This statement was developed by the Board of Governors’ Committee on Socioeconomic Issues in collaboration with the Board of Governors’ Committee on Surgical Practice in Hospitals and Ambulatory Settings. It was approved by the Board of Governors and the Board of Regents in October 2008.
Compassion and our professional ethics mandate that all patients faced with a surgical emergency are provided care. The American College of Surgeons fully supports access for all Americans to emergency care, but major issues of surgical manpower and resource utilization represent a threat to continued access. The American College of Surgeons presents the following analyses and recommendations.
Emergency surgical call serves to meet patient needs. The Emergency Medical Treatment and Active Labor Act regulations support this patient care by Medicare-participating hospitals and provide a funding stream to the hospitals by means of the Medicare system. By means of cost shifting and sharing the burden with other surgeons, surgical practices generally have been able to provide such service.
Our population has aged steadily. The more elderly the population, the more health care required, both emergent and nonemergent. In addition, an ever-increasing population of indigent patients uses the emergency room as the sole avenue to medical care. At the same time, the number of surgeons produced by our graduate medical education programs has remained stable for nearly 30 years.* In general surgery, the ratio of surgeon to population has been steadily declining since 1985. Other specialties with even fewer providers feel they can no longer meet the community demands for their services.* As a result, there exists an increasing chasm between expectations for access to emergency surgical care and the surgeon workforce available to provide such care.
The College recognizes the need for emergency surgical care.† The hospital, mandated by the government, has entered into a contract with the community to provide care without involving the actual care provider in the negotiations. The surgeon feels deeply obligated to care for all individuals who require care. However, the surgeon attempting to provide this care is forced to be practical in the face of increasing demands.
To provide this care, the surgical practice must remain fiscally viable, professionally attractive, and competitive in retaining and hiring colleague surgeons for the community. The challenges to this effort are many and varied. Emergency surgical care detracts from this ability to recruit in many communities because emergency call involves greater risks than care provided during elective, scheduled operations. Operations often must be accomplished under conditions that do not allow for standard preoperative preparations. These patients often have the highest risk for complications due to advanced disease states and associated risk factors. Patient expectations frequently reflect what can be expected with proper preoperative preparation and planning even when this is not the case. Such unrealistic expectations can lead to an increased malpractice risk. Being available for emergency call may appear innocuous, yet excessively frequent on-call duty has a negative impact on the surgeon’s time with family and the ability to provide community service outside of the profession.
Unfortunately, this surgical service is increasingly mandated without appropriate compensation. The obligation to provide care must be balanced by the means to do so; cost shifting to the surgeon is an unacceptable option.
The College recommends that health care payors and institutions commit necessary and appropriate support to surgeons for emergency coverage of surgical care.† Whatever the model chosen to provide this patient service, it must account for the disruption involved with being on call when actual service may or may not be required. Compensation for the service provided must be based on fair value for the risks involved and time allocated.
* Statement on the surgical workforce [ST-57]. Bull Am Coll Surg. 2007;92(8):34-35.
† Statement on emergency surgical care [ST-56]. Bull Am Coll Surg. 2007;92(5):27.
Reprinted from Bulletin of the American College of Surgeons
Vol.94, No. 1, January 2009