency craniotomy, he lives with severe, permanent neurological sequelae.
BG, who had been born prematurely and shunted for hydrocephalus, had mild cerebral palsy but had only required one shunt revision as an infant. At age nine, she presented to her local ER with headaches of one week duration. She had vomited repeatedly in the preceding 24 hours and had become very lethargic. In the ER her pulse was in the 50s and her blood pressure was elevated. An emergent CT scan was consistent with a shunt malfunction, and her shunt series showed that her abdominal catheter was no longer in the peritoneum. There was a neurosurgeon on call for the hospital but he no longer treated children and advised the ER physicians that she should be transferred to the regional children’s hospital. A helicopter transport was arranged, but in flight BG suffered a respiratory arrest. By the time she arrived at the children’s hospital, she was beyond salvage.
Certainly, in the absence of pediatric anesthesia and pediatric critical care at a hospital, it is not feasible for a neurosurgeon to do more than place an intracranial pressure monitor or tap a shunt before transporting the child to the nearest pediatric trauma center. However, in an emergency older children often can be treated in a community setting, and in any case, a local neurosurgeon is needed to ensure a child is stable for transport.
Barriers to Providing Pediatric Emergency Care Locally
There are a number of factors that influence the local neurosurgeon’s
ability to care for critically ill children in a nonpediatric setting, some
of which have been discussed. Two main areas that deserve individual attention
are those of medical liability pressures and a “poor” payer mix.
Medical Liability Pressures Medical liability plays a role in some neurosurgeons’ reluctance to treat children, but their reluctance may be based on perception rather than reality. Treating a pediatric patient in a general hospital emergency room, in the absence of pediatric emergency physicians and the ancillary support necessary to care for children, may expose a neurosurgeon to undue risk. And it is true that there is longer exposure to the possibility of lawsuits when treating pediatric patients. In most states, the statute of limitations for medical malpractice is one-to-two years beyond the “age of discovery.” For neurosurgeons caring for adults the exposure risk is one-to-two years, but for those caring for children it is one-to-two years beyond the age of legal adulthood. A neurosurgeon’s liability exposure after caring for an infant therefore can be as long as 20 years.
But despite the longer liability exposure, pediatric neurosurgeons are not sued more frequently than other neurosurgeons. According to Data Sharing System information for 2005 from the Physician Insurers Association of America, in 2005 alone and cumulatively between 1985 and 2005, neurosurgeons were most frequently sued for procedures involving the spine.
While liability insurance rates have been a great concern recently for all neurosurgeons, rates for pediatric neurosurgeons are the same as those of other neurosurgeons. Further, there is little evidence that liability insurers reduce premiums for those not treating children. With regard to premium reductions for neurosurgeons not taking any type of emergency call, only 2 percent of AANS 2006 Workforce Survey respondents said they received such a break.
“Poor” Payer Mix For treatment of privately insured children, the rates of reimbursement are the same as for adults. However, the care for a large percentage of children presenting at the ER is either unfunded or underfunded. This in part reflects the large number of uninsured people in the United States— 44.8 million or 15.3 percent of the population in 2005, according to the U.S. Census Bureau—many of whom must use the ER as their local clinic.
It may also reflect the fact that for children with chronic disabilities such as spina bifida, seizures, hydrocephalus and cerebral palsy, the insurance often runs out or won’t cover them, leaving them to state spin down programs for coverage.
Bolstering the Pediatric Workforce
Not only have medical liability and payer mix issues influenced
children’s accessibility to receive care at their local hospitals, these
factors impact pediatric neurosurgeons daily. Most pediatric neurosurgeons
find themselves either having to perform some general adult neurosurgery or
having their salaries supplemented by their hospitals or their employer in
order to achieve a standard of living commensurate with the rest of the neurosurgical
community. A commitment to pediatric neurosurgery translates to more nighttime
emergencies, more time away from family, longer liability exposure, and all
for less remuneration than other areas of neurosurgery.
Whereas a decade ago the majority of pediatric neurosurgical cases were done by community neurosurgeons, today pediatric neurosurgeons across the country are reporting that their clinical practice volume is steadily increasing. According to Rick Abbott, MD, chair of the AANS/CNS Section on Pediatric Neurological Surgery, there are currently 44 jobs available in the United States for pediatric neurosurgeons. But too few people are pursuing careers in pediatric neurosurgery to keep up with the growing demands. To support a fully functional emergency medical system one day, neurosurgery as a specialty needs to encourage people now to enter the field of pediatric neurosurgery.
Pediatric neurosurgery entered an encouraging period of development in 1978 when the American Society of Pediatric Neurosurgery was founded by 16 neurosurgeons, according to Leland Albright in his 2004 Matson Lecture. These people “established standards for pediatric neurosurgeons” and “were committed to advancing the development of pediatric neurosurgery through laboratory and clinical research” with “impressive foresight as to how we should advance our field.”
The American Society of Pediatric Neurosurgeons currently has 150 active members who are fellowship trained in pediatric neurosurgery and committed to providing neurosurgical care for children. As of March 2007 the American Board of Pediatric Neurological Surgery has 174 neurosurgeons certified as diplomates in the United States. The number of ABPNS diplomates certified each year since 1996 is shown in Figure 2. In 1996 and 1997 the original members of the American Society of Pediatric Neurosurgeons were grandfathered into membership. Since that time, the number of pediatric neurosurgical fellows entering the job market has remained between six and 10 per year. One or two of those individuals per year ultimately will become frustrated with the demands of a pediatric neurosurgical practice and will enter a general neurosurgical practice. At the present pace, the number of senior pediatric neurosurgeons who are retiring is about the same as the number entering the workforce.
To stimulate the interest of trainees in a pediatric neurosurgery career certainly will require adequate exposure to the field during training. Disturbingly, a recent survey of resident participants in a pediatric neurosurgery review course found that the majority of attendees had only three to six months of pediatric neurosurgery experience during their clinical neurosurgery training. While such training may be adequate to care for a 15-year-old “child” with a sports injury, it is hardly adequate for most neurosurgeons. It also may contribute to a lack of comfort with the pediatric population which may decrease the likelihood that these neurosurgeons will make themselves available to treat children, even on an emergency basis.
Stimulating the interest of trainees in pediatric neurosurgery no doubt will also require reimbursement levels comparable to those of other neurosurgical subspecialty areas.
In the typical pediatric neurosurgical practice, 30 percent to 60 percent of the payer mix is Medicaid and another 10 percent to 15 percent is self pay. Because a number of state Medicaid programs are unable to overcome budgetary shortfalls, reimbursement is either untimely or nonexistent.
Oftentimes children’s hospitals are able to help their pediatric neurosurgeons negotiate reasonable Medicaid and third party contracts through global pricing or carve-outs for subspecialty services. A growing number of children’s hospitals are subsidizing their surgical subspecialty divisions either through emergency call pay arrangements or through medical directorships.
Also, a certificate of added qualification in pediatric neurosurgery may allow pediatric neurosurgeons to better negotiate reasonable rates of reimbursement with both third party payers and with their employers.
Demand Is High Because demand for pediatric neurosurgeons now is outstripping the supply, reimbursement may be less of a barrier in the future for those who want to pursue careers in pediatric neurosurgery. Some academic and larger multispecialty groups have recognized that they may have to pay extra for a pediatric neurosurgeon to join them and assume that component of their practices. This allows other members of the practice to subspecialize in complex spine, adult tumor or cerebrovascular areas.
Many academic institutions find themselves “growing their own”; that is, encouraging one of their graduating residents to pursue pediatric fellowship training with the promise of a faculty position when they complete their fellowship. Some academic departments are even supplementing fellowship training by making the fellow a “clinical instructor” and starting faculty salary early with the stipulation that the graduate will join the department’s faculty upon completion of the fellowship.
Other groups find themselves offering inordinate starting salaries in order to even get a pediatric neurosurgeon to interview.
The few graduates entering pediatric fellowship training generally have a job in hand before they even start their fellowship training. In many instances, hospitals are now offering to pay off student loans as a signing bonus in return for a minimum commitment of two-to-three years.
Keep Pediatric Patients in Mind
Pediatric neurosurgery is an intellectually stimulating and
wonderfully rewarding career for those who like working with children (whose
only goal is to get back to playing again), have a love for developmental anatomy,
and enjoy performing spine, brain, tumor, and peripheral nerve procedures all
in one practice.
The trend toward regionalization is positive in many respects, but as yet the emergency care system, particularly for pediatric patients in some areas, is flawed. Although children’s hospitals are eager to develop their neuroscience programs, the limited availability of pediatric neurosurgeons is starting to reach crisis proportions.
Neurosurgery as a specialty has a responsibility to ensure that a neurosurgeon is available to children when there is a need. All neurosurgeons can:
- perform basic triage, tap shunts and perform craniotomies to stabilize children before transfer.
- participate in local planning for appropriate transfers of children when their facility lacks the capability to care for them; and
- participate in pediatric refresher courses to gain comfort with handling the complexities of neurosurgical care in infants and younger children.
Most importantly, neurosurgeons must keep pediatric patients in mind in all aspects of neurosurgical care.
Frederick A. Boop, MD, is associate professor in the Department of Neurological Surgery, University of Tennessee,Memphis College of Medicine and a member of Semmes-Murphey Clinic. Manda J. Seaver is staff editor of the AANS Bulletin.
Acknowledgements
The author gratefully acknowledges the contributions of Rick Abbott, MD, and
Monica C. Wehby, MD.
For More Information
- Albright AL : The past, present, and future of pediatric neurosurgery.
J Neurosurg 101 (2 Suppl Pediatrics):125–129, 2004
- American Board of Neurological Surgery, www.abns.org
- American Board of Pediatric Neurological Surgery, www.abpns.org
- American College of Emergency Physicians. National Report Card on
the State of Emergency Medicine. January 2006, https://my.acep.org/site/DocServer/2006-NationalReportCard.pdf?docID=221
- American Society of Pediatric Neurosurgeons, www.aspn.org
- Emergency Care for Children: Growing Pains, www.iom.edu
- National Association of Children’s Hospitals and Related Institutions
(NACHRI),
www.childrenshospitals.net
- hysician Insurers Association of America, www.piaa.com
- Seaver MJ: Baseline ER survey explores system’s cracks: 2004
AANS/CNS neurosurgical emergency and trauma services survey. AANS Bulletin 13(4):
19–24, 2004. Article
ID 26367
- Seaver MJ: Completing the Picture: AANS 2006 workforce survey assesses neurosurgical ER coverage. AANS Bulletin 15(2):8–12, 2006. Article ID 40546