Transfers due to Incompetence

Recently, I and my colleagues have taken a lot of transfer calls that have, as their basis, professional incompetence.  Allow me to explain, and then to ask a question.

We’ll get a call from an ER doc with a patient who’s stuck in the middle of a situation: their ED patient has an emergency requiring specialty treatment, they have a specialist in said speciality, but said specialist ‘doesn’t feel comfortable / hasn’t done in years’ the procedure the patient needs, so we’re called to get the patient to a specialist that’ll take care of them.

As a description I’ll tell one bowdlerized tale to give the flavor: patient with an open femur fracture.  Sending hospital does have an orthopedist on call, but “s/he only does spines, and they doesn’t feel comfortable doing this”.  (This happens with virtually all specialties, I’m not singling out ortho, just using them as an illustration of a general problem).

So, yes, medically we can take care of this patient, and medically we accept the transfer; when I talk to admin, I make sure they know all the facts, and then I make sure we do the right thing for that patient, and that’s to bring them to us.

Here’s my question: besides an EMTALA complaint (which the hospital reportedly files a lot of, and reportedly come to nothing), is it time to start reporting this level of professed incompetence to certifying boards?  I would presume a Boarded Orthopedist would be able to take care of an open femur fracture as part of both routine training and certification (and I’d bet they’re credentialed for that procedure at their hospital); if they then profess incompetence in caring for that injury, wouldn’t their certifying board like to know?

What say you, physicians?  Report, yea or nay, and if not, why not?


  1. For egregious cases or repeat offenders, absolutely yes. However, the right thing to do is to discuss it with the physician that is trying to wipe the booger on you. I know that it takes time, but it shouldn’t be lightly done, either. In the case, he will likely be shamed into doing the thing he was too cowardly/lazy to do in the first place… and you should let him correct himself.
    I’m a firm believer in holding physicians to a higher standard, and implicit in this is a willingness to police our own. Afterall, there is no doubt that his ass-hattery gives us all a bad name.
    Boards (I only know second-hand) take this seriously. One interesting logical (and well-deserved) extension of this is a group called where scumbag plaintiff physicians are targeted for board notification for lapsed ethics. Genius.

  2. Goatwhacker says:

    Unless it’s a blatant case I wouldn’t pursue it. I am a FP and work at a small-medium hospital that sends a lot of patients to a university tertiary care center. Much of the time the decision to transfer is based more on the facility capabilities than the expertise of the doctor. Sometimes I’ve transferred patients that if you had held a gun to my head I might have been able to take care of, but the services and consultants available at the tertiary center make it a much better spot for the patient.

    I almost always talk directly to the admitting doc as opposed to the ED doc so it must be set up a little differently where you are.

  3. erdoc_in_tx says:

    I would leave it to the specialist at your facility to make that call. If they are bothered enough by taking care of these transfers, they should make the effort to take action.

  4. The on call doc who “doesn’t feel comfortable”, should arrange for transport. That means, after they have evaluated the patient, if they don’t feel comfortable with the care, they should get on the phone and call a colleage at the mecca. Explaining to them why they want them to accept a fractured leg at 2 in the morning.

  5. Christine says:

    Better to transfer than practice incompetently.

    However, if it’s just a “middle of the night/boring case” transfer. Then you have a different issue entirely and I think that’s what you’ve described here.

  6. I agree that I’m not talking about gettng someone transferred out of the medical sticks for something complicated; I’m talking about the Big Place that wants this transfer to our Big Place.

    Most places will at least tell us they called some of their other docs, and nobody would take the case (not on call); at our place all the ED – ED transfers are accepted by the ED docs. It’s not a perfect system, but it keeps the hospital out of trouble.

    And, yes, I’m only talking about the truly egregious cases. There may be something to letting the Orthpod (in my example) turn in the other orthopod, but I wonder if that’s a political nightmare. Perhaps the hospital should make these referrals to the board?

  7. tough call for the other specialists at St. Elsewhere – if you’re a surgeon that will do what’s expect but one of you’re on-call friends won’t what do you do? If you accept the in-house turf/transfer once; you’re stuck for life. On the other hand, when I get something I only do once or twice a year I transfer it out too and who am I to tell someone what their level of competence should be? The way we handle it is the transfering specialist has to talk to the receiving one. If it was a nasty fracture and the ED isn’t known for pulling this kind of stunt I’d leave it otherwise I’d call the specialist direct and fire a warning shot.

  8. The hospitals where I work are beginning to look at how many cases you/I have done since last credential process. I don’t know if they have actually taken away anyone priviledges for say microvasular cases for lack of cases, but the possibility is there.

    In my case, I withdrew those priviledges (yes, if push came to shove I could possibly pull out the rusty old skills, etc) so I and the ER doctors didn’t have to have said discussions. It’s one thing to pass a written test, it’s another to actually do the procedure in question.

    If said “ortho” still has priviledges for the procedure the patient needs to have done, then he needs to come to the ER and evaluate the patient. Then he should deal with the case or the transfer.

  9. I see this a lot, too. My perception is that a lot of these are truly driven by, not “laziness” per se, but a “I just don’t feel like dealing with this crap case,” and the “I haven’t done this in years” is a pretext to dump the case on someone else. My solution is generally to ask the transferring surgeon to contact an accepting surgeon. It puts the onus on them to explain to a colleague of the same specialty why the patient needs a higher level of care than they can provide. More importantly it gets me (and a receiving ER doc) out of the middle.

    I hate the argument that “it would be better for the patient to go to the Mecca.” It’s almost always better to be at the Mecca, but that’s moot when they’re in your ER. You need to establish that you can’t care for them there before you can legitimately initiate a transfer. Otherwise, we’d just send *all* of out patients to the Mecca.

    Great post.

  10. TheNewGuy says:

    I’ve gotten all kinds of transfers where the patient could have been adequately cared for, if only they had trained-and-boarded ER staff. Things like shoulder dislocations… what kind of physician works in an ER and can’t relocate a stinking shoulder?? (answer: somebody who has no business working in an ER).

    It’s one thing if you attempted a reduction and were unable to get it… that happens to everybody. I’m talking about not even attempting the reduction… just sending the patient someplace else.

    I accept these transfers… because somebody has to take care of the patient, and it might as well be me.

    Mighty inconvenient for the patient.

  11. beachdoc says:

    I had a footling breech with a prolapsed cord about 15 years ago in a hospital that did not provide OB services. Coincidentally, the “GYN department” was having a meeting in the hospital. The on-call OB-GYN declined to come to the ER to provide care for the patient as he explained “I don’t have OB privileges in the hospital” and “don’t care for that type problem.”

    No one in my administration ER or hospital nor the medical staff offered any support in the problem. I guess nothing has changed. That is one of the reasons I no longer practice hosptial based emergency medicine.

  12. agree with happy hospitalist but then expect blowback with the next consult to the same ‘uncomfortable’ doc. no surprises here. specialists eschew small towns for the safety of large groups where their call is reasonable. EMTALA has made us fight each other and has killed collegiality (along with ‘standard of care’ issues and the sometimes unreasonable fear of litigation). the real crisis on the doctor side is not in primary care, it is in the surgical subspecialties. who is going to do it? who is coming to my small town to do neurosurgery? no one.

  13. I’m at the smaller, sending hospital, and this happens not infrequently. When I am asked to secure transfer because of an issue that falls within a given speciality but not within their “comfort level,” I ask our specialist to secure a receiving specialist at the receiving hospital.

    So for these questionable cases I’d ask the sending ED doc to get the sending specialists to talk to the receiving specialist prior to accepting transfer. Personally I’d be hesitant to file a complaint to their board, I’d rather put the onus on the accepting specialists to determine if the sending specialist’s transfers are inappropriate.

  14. I believe that certifying board should be notified when someone who holds certification from them do not feel capable of carrying through a medical precedure that they are supposed to know.

  15. I’m a general surgeon in my 3rd decade of practice. My Board believes that I am Superman- it tests me (every ten years) on stuff that I haven’t ever seen, or not since my residency. Trust me, there are a lot of procedures that the Board believes I should be able to do that you would not want me doing on you. I don’t want an orthopod who does only spine procedures fixing my femur fracture either. I’m the best judge of what I can do, and in the absence of a mass casualty situation, my policy is that if I don’t more or less routinely do a procedure at 2 p.m., it’s not right for me to do it at 2 a.m. either.

    In the old days, when docs were allowed to decide what they wanted to do and when they thought it best to do it, it was rare for anyone to die in the streets for lack of medical attention. Now, with government, administrators, bureaucrats, lawyers, and various other regulators telling us what to do, where and when to do it, and whether and how much we’ll be paid to do it, it’s only a matter of time before people start dying, not in the streets, but in the ER, where they can force a facility to do the precious screening exam, but then only hope that there is a gullible specialist around who will subject himself to the stress, liability, and general unpleasantness of serving on an ER panel. It’s terrible that it has come to this, but, as they said in the movie, “Who you gonna get?”

  16. IglooDoc says:

    A real interesting topic.

    EMTALA is really specific and, as you have found out, rarely applied except when it comes to things that your hinder care and slow you down. The, as Dr Leap says, it grows fangs, claws, develops bad breath and reached 20 stories in height. One day soon hospitals will realize that if they drop Medicare, the all this crap goes away (a whole other topic, but mark my words, hospitals will start dropping Medicare…)

    So, let’s deal with the real world.

    The risk today is that if you push the issue, the specialist may balk and cease taking call, which in a smaller hospital could cripple the ER. The ramifications to you, in the mecca, are obvious. You will be getting all my ortho (for example) patients if my one ortho guy stops taking call, instead of the occasional “comfort level” patient. OTOH, if this situation is allowed to occur and goes unchecked then the specialist comfort level rapidly deteriorates after midnight, only to return at 7am.

    What I do in the sending hospital is notify our (useless) hospital administrator to expect an EMTALA call from the mecca. They usually will have a talk with the offending specialist (along the “why are you turning away cash” discussions… something hospital administrators understand).
    If I am working at the mecca, I usually get the name and number of the sending hospital specialist and give the name to our forced accepting specialist, and let those two hash it out. I also give the mecca (even more useless) administration a heads up call.

    Reporting docs to their boards becomes a slippery slope, and should be reserved as a nuclear option. And remember Newton’s law: For every action there will be a reaction. I have seen stuff like this in up in court.

  17. I remember working in a very,very tiny thirty bed total for the whole hospital tiny and we had the opposite problem. We were grossly overstaffed. We had three general surgeons with one fancying himself a very good orthopod, two cardiologist/internists and fifteen family docs who all thought they could handle anything.We even had one infectious disease specialist who spent most of his time in Costa Rica.
    This was for a very small Kentucky town that was a very short ambulance ride to some of the best hospitals in the US (in Nashville).
    Our docs insisted on holding onto patients that had no business being in a hospital with no cath lab and a two bed ICU.
    I can remember getting screamed at by some family doc martinet when I overrode his attempted admission of a five year old with bacterial meningitis who was comatose,intubated and requiring pressors. The ER doc and I held the line and had the child flown to a children’s hospital where she ultimately survived but not without significant deficits.
    These guys truly thought they could handle anything.
    I applaud the lazy, the possibly incompetent for knowing they either can’t or don’t want to provide the highest quality care…the alternative was damn scary and I got my behind out of that hospital within eight months.
    I also know that reporting these people has little or no effect on their practice. They get a slap on the wrist or a lecture and they go right back to what they were doing. It’s not worth wasting your energy

  18. Dr. Kranky says:

    How about “Consults due to Incompetence” on the part of the ER doctors? This was alluded to briefly further up, but not commented upon. Trust me, as a specialist I tire of having to respond to “serious” problems that in fact turn out to be simple things that the ER doc coudln’t be bothered to take care of or, was incompetent to manage. Like the suggestions above, perhaps we could start reporting such individuals to THEIR respective certifying boards for possible disciplinary action (up to and including supsension of privileges for those particular problems). At my particular ER, this is NOT an occasional problem.

  19. good one dr kranky,
    good one. i’m sure you are a pleasure to deal with and have a keen insight into what the er guys go through every shift. you are a putz.

  20. Dr. Kranky says:

    Thank you for that clever rejoinder 911. That’s pretty typical of how I’ve seen you respond to things that rub your fur the wrong way. Why don’t you post a similar protest to the ER docs complaining about consultants?? I did nothing but turn the tables on you with exactly the same (justified) complaints. I’m sure YOU are a real treat to work with in the ER, given the fact that YOU have absolutely no idea what consultants have to go through after hours, NOT, mind you “on shift.”

    Want to have an intelligent discussion on a point of disagreement? Fine. Whan to act like an idiot and hurl insults needlessly? Get your own blog and reign like an anal sphincter.