When Dr. Mark I. Langdorf began practicing emergency medicine more than 20 years ago, finding a specialist to help with a complicated case was easy. Newly minted surgeons and fledgling ear, nose and throat doctors would show up in the emergency room with boxes of doughnuts, hoping to pick up patients and build their practices.
Today, specialists not only have dumped the doughnuts, they've abandoned emergency rooms in droves. One more sign of a deteriorating safety net, their exodus is both a cause and a result of the backlogs that plague hospital emergency rooms across Southern California. Their dwindling numbers affect the uninsured and the insured alike.
"Calling 911 gets you a waiting room," said Langdorf, the emergency department director at UC Irvine Medical Center in Orange. "It doesn't get you an emergency doc, and it certainly doesn't get you a right to a medical specialist."
Emergency room doctors can take care of about 80% of the patients who go through their doors, Langdorf said. But 20% of patients need an orthopedic surgeon to set a badly busted leg, an ophthalmologist to treat a shattered eye or other experts. That can mean hours on the phone trying to find a specialist or arranging a transfer to a larger hospital.
Contrary to what many patients may assume, California hospitals don't directly employ physicians. Under a state law that seeks to limit hospital pressure on a doctor's professional judgment, hospitals contract with emergency physicians or physician groups, who do their own billing. (The law does not apply to university and county hospitals.)
In the past, specialists in private practice who wanted to be able to admit their patients to a hospital would seal the relationship by agreeing to be "on call" for emergencies. But today, plastic surgeons and some other specialists do more procedures in office settings than in hospitals. And hospitals' financial struggles have given specialists the upper hand; if told to take emergency calls, specialists can take their elective surgery patients to another hospital.
As a teaching hospital, UCI Medical Center -- like Harbor-UCLA and County-USC medical centers in Los Angeles County -- can draw on doctors in training from the full roster of specialties. That's not the case at community hospitals, the local non-teaching facilities that are far more numerous.
A 2006 survey by the American College of Emergency Physicians found that 73% of emergency departments in the United States had inadequate on-call coverage by specialist physicians.
"If the state of California's licensing and certification division came into our hospitals to examine whether we had all the specialists we say we do, they would shut down over half of the hospitals in Los Angeles County because we don't have coverage," said Jim Lott, executive vice president of the Hospital Assn. of Southern California.
The most obvious reason for the flight of specialists from emergency rooms is the surge of patients who have no medical insurance or who use Medi-Cal, which pays some of the lowest rates in the country. It has become virtually impossible for these patients to find specialists in private practice to treat them, so they turn as a last resort to the emergency room, which under federal law must treat them regardless of their ability to pay.
On-call specialists could grow even scarcer under state plans to shrink the budget deficit by cutting Medi-Cal payments 10% this summer.
Lott and others cite additional reasons for the exodus of specialists: patients who are often drunk or on drugs; the higher risk of being sued that comes from treating strangers instead of longtime patients; and insurance companies that tightly limit doctors' payments. And now that so many insured patients are in managed care plans, being on call is no guarantee that the doctor on call will be the one who provides follow-up care.
Such changes have led to an evolution in doctors' expectations.
"Many of these specialists are looking for a lifestyle that doesn't tie them to a hospital on evenings and weekends," Lott said. "Some of them you couldn't pay any amount of money to -- they just won't take the call."
It has become common for some hospitals to pay stipends to specialists to be on call.
"That's a finger in the dike," said Dr. Irv Edwards, former president of the California chapter of the American College of Emergency Physicians. "It gets you by for a week or a day or a month, but many of the hospitals are losing money."
Edwards, an emergency physician himself, is president of a physicians group that staffs more than a dozen emergency rooms in Southern California. The difficulty hospitals have filling on-call panels varies by neighborhood.
"If you're living in Beverly Hills and trip on your lawn sprinkler, you won't have a problem at Cedars-Sinai," he said.