Emergency providers request specialty consultation to seek opinions and expertise to provide high-quality care for patients. This request is made with expectations of minimal or no delay in care, but, increasingly, seeking a consulting physician prolongs lengths of stay and exacerbates volume dilemmas.

Similarly to most emergency providers, covering consultants also face higher patient volumes and several global and specialty-specific disincentives to cover call. The Emergency Medical Treatment and Active Labor Act (EMTALA) guidelines, established to protect uninsured patients who need acute care, have also increased nonreimbursed and nonurgent care being delivered in emergency departments (EDs). Increasing malpractice insurance costs and low or nonexistent compensation for taking call further deters specialists from participating in call pools.¹ This creates an even larger burden for surgical specialists who might need to perform emergency procedures that are not reimbursed.² Related to these reasons, surgical specialty coverage is demonstrating a well-documented decline across the country.² The lack of specialists available to EDs may result in negative outcomes for patients owing to delays in definitive care or increased number of transfers to tertiary centers.³

The limited literature suggests serious gaps in ophthalmology coverage for EDs.⁴ An analysis in Florida indicates that ophthalmologists take less call than other surgical subspecialists.⁵ The American Academy of Ophthalmology also published an editorial to describe the reasons why the ophthalmology coverage gap exists and why they speculate it will continue to expand. The article suggests the growth of ambulatory surgery centers, which reduces private practice surgeons’ dependence on hospitals, outdated ED equipment, and growth of specialization, which reduces the number of ophthalmologists who feel clinically comfortable taking call.⁶ This same update indicated that consultants rarely need to physically come in because most calls are for advice or follow-up.

Many ophthalmologists who take call will often remotely discuss a patient and make a recommendation. A conversation between two physicians about a patient without examination, review of the chart, or consultant documentation of their findings and recommendation is defined as a curbside consult. There are several perils in performing curbside consults. First, providing an opinion about a patient without knowing the individual details of the case can lead to unsafe decisions by the care team and may result in delay of appropriate care or patient harm. This can also lead to wasted resources to correct the care plan or manage complications. There is also liability that the consultant incurs during a curbside consult. Often, the requesting physician will document the consulting physician’s name and whether a curbside or formal consult was performed. This puts the consultant at risk for recommendations that they might not have made after examining
the patient or reviewing diagnostic testing. Additionally, without a documented request and written recommendation, the consult is generally not billed and reimbursed, reducing revenue for the hospital that is potentially paying the physicians to take call. Although ophthalmologists are accustomed to giving opinions over the phone as an alternative to coming to the ED, this method of practicing medicine can be unsafe and lead to poor quality yet more costly care.

Specialty coverage inconsistencies, especially when there is no physician to take call, are particularly problematic, resulting in delays, potential errors, or excessive and costly transfers. The poor availability results in significant clinical, financial, and operational impact for patients, providers, and health systems.