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Podiatric Medicine and Emergency Room Call
When I first applied for hospital privileges at the new, county supported hospital 21 years ago, my
application was at first, denied. I was told that there was an on call schedule for podiatrists and because my home was more than twenty minutes from the hospital, it was felt that I would not be able to respond in a timely manner.
Six months later, after relocating my family closer to the hospital, I was finally granted privileges. For the first two years, I was not called once. After a lengthy meeting between the department of podiatry and the hospital administration, the situation changed. Podiatrists began to get called more often, but strictly for the occasional paronychia, subungual hematoma or digital fractures.
Invariably, these patients were uninsured or had a personality flaw that made them unattractive to any of the other on call physicians. I recall one of the ER physicians testing my fortitude by calling me at 2:00am for a mild ankle sprain. No, I didn’t say put a compression dressing on and send him to my office. I went in and evaluated the patient myself.
During these early years, the practices of young orthopedists flourished with the help of emergency room referrals. Young podiatrists were not as fortunate. Despite presenting a log containing experience with over 1000 emergency room patients to the credentials committee, my participation in the ED was extremely limited. The “company” line was “it’s not the standard of care in this community”. Curiously, it was indeed the standard in my private practice and the practices of other podiatrists. Once professional relationships with local primary care physicians were forged, regular referrals of injured patients became the norm.
Another roadblock was the hospital bylaws, which prevented podiatrists from doing their own H & P’s or admitting a patient. As a result of this rule, a second physician needed to be called for admission or for OR clearance. To me, this problem seemed to be a restriction of trade. Nothing more and nothing else.
Years later, participation in the Emergency Department became less attractive to physicians altogether. Reimbursement was cut back and there was a malpractice crisis. More and more physicians opted out of participating in the Emergency Department.
Suddenly, I was getting called two to three times a week to participate in ER cases. All of a sudden, “standard of care” was not an issue and we were able to work around the admitting privileges issue also. Although the compensation was minimal or non-existent in some cases, I accepted every patient sent to me, believing that ‘I was paying my dues” by helping out the hospital in it’s time of need. A local orthopedist had conveniently recalled my desire to participate in the ER and the hefty log of cases that he had reviewed years earlier during my credentialing.
During those years, I saw my share of challenging cases and felt really good about the work I was doing. I responded at all hours of the day and night. Despite the limited compensation, I truly enjoyed what I was doing.
Over the last two years the tide has changed once again. Hospitals are now augmenting the compensation received by physicians for their participation in the ER. Some specialties contract with the hospitals to handle all of their emergency care. What do you know? ER referrals have dried up again.
Is it truly their belief that calling the podiatrist is below the standard of care ? Do they think our training is
sub-standard ? Baloney...it's competition, pure and simple. Those who bring the most revenue into the hospital, get the privileges.
And it also pays to speak up. The squeaky wheel gets oiled.
Even today, our well-trained residency graduates are subject to limitation in their participation in the Emergency Department. The privileges that they are granted when they first apply to the hospital will be lost upon re-application, if they cannot demonstrate reasonable experience with foot and ankle trauma in their first few years. It is really a shame!!!
I would like your feedback on this issue. What is taking place at your hospital? Do your residents have adequate exposure to ER patients? Are they participating in foot and ankle call upon graduation? Do the podiatry attendings participate in the ER?
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Feedback
Jay
Lieberman, DPM
Editor - PRESENT
Director of
Podiatric Medical Education
Northwest
Medical Center
Margate,
Florida
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