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One of the private patient rooms at Tampa General Hospital’s new emergency department that opened in November.

Despite the growth in freestanding urgent care centers, more Americans are still heading to the hospital emergency room and waiting longer than ever before. In Florida, the situation is particularly acute.

Visits to the ER have been increasing in Florida since 1995, from 5.3 million visits annually to 7.3 million in 2006, according to the Florida Hospital Association.

At the same time, the number of emergency departments has declined by 10, from 220 in 1995 to 210 in 2006. In November 2007, Tampa General Hospital opened a new emergency department that handles 250 patients at once.

Nationally, the problem was documented in a study published in Health Affairs in January, which reviewed more than 90,000 emergency department visits from 1997 to 2004. As the number of visits increased and the number of emergency departments declined, the time it took for a patient to see a doctor grew 36 percent.

Alarmingly, it took nearly an hour for 25 percent of all heart attack victims to see a doctor, according to the study by Dr. Andrew P. Wilper and colleagues at Harvard Medical School.

Officials at the Florida Medical Association (FMA) believe the overcrowding in emergency departments has something to do with the trend in fewer doctors willing to work on-call. Often, doctors are reluctant because they feel the hospital doesn’t pay them an adequate stipend or doesn’t provide one at all, according to a survey of FMA doctors.

Out of 471 Florida physicians who had taken emergency room on-call services, 45 percent had dropped it in the previous five years. The most common reason was due to liability issues (57 percent) with economic and workload issues a common concern (roughly half). A minority was paid an on-call stipend (26 percent) and most (85 percent) were required to be on-call to be on staff. More than half (65 percent) considered not participating.

This year at the legislature, the Florida Hospital Association is attempting to get at least two bills passed dealing with emergency room coverage. One would provide sovereign immunity to physicians in the ER, which would amount to a $100,000 tort liability cap. Another would allow the Agency of Healthcare Administration to adopt rules for physician on-call coverage.

The FMA is worried that the rules would “mandate oppressive responsibilities,” according to the association’s Specialty Society Section.

The backlog of patients in the ER waiting room across the state also has to do with an overall physician shortage caused in part by the limited number of graduate medical school residency programs.

In 2006, there were 309 residency programs in Florida with more than 3,200 resident physicians in training at any given time, according to the 2007 annual report by the Graduate Medical Education Committee. Yet still, Florida ranked 41st nationally in terms of the number of residencies per 100,000 people.

The desire to be an ER doctor is certainly prominent among medical school graduates, but they have limited places to train. The University of South Florida in Tampa had 800 applicants for its 20 emergency medicine residencies at Tampa General Hospital, said Dr. Kelly O’Keefe, program director.

“The number of slots is truly dependant on funding from the government,” O’Keefe said. “Anytime we do expand, we have to show there is qualified faculty. For every three students there needs to be one trained faculty.”

The shortage of available doctors has affected recruitment for full-time physicians in the ER, O’Keefe said. “Even those places that may at one time have been well staffed, it’s not the case anymore,” he said.

Filling positions at Orlando’s Florida Hospital has too been difficult, said Dr. Dale Birenbaum, program director of Florida Emergency Physicians, a group of about 100 doctors who staff eight Florida Hospitals. Shortly after the hospital announced its new residency program in Orlando, which will offer 10 slots beginning in 2009, the program received more than 400 applicants.

“The greatest step a hospital can do is support graduate medical education and residencies,” Birenbaum said. “By increasing the infrastructure and training, we will help support the clinical care of patients by not only helping to produce more doctors that will likely stay in the region but increasing quality of care patients receive.”

The number of available residencies in emergency medicine will also increase at the University of Gainesville, which plans to add eight this spring to the 16 it already trains at a time. There are 48 through its Jacksonville campus. Orlando Regional Medical Center trains 37 emergency medicine residents at a time, while Mt. Sinai Medical Center has 21.

U.S. Sen. Bill Nelson (R-Florida) hopes to bring more residency programs to Florida and other states with the Resident Physician Shortage Reduction Act. Currently working its way through Congress, the bill would base residency programs on population.

“Emergency room doctors are getting called on to do more and more,” said Rich Morrison, senior vice president of government and regulatory affairs at Florida Hospital. “It’s incumbent on us to be on the forefront of that curriculum.”



March 2008

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