Ideal length of stay in the ED
William Bromberg
brombwi1 at memorialhealth.com
Mon Oct 15 21:08:44 BST 2007
A few points
>>> "Moore, Rick" <Rick.Moore at TriadHospitals.com> 10/15/2007 3:17 PM
>>>
1. <snip> The main reason we and many other hospitals in Texas are
designated is that trauma designation is tied to Medicaid
disproportionate share funding. No trauma designation no dispro.
Right, so the hospital gets paid more to be a trauma center. Or less to
NOT be one, just what I said. And the surgeons don't share in that
(Medicare part B payments are not increased only Medicare Part A,
right?)
2. <snip> As far as nurses on call, I are one, and so is every other
nurse
supervisor or administrator here and we all take call for free, it's
part of the job description. [my emphasis] Just like to perform surgery
on the sick
and injured is part of the job description of the surgeon.
Right, and you got the job description when you applied for the job and
were told the salary. If your hospital tried to then come back and
double your call they would be in breach of contract and you could
either 1) leave without penalty (actually, they would have penalties
such as reimbursement of your unemployment insurance) or 2) renegotiate
for more money.
The surgeons signed on at a hospital which was NOT a trauma center . I
assume if they wanted to work for a trauma center they would have signed
on at one (as I did). The hospital then became a trauma center (to get
more money, no matter how it's paid, directly or by upping the medicare
dispro funding) and either unilaterally increased the call requirement
or negotiated the requirement up front with the surgeons, dangling call
pay as the carrot. The surgeons exercised their rights to either leave
or renegotiate the relationship.
3. <snip> We do have some units that routinely have a nurse on call and
that nurse makes the
whopping sum of $1.00 per hour for period of time on call. Granted if
called in they make at least their regular hourly rate and many times
an
overtime rate, but that doesn't come close to what a surgeon will bill
for a couple hours of patient care.
See #2. The nurses signed on for that. There are a lot of jobs in my
hospital that require call, lots that don't. It's one of the reasons
that cath lab nurses get payed more than the floor nurses. And if you
want to be a physician go ahead, we'd love to have you. There's times I
regret not being an cardiac PA, all the operating, none of the stress
for only about half of what I get paid.
4. Ironically the very surgeons that now demand back-up call pay,
initially
volunteered to take call and help with oversight of the trauma program
so the facility would qualify for designation then they occasionally
begin to snivel and threaten to walk if more money is not put on the
table.
If the surgeons initially agreed to do something for free and then
reneged, they are in the wrong. If they did not agree to take back up
call for free then it wasn't part of the deal.
5. IMHO if you don't want to be on call and have your nights, weekends
and
holidays interrupted then be a dermatologist.
REM
Well, unless you can find (or found) a religious order to be the
philosopher-surgeons of the future I think that's a silly response —
that's EXACTLY what is happening. People perform for incentives, be it
respect/gratitude, money, lifestyle, or enjoyment. That's why 30% of
OB/GYNs don't do OB anymore (supplementing their salary with Botox
injections). That's why many trauma fellowships fail to fill every year.
That's why trauma orthopods can demand 7 figure starting salaries at
certain trauma centers. It's all well and good to ride the high horse of
holier than thou, but this one is heading out into the desert of "why
the hell can't I get anyone to take call." And it's why Dr. Mattox keeps
talking about the increasing need for surgeons who aren't afraid of the
big whacks in the middle of the night.
And I say all this as someone who takes every 4th-5th night trauma and
emergency general surgery call at the second busiest trauma center in
Georgia (Memorial in Savannah). Our group of 6 (two half-time) takes
ALL the emergency surgery at night even though there are at least 10
other general surgeons on staff. I do it b/c I like it, I'm good at it
(I think), and I think it's important work — but I sure as hell
wouldn't do it for free, and I couldn't even cover my (non-physician
salary) practice expenses without hospital support with 35% no-pay 25%
Medicaid and 20% Medicare payer mix that we have here.
I reiterate, as far as I can tell this is NOT question of not taking
call. It's a question of the hospital doubling the call responsibilities
of the surgeon after the fact so the hospital can make more money.
Bill Bromberg
-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of William Bromberg
Sent: Monday, October 15, 2007 12:49 PM
To: Trauma & Critical Care mailing list
Subject: RE: Ideal length of stay in the ED
I gotta tell you, I disagree. If I'm not mistaken the surgeons to whom
you refer already take primary call for "free". The hospital,
(probably
in order to get some sort of state financial support) decides to be a
trauma center. This then essentially doubles the amount of call the
surgeons are required to take. Now, you may think that back-up call is
worth nothing but it is two more weekends a month that you can't leave
town, can't have a beer, can't make plans with your family, etc. etc.
The fact that they rarely do anything on backup is not a feature, it's
a
bug. At least when you are on primary call you can make a living by
billing patients - the hospital was asking for unpaid
labor/availability
over and above the normal, and certainly not what the docs signed up
for
when they got privileges initially.
Let me make it clear, all doctors should take call. This does not give
the hospital the right to unilaterally decide to double your call
responsibility AND make sure you don't get remunerated for it. If the
plan had already been in place ( i.e. the doctors started demanding
fees
for what they had already been providing), that's different IMO. Try
that same trick with your nurses and see what happens.
Bill Bromberg
>>> "Moore, Rick" <Rick.Moore at TriadHospitals.com> 10/15/2007 12:36 PM
>>>
I don't deny that call is hell, in or out of house. I myself pull 60
hours of call every third weekend as the on-call ED Supervisor and
many
times that means working at least a 12 hour shift once I have been
called.
When we designated as a level III center, we had to put a general
surgery back up call schedule in place in order to receive our
designation. Since we had to do it the surgeons of course held out for
call pay an knew they would get it. Now a surgeon makes $1000. a day
just to carry a beeper and stay within a 30 minute response radius to
the hospital. Our volume is still somewhat low and the back-up gets
activated an average of once a month.
REM
-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of Robert F. Smith
Sent: Monday, October 15, 2007 11:23 AM
To: 'Trauma & Critical Care mailing list'
Subject: RE: Ideal length of stay in the ED
Well Ron is in the midst of a stretch of every other night in house on
call and stays till at least 5 the next day. You couldn't pay me
enough
for that.
The Chair of Trauma at Cook County, the young and beautiful Dr.
Roberts,
will be taking two such calls in the next 7 days for free. But yeah,
it
should include that.
Rob Smith
-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org]
On Behalf Of Moore, Rick
Sent: Monday, October 15, 2007 12:14 PM
To: Trauma & Critical Care mailing list
Subject: RE: Ideal length of stay in the ED
Wouldn't acting "in the patient's best interest" include having
surgeons
that take trauma call without insisting on exorbitant amounts of call
pay or shipping the uninsured or under insured?
REM
-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of Ronald Gross
Sent: Monday, October 15, 2007 11:04 AM
To: 'Trauma & Critical Care mailing list'
Subject: RE: Ideal length of stay in the ED
Another novel concept - acting "in the patient's best interest".
Rob, I think that you and I just might be on to something wonderful!
LOL
Ron
>>> "Robert F. Smith" <rfsmithmd at comcast.net> 10/15/2007 12:01 PM >>>
IMHO it is essential that ED physicians have admitting privileges.
Otherwise their job is impossible and the ED is a total dumping ground
and they ED docs become slaves to all the other in house services.
Of course people will object strenuously to this but if people can't
act
like adults in the patient's best interest this becomes a viable
solution.
Rob
-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org]
On Behalf Of Krin135 at aol.com
Sent: Monday, October 15, 2007 11:52 AM
To: trauma-list at trauma.org
Cc: KMATTOX at aol.com
Subject: Re: Ideal length of stay in the ED
In a message dated 14-Oct-07 10:35:16 Central Daylight Time,
KMATTOX at aol.com
writes:
In a message dated 10/14/2007 9:57:26 A.M. Central Daylight Time,
andrewj.bowman at gmail.com writes:
What then do we do about the attendings (fill in specialty here) who
are reluctant to admit a patient without the complete workup????
Create a hospital policy that allows, encourages, mandates that the
EC
staff have the authority, and supported by the Medical Executive
Committee to admit a patient to any hospital in-service where the
service is slow to evaluate the patient or require that an entire work
up occur there prior to going to
an
in house bed.
k
I'd love it...now just need to convince the med exec committee (and
the
hospitalists) that the hospitalists and attendings don't need every
jot
and
tittle done in the ED prior to admission....
and convince some of the residents at major teaching hospitals that
they
can finish the work up faster after they have the patient in their
hands
than the smaller hospitals can do prior to transfer...
ck
Charles S. Krin, DO FAAFP
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