The American College of Emergency Physicians surveyed 4,444 U.S. emergency department directors between April and August 2004. Thirty-two percent responded, with 66 percent reporting inadequate on-call specialist coverage. Of those who reported specialty shortages, the largest group, 27 percent, thought the greatest harm resulting from lack of specialty coverage was “risk or harm to patients who need specialty care,” followed by 21 percent whose response was delay in care, and 18 percent whose response was growing frequency of transfers. This survey, undertaken some eight months after revisions to the Emergency Medical Treatment and Labor Act became effective, asserted that the easing of EMTALA requirements has worsened, rather than improved, specialty on-call coverage.
Last fall 3,213 neurosurgeons practicing in the United States were asked to respond to the 2004 AANS/CNS Neurosurgical Emergency and Trauma Services Survey. The survey sought answers to questions about which neurosurgeons limit emergency call and why, how much call coverage is being provided, what problems are encountered with hospitals, what alternative coverage arrangements are established with hospitals, what stipends are received for coverage, and the like. Thirty-two percent responded; survey results are reported in this issue.
The two surveys illustrate, in principle, the opposite sides of the emergency call coverage debate. On the one hand, hospitals have a charitable tradition of providing emergency care to the communities they serve. This tradition is one of generally providing, without discrimination between rich or poor at the time of urgent need, the safety net to anyone. This tradition was transformed into a federal mandate in 1986 by EMTALA, which established by law the responsibility of hospitals to treat trauma, and to prevent worsening of injury by withholding urgently needed and available resources, based on a patient’s ability to pay. EMTALA defined an unfunded national social policy of a citizen’s right to emergency care.
On the other hand, it is physicians who provide the emergency care. Specialists, such as neurosurgeons, who bear much of EMTALA’s load by virtue of their affiliation with a hospital, see the other side of the policy: practice disruption, uncompensated work, heightened malpractice risk in a storm-tossed liability climate, unrelenting call assignment, irreplaceable loss of private or off-duty time, recurring sleep deprivation, thankless personal sacrifice, and substantial civil liability if sanctioned for EMTALA violation.
Today, the medical community and neurosurgeons nationwide are deeply concerned about patients who must be transferred in order to receive neurosurgical emergency care. Judging by numbers alone, there are not enough neurosurgeons to provide emergency coverage for all the nation’s emergency rooms. Some of those who are available are insisting on more bearable call schedules, relinquishing cranial surgical privileges, resigning from hospital staffs, instituting ER diversion policies, and demanding stipends in compensation for covering emergency call, all in an effort to find refuge from liability risk and decreasing reimbursement for professional services, among other concerns.
This emergency call conflict has contributed to what only can be termed a profound cultural shift in neurosurgeons’ perception and conduct with respect to professional responsibility. While neurosurgeons once accepted unlimited demands on time and attendant unending personal sacrifice, now many demand time protection. They once accepted disruption of their practices, unquestioned hospital call duty, unacknowledged charitable contribution of time and expertise, and unshielded medical liability in a high-risk setting. They now expect reasonable scheduling stability, reasonable duty limits, compensatory remuneration, and protection from unwarranted lawsuit exposure.
This cultural change marks a break in the tradition of a neurosurgeon’s unquestioning acceptance of a community service obligation that is counterbalanced by the opportunity to use the community’s hospital and medical support system resources for neurosurgical practice. It is a break also from a more strictly defined traditional medical staff obligation to provide emergency room services in exchange for medical staff privileges. In both respects, the professionalism which once dictated public and personal duty has been replaced by the more formal dictates of public law (EMTALA) and private contracts between neurosurgeons and hospitals.
This issue of the Bulletin examines the socioeconomic and legal issues affecting neurosurgical emergency care. We, a profession in transition, are searching for a new equilibrium and a means for ensuring that the neurosurgical emergency safety net is dependably in place.
James R. Bean, MD, is editor of the Bulletin and the AANS treasurer. He is in private practice in Lexington, Ky.