Neurosurgeon shortage critical

By Jennifer CalhounStaff writer

As of Monday, Fayetteville will only have a neurosurgeon on emergency call three days a week. The rest of the time, patients who may need emergency brain surgery will be sent to UNC Hospitals at Chapel Hill.
Cape Fear Valley Health System previously had neurosurgeons on call 24 hours a day, seven days a week through an exclusive agreement with Carolina Neurosurgical Services, a group of four brain surgeons — the only ones in town.
Earlier this month, however, one of the group’s surgeons, Dr. Rene Kotzen, voluntarily gave up privileges at the hospital to lower his high malpractice insurance costs, said one of the group’s leaders, Dr. Carol Wadon.
As a result, the group told the health system it could no longer provide around-the-clock coverage of the emergency room.
“I think the problem is that the emergency room has become busier, and we have gotten older,” Wadon said. “And with malpractice going up, it’s almost impossible to keep the business going.”
Dr. Jim Hunter, Cape Fear Valley Health System’s chief medical officer, said head trauma patients in the region who need surgery on the days a neurosurgeon is not on call will be flown to UNC by helicopter or taken by ambulance.
“What I’d like the public to know is that they will get care,” Hunter said. “I don’t want to send a panic through this community that we can’t give care.”
The health system also could look into forming an alliance with other medical centers or teaching hospitals, said Joyce Korzen, the health system’s interim chief executive officer.
Southeastern Regional Medical Center in Lumberton has a similar agreement with Duke University Health System.
Beyond that, Korzen said she hopes to solve the problem by using a collaborative approach that would include recruiting neurosurgeons and working with Carolina Neurosurgical to find ways to deal with the shortage.
Hunter said the shortage of neurosurgeons is a problem that’s been going on across the country for years.
With only a hundred or so doctors in the specialty graduating every year, competition to recruit can be stiff.
In Fayetteville, it can be almost impossible, Wadon said.
“About one out of every 10 (neurosurgeons) I interview over the phone actually come here to interview,” she said.
Fayetteville’s reputation as a military town and long hours working as an on-call trauma physician at the emergency room don’t help recruitment efforts, she said.
In addition, the practice receives low reimbursement rates from Medicare, Medicaid and Tricare — the insurance plans held by about 70 percent of their patients.
But Wadon said she believes the biggest problem with recruiting neurosurgeons comes from the fact that North Carolina is one of 12 states that has not passed significant tort reform legislation. Passing reforms could reduce damages awarded to patients from medical malpractice lawsuits or cap them at $250,000. The reforms also could keep doctors’ insurance rates from rising.
With those reforms, Wadon said she believes it would offer a more hospitable environment for neurosurgeons, who pay some of the highest premiums for medical malpractice insurance.
Dick Taylor, CEO of the North Carolina Academy of Trial Lawyers, disagreed.
“We recognize that there really are issues with malpractice insurance rates, and that it is unregulated,” Taylor said. “But we also need to make medicine safer. To take away the incentive to make it safer is the wrong way to go.”
Tort reform, he said, would also bring an economic advantage to an already privileged class at the expense of people who have been catastrophically injured because of medical malpractice.
The “privileged” moniker is one that Wadon and her group members — Drs. Bruce Jauffmann and Kim Koo — take exception to.
“Every year, we wonder if we’re going to be able to stay open,” Jauffmann said Friday.
Wadon added: “People think we make millions of dollars, but that’s not true.”
With reimbursements low and malpractice insurance costs high, Jauffmann said they’ve been taking hits from all directions.
It was the combination of those hits that ultimately caused Kotzen to bow out of surgical work at the hospital, Jauffmann said.
Kotzen’s yearly malpractice insurance costs had reached the upper six figures, making it impossible for him to continue performing surgeries, Wadon said.
And while Kotzen will continue to see patients in his office, his current malpractice insurance will not cover him if he performs surgical procedures.
Wadon said Kotzen’s surgical malpractice insurance was high because of previous lawsuits in New York.
According to the New York State Physician Profile Web site, Kotzen was sued in at least three different medical malpractice cases in Kings County, N.Y., in the late 1990s and early 2000s.
One of the incidents involved Kotzen operating on the wrong side of a patient’s brain, according to a Feb. 26, 2001, article from The New York Times. Another neurosurgeon had prepped the wrong side of the brain, and Kotzen began the operation on the wrong side, the article said. He recognized his error and resumed the surgery on the correct side of the brain.
Wadon said some of Kotzen’s suits were the result of working in a state with very high rates of malpractice lawsuits where liability was spread to everyone involved with the surgeries.
With Kotzen out of the picture and no new neurosurgical recruits in sight, trauma patients in the region could be compromised, Wadon said.
And much of that comes down to whether the state passes tort reform, she said.
“We’re just the canaries in the coal mine,” she said. “This could happen with other specialties, too.”