Hand microvascular trauma call is uncomfortable. To awaken at 1:23 am, treat hand-saw injuries until 5:08 pm, and then freshen up to start the elective hand practice at 7 am is not easy. It’s particularly difficult when the load of trauma call falls on few. In the typical life of a surgeon who takes call and cares for upper-extremity trauma, there are no “off hours” within the typical “business day.” It is part of our duty as surgeons to share the load. As physicians, we have the option to decide whether we wake from the buzz of a sudden unexpected pager alert or the scheduled alarm clock. Although either way, we assist in the well-being of local, regional, and national communities and we must start to consider cases of unplanned treatment as part of our regular business day.
In the 2014 Orthopaedic Surgeon Census, one of the most frequently cited orthopaedic subspecialties was hand surgery.1 Despite this seemingly large pool of hand surgeons, we face an alarming shortage of available physicians in emergency settings. A national study by the American College of Emergency Physicians noted that our overall emergency system operates with a “failing grade” of D+, specifically in patient accessibility to care.2 Several studies have explored the causes of this problem; one of which suggested that, in the particular field of hand surgery, states with lower per-capita income are underserved.3 Ultimately, it is quite clear that an issue exists with patient accessibility to hand surgeons in emergency settings—but why?
The reality of available hand surgeons on call may help illuminate a part of the answer. In New Mexico, seven surgeons are registered as hand surgeons.4 Two of these seven hand surgeons take hand call. The reasons for this are multifactorial. In our situation, the outlying hospitals would not provide compensation for call. Hand call was deemed part of the contract salary but not a required contract duty, and therefore the surgeons declined to cover. This uneven ratio is not particular to New Mexico.3,5 The reasons for opting out of hand call are many and cannot be all enumerated here. We get it. The ideal set up to be an on-call hand surgeon is tough to come by. However, it’s even tougher to have the entire load carried by a fraction of those capable.
Instead of focusing on which particular hand surgeon is or is not on call, we must move forward to a solution. How can we promote hand call to hand surgeons in these underserved regions of the United States? There has been a move toward the establishment of dedicated hand centers. However, west of the Mississippi, they are few and far between.
Ultimately, the change requires a unified, joint effort from state-wide providers and hospitals. It requires the understanding that we are not only working together to care for patients with hand injuries, but we are helping each other by sharing the time and mental effort necessary to be accessible 24/7. It does not matter whether we work for a hospital or in private practice. When hand trauma hits the emergency room, having a list of available helpers is critical. We, together, are that list.
Hand surgeons are spread thin. We joke that we need thirty-hour days. Our lives are dedicated to the well-being of others, yet the reality is that doctors are humans. Few humans bubble with excitement at the prospect of waking up at 3 am on Christmas morning to treat a patient with an amputated thumb. However, doesn’t it make sense to share the load? We chose to be physicians and help others—be it planned or unplanned.
Sahar Freedman contributed to this blog post.
References
- American Academy of Orthopaedic Surgeons. Orthopaedic surgeon quick facts. http://www.aaos.org/CustomTemplates/Content.aspx?id=6408&ssopc=1. Accessed August 30, 2016.
- American College of Emergency Physicians. America’s Emergency Care Environment: A State-by-State Report Card. Irving, TX: American College of Emergency Physicians; 2014. http://www.emreportcard.org/uploadedFiles/EMReportCard2014.pdf. Accessed August 30, 2016.
- Rios-Diaz AJ, Metcalfe D, Singh M, et al. The distribution of specialist hand surgeons across the United States. Plast Reconstr Surg. 2016;137(5):1516-22. doi: 10.1097/PRS.0000000000002103.
- American Association for Hand Surgery. Find a hand care provider. http://handsurgery.org/locator/. Accessed August 30, 2016.
- Chung SY, Sood A, Granick MS. Disproportionate availability between emergency and elective hand coverage: a national trend? 2016:16;e28. http://www.eplasty.com/index.php?option=com_content&view=article&id=1712&catid=15&Itemid=116. Accessed September 13, 2016.
The emergency on-call burden shouldered by a few in your state is clearly not ideal, nor will a blanket appeal to the young surgeons of tomorrow to “share the load” necessarily inspire those who choose not to take call, or are allowed not to take call, to change their minds. It’s clear that our communities will continue to be in need of emergency coverage, but I think it is also clear that expecting hand surgeons to shoulder this very difficult responsibility forever simply because they chose hand surgery as a profession is unreasonable.
So, what is the solution?
First, employed doctors may not have a choice. It may be embedded into their contracts. But, any time someone is forced to do something without perceived benefit, the marketplace will adjust. And then we are left with the potential that we hand surgeons, who can do the majority of the work in outpatient centers, will refuse to participate in emergency call and be entitled to opt out. A potential solution is appropriate incentivization. Just as the recent United Airline’s debacle could’ve been avoided by offering customers the opportunity to leave the plane for an attractive “return”—- tickets or money, as opposed to forcing a customer to leave against his will, so too might many hand surgeons agree to take call if they were reimbursed for their time regardless of payer status; this might make it feasible to schedule a half a day off after being on call.
Now many might think this is impractical, but anytime there is a problem in need of a novel solution, strategy must be appropriately aligned with structure, and currently the structure of our practices provides a “zero sum game” for many in terms of the benefit of taking call. I would be more inclinded to start a case at 6 am than at 2am, for example, and there are few cases—even replants– that could not wait for a few hours. The burden of “emergency” cases arguably diminishes as daylight approaches, and dissapates to what we all experience during our elective surgery (regardless of the time of day) if we can work with a high performing team.
For many of us who took lots of call in the past, but are approaching our late 50s and 60s, it’s just not feasible to have the same expectation. Nor is it feasible, I believe, to force the younger in our field to do something they don’t want to do. Rather, we need to collaborate with administrators, insurance companies, and politicians, as competent and principled providers, to work towards a mutually beneficial, “win-win” solution.
The Hand Trauma committee has been focused on addressing this issue. We have been working with the ACS over the past 11 years to address this concern, and regain the public trust that members of the ASSH and other colleagues with microvascular skills will be available 24/7/365 to care for patients requiring replantation and revascularization. An evolution towards a national program that would provide regional coverage for such emergencies is underway. We should all agree that doing the right thing at the right time for any patient in need is what guides care. We are working hard on creating a viable solution that benefits patients and physicians as well.