Letters from our readers
Emergency coverage crisis
The June 2005 issue of the Bulletin contained a reference to the State of Hawaii/Queen’s Medical Center conference (“From the States—In Brief”) regarding the overloaded trauma system there. It included a statement that because physicians on the outer islands are refusing to take emergency room (ER) trauma call, many cases are flown to Oahu for care at the Queen’s Medical Center. The situation is much more complicated than the simple treatment it received in the article.
In many of the outer-island hospitals in Hawaii, there are simply too few orthopaedic surgeons (one or two in some locations) to provide 24/7/365 ER coverage. We have not “refused” to take call; we have individually decided that our time is not unlimited, and that, while we feel an obligation to assist the hospitals and the communities with their responsibility to provide this care under EMTALA [Emergency Medical Treatment and Active Labor Act], we cannot go on providing uncompensated coverage because we need to save our financially threatened, often solo-office, practices and family lives.
The situation may require a significant financial contribution from the communities and hospital systems to balance the burden and satisfy the EMTALA requirement (money for call). Otherwise, those patients who are unfortunate enough to have a severe injury on an “uncovered day” will need to be transported to where more available facilities exist. On Oahu, there is a residency program that provides doctors to admit patients at night or on weekends when needed. And on-call physicians are compensated with a modest stipend (on the order of $1,000 per night) to be on duty.
The state legislature balked at the opportunity to lend financial support to the Queen’s Medical Center in the last legislative session. A consequence of the unfunded EMTALA mandate is that hospitals on the outer islands are facing an increasingly difficult time transferring cases to Queen’s, where traumatology-type care is available, because physicians there are at times refusing or delaying the transfer with threatening overtones of invoking or promoting EMTALA violation investigations of orthopaedists who are not officially on call on the outer-island hospitals.
With a significant financial contribution to make taking an ER call not such a practice money-loser (because of lost office revenue, lost sleep and elective cases canceled to care for patients coming into the ER), the market approach should be able to solve the problem very effectively. Until this happens, the residents and visitors to the outer islands will face an increasingly difficult time receiving care. As the level of compensation for orthopaedic services in our quasi-monopolistic insurance market declines (90 percent of the health insurance market is cornered by the Kaiser system and the Blue Cross carrier [HMSA]), the incentives for young orthopedists to move here continue to decline. The high cost of living and the difficulty in making enough to cover the costs of doing business will continue to escalate.
As in other areas of the country, the Medicare fee schedule reductions will likely force some of us out of practice in the coming years, making the situation worse. If society deems it a necessity to provide 24/7/365 coverage, it will need to pay for it.
Charles A. Soma, MD
Wailuku, Maui, Hawaii
Thank you for reporting on the emergency coverage crisis in Hawaii (Bulletin, June 2005). Your writer is misinformed, however, about the cause of the crisis. All hospital staff orthopaedic surgeons in Hawaii provide emergency coverage as required by their hospital. The crisis has many causes—one being that Queen’s Medical Center, the state’s only trauma center and the orthopaedic residency training center, has only two orthopaedic surgeons providing emergency coverage. The residents of Hawaii are indebted to these surgeons and need to express thanks for their hard work.
Unfortunately the present situation is unsustainable. The orthopaedic community needs to continue to demand changes by hospital boards, state and federal government and private insurers to resolve the crisis.
Robert D. Irvine, MD
Minimally-invasive hip replacement
I enjoyed the August 2005 Bulletin Point/Counterpoint on “minimally-invasive” hip replacement (“Less invasive hip replacement makes sense”). This clearly is a topic of stimulating debate. As a young, fellowship-trained joint surgeon who performs a fair amount of revision total hips, I was disappointed to see Dr. Sculco’s suggestion (number 5 of 7 lessons learned) to use monoblock acetabular components to make the procedure “less problematic.”
With many of these “minimally invasive” total hip replacements being performed in younger patients who often will require revision surgery, I question the wisdom of using a component with poor revision options. Especially when we consider that poor visibility may lead to poor cup position and early liner wear.
Gregory M. Martin, MD
Delray Beach, Fla.
Pay for performance
I am disturbed by the letter from David Hubler, MD, which was published in the June 2005 issue of the Bulletin. I hope and expect his second paragraph, “Physicians give better care to patients who pay more for their performance. Same good idea!” was written after a long, frustrating weekend of call.
We all must realize that providing quality of care based on level of reimbursement is unethical. Once any surgeon agrees to treat a patient, the surgeon will provide the best care that he or she is capable of, regardless of the patient’s social and/or economic status. This is what we are all trained to do and what society expects of us. I believe most members of the AAOS will agree with me. It may be worthwhile to remind AAOS members of our moral and ethical obligations every time we renew our membership.
Robert D. Irvine, MD