Overworked doctors sue for a breather

Two very busy physicians almost lost their hospital privileges because they wanted to restrict the scope of their practice.

By Berkeley Rice
Senior Editor

Edgar Weaver and James Vascik were often exhausted. The two Virginia neurosurgeons were longtime staff members at Roanoke Memorial hospital, owned by Carilion Health System. Because of a shortage of neurosurgeons in their area, however, and the demands of their call obligations at the ED, they were working up to 100 hours a week, sometimes as much as 72 hours straight.

On some occasions, they had to work all night in the ED, just before a lengthy surgical procedure scheduled for 6 a.m. Urgent calls from the ED often forced them to cancel appointments and reschedule spinal surgeries at the last minute. "We do a huge number of difficult elective cases," says Weaver, "and you just can't do that if you're on call every third night. It's just too much."

The cause of the shortage was obvious: Of the 10 neurosurgeons who had once worked at the hospital, some had retired, some moved away, and others had moved their practices to another hospital in a nearby city. That left only Weaver, Vascik, and their partner Raymond Harron covering the ED.

Last June, Weaver and Vascik announced their intention to limit their practice—and their call obligation—to spinal surgery, their primary specialty. In August, Roanoke Memorial's chief of staff informed them that if they did so— as permitted by hospital bylaws—they would still have to continue providing ED coverage for both spinal and cranial cases. If they refused, he told them, the hospital would revoke their admitting privileges and drop them from the staff.

The hospital's concern was understandable. If Weaver and Vascik did drop call coverage for cranial surgery cases, their partner Harron would be the only one left to handle them. The hospital claimed it couldn't allow that to happen because one neurosurgeon couldn't possibly cover the ED 24 hours a day. (To retain its status as the only Level 1 trauma center in western Virginia, Roanoke Memorial is required to have full neurosurgical services available at all times.)

Last October, after the hospital rebuffed their request, Weaver and Vascik filed a suit claiming that the "excessive" demands of their call schedule "compromised [their] ability to provide the best possible care" to their patients and to referring physicians. They claimed that they had been arbitrarily threatened with the loss of their hospital privileges without a hearing. They accused Carilion of acting from "primarily economic" motives to preserve its lucrative status as a Level 1 trauma center. Finally, they asked the judge to enforce their right to limit their practice—and their call coverage—and to issue an injunction preventing the hospital from revoking their privileges.

After some negotiation, "the crisis has been averted—at least for now," says cardiologist Joseph Austin, chief of the hospital's medical staff. Two neurosurgeons who had moved their practice to another hospital have agreed to share coverage at Roanoke Memorial, and Weaver and Vascik have agreed to continue handling ED call—both spine and brain cases. Meanwhile, the hospital will try to recruit several more neurosurgeons.

The critical shortage of emergency specialists is hardly unique to Roanoke. It's a national problem, and one that's growing worse because many EDs are already overcrowded, and traffic is increasing. There are several reasons for this: Millions of uninsured patients routinely use the ED because they don't have personal physicians. Many local hospitals have closed their EDs (about 500 in the 1990s), putting more pressure on those that remain open. And finally, the federal Emergency Medical Treatment and Active Labor Act (EMTALA) requires EDs to treat anyone who comes through the door—whether or not they have coverage.

Thus it's not surprising that many emergency physicians are feeling overworked these days, particularly the specialists who handle complex trauma cases, such as orthopedists, neurosurgeons, and plastic surgeons. The pressure is particularly intense for those who cover more than one hospital, because they may have to respond to simultaneous calls from each ED.

As a result, a growing number of physicians are dropping ED coverage or thinking about doing it—if they can. Often they can't, however, because hospital bylaws make it a condition for maintaining their staff privileges, as in Roanoke.

Going to court to win freedom from call obligation is an option few physicians are brave enough to try. As attorney Roberts Moore, who represented Weaver and Vascik, points out, "In most cities today, the big, hospital-based health systems have the economic power to control local medical practices. Often it's essentially a monopoly. So even if they're unhappy with their call obligations, very few physicians would ever sue the hospital for fear of retribution."

 

Berkeley Rice. Overworked doctors sue for a breather. Medical Economics Apr. 25, 2003;80:44.