Specialist shortage crimps Valley health care - East Valley Tribune: News

Specialist shortage crimps Valley health care

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Posted: Sunday, October 7, 2007 1:40 am | Updated: 7:00 pm, Fri Oct 7, 2011.

A woman is flown from a West Valley hospital to Mesa, but the delay proves fatal and she dies from internal bleeding, which one doctor calls “very fixable.”

Another woman is transferred among three different East Valley hospitals and waits six days before being diagnosed with a kidney tumor.

A man waits several hours, under anesthesia on an operating table, while a general surgeon searches for a specialist who will come to the east Mesa hospital and take a look at the patient’s bladder.

Even with the opening of four new hospitals in the East Valley since last year, hundreds of people each month are transported across the Valley, or out of state, and wait days for care because of a dearth of medical specialists.

One facility can’t admit kids, another can’t fix broken bones and most all hospitals, old and new, will have to transfer certain neurosurgery candidates to Barrow Neurological Institute in Phoenix.

“There has been significant patient harm due to undersupply, or no supply, of certain specialties,” said Mesa surgeon Greg Rula.

“There are patients who are clearly suffering,” said Rula, medical staff president at Banner Desert Medical Center. “Crisis may be an overstatement. But it’s pretty darn close.”

The new hospitals, including Banner Gateway, Mountain Vista and Mercy Gilbert medical centers, have eased a bed shortage but struggled to recruit specialists.

And even the older, larger hospitals, like Banner Desert, transfer dozens of people every month to other facilities because they can’t fix what’s ailing them. The hospital shipped out nearly 2,000 patients from its emergency department in 2006, nearly half of them with a mental health diagnosis.

“The specialists haven’t caught up with the hospitals,” said Don Evans, CEO of Banner Baywood Medical Center. “If you, through just good faith, show up in an emergency room, you may learn that they don’t have specialists and you’ll need to be transferred.”

It’s not for lack of trying.

Hospitals are offering big bonuses to recruit specialty doctors who will take emergency calls, more than $2,000 a shift. Some hospital groups, like Banner Health, are hiring specialists in addition to contracting with physician groups to improve coverage in the ER.

Scottsdale Healthcare will offer guaranteed salaries to help new specialists get their practices up and running, provided they pull ER shifts at one of the hospitals.

“In the past, Scottsdale, Arizona, was all you needed to say,” said Dr. Jim Burke, chief medical officer for Scottsdale Healthcare. “Now, it’s not a slam dunk.”

Burke said the Scottsdale hospitals, including Scottsdale Healthcare Thompson Peak, which opens next month, have all specialties covered.

Like Scottsdale, the East Valley hospitals are part of larger hospital groups that, at least on paper, have physicians in all specialties. It may mean, though, that a patient in Gilbert gets taken to St. Joseph’s Hospital and Medical Center, Banner Good Samaritan or St. Luke’s Medical Center in Phoenix.

But no one has 24/7 coverage for every specialty. So on any given night, ER doctors and nurses can spend hours on the phone “hospital hunting” for a place that can treat their patient.

Depending on the urgency of their condition, patients may be transferred to Flagstaff, Tucson, California or other neighboring locales. It’s either that or hold the patient for hours, sometimes days, until a specialist can find time to see them.

“You feel horrible. You try and explain it, but it’s difficult,” said Dr. Paul McHale, medical director for Chandler Regional Medical Center’s emergency department, which has transferred more than 900 patients in the past year.

“They think we’re screwing up.”

In fact, hospitals are at the mercy of specialists, who have been fleeing emergency departments because of burnout, financial pressure, legal liability or all three.

Shortages are most acute among neurosurgery, behavioral health, hand surgery, urology, orthopedics, gastroenterology and otolaryngology (ear, nose and throat).

Though the problem is nationwide, it’s become particularly acute in the fast-growing Valley, where physicians say their colleagues fear managed care and malpractice suits.

The emergence of specialty hospitals and surgicenters gave specialists an opportunity to practice their crafts without pulling late-night ER shifts. Their surgeries are scheduled, their patients insured and their lives less chaotic.

Several years ago, Banner Desert lost more than a dozen orthopedists to other hospitals and has only recently built back the staff.

*** Note: An earlier version of this story contained incorrect information. Doctors at the Arizona Spine and Joint Hospital still maintain privileges at Banner Desert and other East Valley hospitals.

Those who remain on hospital call lists are run ragged.

“ER patients are high-risk patients. A disproportionate number of them are uninsured and there’s a disproportionate number who are going to sue,” McHale said.

Even with hospitals offering bonuses and guaranteed reimbursement, he said, “(Specialists) are saying, 'Sorry, it’s not worth it,’ which gives you an idea of how miserable those call nights can be.”

Federal law requires hospitals to treat whomever walks in the door, or transfer them to an appropriate hospital. A specialist on call is obligated to treat patients, regardless of where they come from.

To hold a state license, a general hospital must have an emergency department and offer surgical services. There are no specialty requirements.

“A lot of these new hospitals don’t have the services,” said Mesa urologist David Grossklaus, chairman of the surgery department at Mesa’s Banner Baywood.

“They have pretty facades and pretty ads in the newspaper, but they don’t have the services.”

Holes in hospital coverage put more pressure on specialists and take away from their private practice, not to mention their private lives.

Dr. John Comerci moved his family to Mesa from Pittsburgh, hoping to start a new practice and a new life. But it took just two years for the gynecologic oncologist to pack up and head back home.

His August departure leaves just two specialists in the Valley to care for women with ovarian cancer and other malignancies, compared with about 14 in Pittsburgh.

“There really is a true hole in taking care of those patients,” Comerci said. “It is a crisis.”

The grind of his Mesa practice left Comerci with a heart-rending choice: his patients or his family, which includes children 13, 11 and 3.

“I’ve never worked anywhere where I ran out of time on a monthly basis. I was operating on Saturdays and Sundays,” he said.

“We left a very large extended family in Pittsburgh. I kind of plopped them here and then abandoned them. But it’s very hard when you’re an oncologist to abandon patients.”

The difference is, he said, “Here, there was nobody to pick up the slack.”

Managed care paid him a fraction of what his years of specialty training were worth, he said, and battles with insurance companies drained what little energy he had left.

Comerci had high praise for Banner Desert and its efforts to keep him sane while recruiting others to ease the load. The hospital asked him to hold on awhile longer.

In the end, Comerci said, he looked at his kids and made his choice.

“My oldest will be out of the house and gone, forever. I just was not willing to make that sacrifice.”

While hospitals work on establishing specialty groups, like urologists including Grossklaus, who will rotate coverage among the facilities, the long-term solutions seem elusive.

Tort reform, which would make it harder for patients to sue ER personnel, has been passed by the Legislature but vetoed by Gov. Janet Napolitano.

Collaboration among competing hospital systems, while a worthy goal for patient safety, can be a dicey business practice.

Additional state funding for graduate medical education may pay off, since research shows that most medical residents put down roots in the communities where they complete their residencies. But that’s years away.

“Unfortunately, I don’t see the light at the end of the tunnel,” Rula said. “This gets worse before it gets better, in my opinion.”

McHale agrees.

“I think everybody knows what’s at stake. We’re all physicians and we all want what’s best for the patient,” he said. “Every single day patient care is getting delayed. Every delay is a moderate increase in risk.”

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