‘On Call’ but Not Replying

The man had nearly cut off three fingers with a table saw and arrived at the hospital in desperate need of a surgeon to reattach them.

But the hand surgeon on call refused to come in, saying he was too tired and busy caring for nonemergency patients in his office.

By the time Scripps Memorial Hospital in Encinitas located another surgeon five hours later, it was “too late,” said Dr. Michele Grad, an emergency room physician involved in the case about a year ago. Two of the fingers had to be amputated.

The consequences were extreme, but the dilemma was not unusual. Increasingly, doctors say, physician specialists are refusing to honor expectations that they drop what they are doing to care for strangers in emergency rooms.

In California and elsewhere, specialists have launched an unofficial rebellion: They are fed up with the losses of money, autonomy and prestige that they attribute to rising numbers of uninsured patients and the pressures of cost-conscious managed care.

The head of California’s medical association, Jack Lewin, has described the refusals as a “serious problem verging on a crisis.” And a federal survey of emergency room personnel published this year found that refusals are particularly troublesome not just in California but in other states with high rates of uninsured patients or managed care members, including Nevada, Pennsylvania and Texas.

Feeling undercompensated and underappreciated, many doctors wonder why they should bother with the onerous inconvenience.

“I’m getting called at 3 o’clock in the morning, and the only people I’m getting called for are people who are not going to pay? Why would I do that?” asked Dr. Steven Ross, president of the California Orthopedic Assn., who still takes emergency calls but understands his colleagues’ frustrations. “When was the last time the community really stood up and said, ‘Thank you guys for getting up at 3 a.m. and helping us out’? “

In California, doctors say that:

* Patients are being harmed. Damages range from noncritical delays in care that involve added pain, to death.

“I’ve definitely been involved in cases where the on-call [specialist’s] refusal to come in has not only jeopardized a patient but has resulted in death,” said Dr. Graham Billingham, chief medical officer for EMSource, a Northern California firm that supplies emergency room physicians to 30 hospitals.

* Relationships between physician specialists and emergency room doctors are deteriorating. ER doctors say they feel as though they must beg specialists to show up. Though in most cases they ultimately are able to find a specialist, the effort can be time-consuming and demoralizing.

“It’s certainly not what I went to medical school for, to spend four hours on the telephone to find a specialist willing to take care of a patient,” said emergency room Dr. Paul Kivela, who works in Napa and has lectured in several states on the problem.

* Friction is also intensifying between specialists and hospitals. To free themselves from taking emergency calls, some specialists have stopped using hospital facilities, taking advantage of new technologies that allow them to perform surgeries on outpatients.

Others have campaigned to change hospital bylaws to make on-call services voluntary or garner pay for being on standby. Hospitals around the state are “undergoing what we call the battle of the bylaws,” said Dr. Loren Johnson, president of the California chapter of the American College of Emergency Physicians.

* The 15-year-old federal law to keep hospitals from dumping impoverished emergency room patients on other hospitals is being undermined.

The law requires hospitals to try to stabilize emergency room patients before they can be transferred. But because specialists are often needed to stabilize patients, hospitals that can’t summon a specialist are in a fix. Sometimes, they must transfer an unstable patient, putting the patient at grave risk.

Estimates of how often such transfers take place vary widely. Dr. Thomas Hoyt, president of the California Assn. of Neurological Surgeons, said that at his Central Valley public hospital “dumping is going on even worse now than it was” before the law went into effect. He said about one-third of the transferred ER patients he sees could have been treated at the hospital that sent them.

Emergency room doctors at Los Angeles County’s largest public hospital, County-USC Medical Center, said dumping happens often enough to be troubling but less frequently than before there was an anti-dumping statute.

Up and down the state, however, ER doctors can recall instances in which patients have been put at risk by specialists’ refusals or reluctance to come in.

At St. Rose Hospital in Hayward, where six of eight orthopedic surgeons have refused to take calls, emergency room Dr. Elliot Nipomnick said he recently could not find an orthopedic surgeon to come in and operate on a patient whose leg had been shattered in a forklift accident.

Nipomnick said a surgeon he contacted offered the “outrageous” suggestion that Nipomnick splint the man’s leg and send him home; the orthopedist would see him in his office the next day.

The injured man, whom Nipomnick had put on morphine for extreme pain, was taken by his wife to another hospital.

In other cases, emergency room doctors say, they succeed only by begging--and sometimes not even then.

At California Pacific Medical Center in San Francisco, emergency room Dr. Tom Peitz said he recently was confronted with a urological emergency at a time when all the urologists on staff were refusing to take calls.

The mother of an 11-year-old boy showed up in the emergency room, seeking help for her son, whose testicle was painfully twisted and cutting off blood flow.

Peitz knew that he had only six hours to see that the blood flow was surgically restored. Otherwise, the boy’s testicle would have to be removed.

The ER doctor had to “beg someone to come in,” and succeeded in this case only by calling in a favor from a urologist with whom he was friendly.

Peitz said the hospital has since resolved its problems with urologists by paying them to be on standby, but it still has trouble summoning other specialists.

Like other ER doctors, Peitz said he generally succeeds “when I have a big problem”--but when it’s simply a matter of pain, specialists frequently tell him that patients can wait.

For all their frustration, emergency room doctors interviewed for this article declined to name the specialists whose actions they felt harmed patients.

In the case of the man who lost two fingers, for example, emergency room physician Grad would not name the hand surgeon who refused to come in. Nor did she report him to federal authorities, even though, by agreeing to be on call and then failing to come in, he had probably violated the federal anti-dumping law and made himself liable for a fine of up to $50,000.

Grad said she was concerned about retribution. Emergency room doctors typically work on contract with hospitals; specialists tend to have more clout because they are on hospital staffs.

“You start [complaining] about [a specialist] and they’ll go to the [hospital] administration and say, ‘They’re being pains. . . . Next time their contract comes up, maybe you should consider not renewing it,’ ” Grad said.

Her attitude was typical of the emergency room doctors interviewed, although some also cited fear of litigation.

The precise scope of this rebellion by specialists is unknown, but a survey of emergency room personnel published this year by the U.S. Department of Health and Human Services provides the best measure.

Half of the doctors and nurses surveyed nationwide said their hospital emergency rooms were having difficulty filling on-call rosters with certain types of specialists. Most attributed these difficulties to shortages of specialists in their communities.

But 12% of those surveyed--concentrated in a few states--identified the reason for the difficulty as specialists’ refusals to take calls.

In California, a state medical association survey last year found that 60% of specialists at hospitals where serving on call was voluntary had either stopped or reduced this service. Forty percent said that they had cut back and 20% that they no longer participated.

Lewin, chief executive officer of the 35,000-member California Medical Assn., estimated that “two-thirds of the larger hospitals now have voluntary on-call” and said this number is on the rise.

Fundamentally, specialists say, they are withholding their services because there is no guarantee they will be paid. But doctors say there is more to their rebellion than money. It is also about a disheartening loss of status in a changing health care economy.

“They’re not bad guys,” Dr. Jeffrey Kaufman, president of the California Urological Assn. and former chief of staff at Western Medical Center-Santa Ana, said of his colleagues. “They’re in a bind. If you’ve got an office full of patients and you’re called to take care of an unfunded patient in the emergency room and he’s got a complicated problem that’s going to take a great deal of time, how motivated are you to do that?”

Helping patients who cannot pay in emergencies has long been perceived by doctors--and patients--as an ethical imperative.

“Doctors have a professional obligation to provide charity care,’ said University of Pennsylvania bioethicist Arthur Caplan.

But even Caplan said he sees the current specialists’ rebellion primarily as a business dispute. “Businessmen and women do not come out for free in the middle of the night,” he said.

He explained that specialists feel slighted by managed care companies, which they say try to avoid using them at all--except in emergencies. Another disincentive is the heightened possibility of being sued by emergency patients whom the specialists do not know.

Much of the squabbling plays out on legal terrain established by a 1986 federal law aimed at preventing hospitals from refusing to care for indigent patients in emergencies.

If a hospital has specialist services available during the day, the law says it must make the same types of care available at all hours in emergencies, on penalty of losing its ability to collect from Medicare, a key hospital revenue source. Fines of up to $50,000 are authorized but seldom levied against specialists who agree to take calls but do not show up.

But the law leaves it to hospitals to figure out how to get specialists to take calls.

At many hospitals in California, specialists have cranked up the pressure to get paid for being on standby. Some hospitals, though pressed for cash, have agreed to pay up to $1,900 per day. These fees are in addition to whatever the specialists can collect from emergency room patients and insurers.

At some hospitals in California, specialists’ refusals to care for patients are creating pressure to transfer patients from one hospital’s emergency room to another’s--the very situation the law was designed to curb.

At Mercy Merced Medical Center in the Central Valley earlier this year, emergency room Dr. William Stiers suspected that a surgeon wanted him to transfer a gunshot victim only because the surgeon did not want to operate on a patient whom he presumed did not have insurance.

“I have a general surgeon standing next to me telling me the patient should be transferred to a trauma center and I’m saying, ‘You’re a general surgeon. He has a gunshot wound to his belly and you should explore,’ ” Stiers said. “I had to call the chief of staff and he had to insist that the patient be taken to the operating room.”

One of Stiers’ emergency room colleagues, Dr. Tim Bechtel, had a similar experience when an on-call surgeon refused to come in to treat a man seriously injured in a motorized water-ski accident. The victim was in danger of bleeding to death from a ruptured spleen, Bechtel said. But Bechtel said the surgeon insisted that the man be transferred to a larger hospital 30 miles away. He was transferred.

The patient survived, Bechtel said, but he and his supervisor decided to take the rare step of reporting the surgeon to federal authorities. Even so, neither he nor his supervisor would identify the surgeon to The Times.

Sometimes, hospitals don’t even bother to call specialists, assuming they will not come in.

According to a tape-recording obtained by The Times under the California Public Records Act, nurses at California Hospital Medical Center in Los Angeles earlier this year said they didn’t bother to call a surgeon to examine an indigent 26-year-old woman who was vomiting and experiencing abdominal pains.

“We don’t call anybody,” an ER nurse later explained to a county official.

Instead, the hospital automatically arranged to transfer the woman to the larger, taxpayer-supported County-USC Medical Center, saying she needed a higher level of care than their hospital could provide.

The ER nurse offered this explanation to the county official questioning the transfer: “It basically comes down to she has no insurance and the surgeons won’t come in.”

*

Times staff writer Nicholas Riccardi contributed to this report.

(BEGIN TEXT OF INFOBOX / INFOGRAPHIC)

Why Specialists Don’t Take Calls

A survey of 338 doctors by the California Medical Assn. concludes that:

* Payment difficulties are a significant factor in specialists’ willingness to answer calls.

* Nearly eight in 10 surveyed said they have trouble obtaining payment for on-call services.

* Four in 10 said they have reduced the amount of time they serve on call because of payment problems.

* Two in 10 said they have stopped taking calls altogether because of payment problems.

* One ER patient in four needs help from a medical specialist.

Source: CMA Survey, CMA Center for Medical Policy and Economics, July 2000