Published 6/1/2012
Terry Stanton

On-Call Solutions Need to Balance Patient, Physician Needs

Improvements in ED coverage could ease liability issues

Many orthopaedic surgeons have misgivings or trepidation about taking call because of concerns about liability. Although tort reform might address a number of these concerns, another important step would be to improve the call system by removing barriers to good care, according to James F. Kellam, MD, of Charlotte, N.C.

Dr. Kellam, who spoke at the 2012 Orthopaedic Trauma Association Specialty Day, summarized results of an American Orthopaedic Association survey of 1,527 orthopaedic surgeons, three quarters of whom practiced in a community setting and took general call. Asked why they took call, 73 percent said they were mandated by hospital bylaws, half said doing so was “my personal responsibility to my community,” and 38 percent cited their “professional obligation.” Two thirds said their communities had a problem with emergency department (ED) coverage.

Asked to name barriers to good care, the surgeons ranked the following issues:

  1. Inadequate compensation from the hospital for taking call
  2. Disruption of elective practice
  3. Impact of uninsured patient volume on practice and personal finances
  4. Increased liability risk
  5. Inadequate training

Systems issues
Dr. Kellam said most of the surgeons’ comments focused on “systems issues,” such as a lack of nonfinancial support from the hospital, including poor coordination of care, transport, and issues involving personnel interactions. He described dissatisfaction with hospital professionalism in terms of how surgeons think their hospitals relate to their communities, carry on rivalries, and impose “all the nonpaying patients” on surgeons.

The real dissatisfaction with compensation actually stems from issues of recognition, according to the survey results. Respondents wanted “some mechanism for recognition of surgeons by the hospital and society for their care of people, including the uninsured—not only money.” Surgeons, he said, “want a system where patients in their office get their total care,” and they aren’t overwhelmed with unreasonable numbers of patients.

As for elective-practice disruption, Dr. Kellam noted, “Everyone wants a planned, organized life; few can tolerate chaos.” Surgeons, he said, want a system that enables them to provide all patients, including their emergency ones, with their undivided attention.

Although liability was ranked as a barrier, few respondents commented on it. The reported degree of the problem varies around the country. Data indicate that the poor and uninsured are not more likely to sue than other patients. The cases that most commonly lead to litigation, said Dr. Kellam, involve fractures and have relatively low settlements.

Most claims, he said, are the result of gross technical errors or “failure to do the right thing,” reflecting inadequate training, erosion of skills, or a medical error.

“Surgeons who don’t perform trauma surgery regularly or see a lot of trauma patients may lose some of the core competencies for treating these patients,” said Dr. Kellam. Perhaps reflecting this concern, survey respondents worried about being held to an unreasonably high standard of care in litigation.

The respondents said that hospitals that require surgeons to take call should support this mandate with proper operating rooms and equipment, trained staff, a referral system, and transfer agreements. “If this issue was solved, if the care of the emergency patient was made ‘easy,’ more surgeons might be willing to take call,” he said.

Local solutions needed
Because most of the issues surrounding on-call care are local, local solutions will be needed. For example, compensation must recognize that physicians in private practice need to receive compensation that enables them to pay their employees and provide services to patients.

Ethical issues surrounding the provision of free care must also be addressed. The surgeon must ensure that, at a minimum, no life- or limb-threatening problem goes untreated, that the patient is treated on a timely basis, and that transfers of care are handled appropriately. Surgeons should be aware of available resources to assist patients experiencing financial hardships.

Dr. Kellam said that third-party payers can play an important role in improving emergency care. He cited the case of Rochester, N.Y., where insurance companies found that increasing reimbursements for orthopaedic trauma care would “improve the delivery of care for all in the area.”

To address disruptions to a physician’s elective practice, Dr. Kellam suggested coordinated, cooperative call schedules; hospital support; defined referral systems; and some changes in the delivery of emergency care, including the presence of a hospitalist surgeon.

The overall solution lies in professionalism, Dr. Kellam said. “All of us are in this together, and the solution rests with us. We need to act as professionals and work together to get a coordinated system that will bring order out of chaos. If we are going to have more people taking call, all sides have to cooperate. It is time we came up with a new definition of how we deliver emergency care, so that we all can get along. In the end, it comes down to care for the patient.”

Disclosures for Dr. Kellam: Canadian Orthopaedic Association, Orthopaedic Trauma Association, AO Foundation.

Terry Stanton is senior science writer for AAOS Now. He can be reached at tstanton@aaos.org