Iread the interesting article "Who's on Call?" in the June 2009 Practical Neurology (vol. 8, no. 5, pp. 27-30). You wrote the article, but several comments in the article were paraphrased comments by Dr. Likoski, Chair of the American Academy of Neurology's Neuro-hospitalist Section.

On page 28 of the article, it states:

Plus, he adds, until relatively recently, neurologists going into practice did not anticipate after-hours emergency call duty as a significant responsibility. An obstetrician going into practice 20 years ago, for example, would know that his/her career would require call. But until the dawn of tPA, there wasn't much need for neurologists to be available to emergency departments at all hours, Dr. Likosky observes.

Now I am not sure how old Dr. Likoski is or how long he has been in neurology practice, but his comments are very wrong and misinformed. I have been in private neurology practice since 1974 and continue to practice at this time. I am sure I am speaking for many of the neurologist readership that have been in private practice for the last thirty plus years. When I entered neurology practice in Houston, Texas, in 1974 it was a given and accepted responsibility that I would be taking ER calls on my call day. The ER call was one of the reasons I elected to join a neurology group, so I would have built-in ER call coverage. Many neurologists in solo practice would align with other solo neurologists to cover ER calls and their practice. This was not a choice in my practice. Of course, I was not happy getting up to go to the ER or even hear the phone ring in the middle of the night for an ER call, but this was a given and we did it.

The neurologist played a very important part in the emergency room, and with the ER physicians we consulted. We admitted all strokes, TIAs, head traumas, seizures, and many coma patients, and we were needed on a regular basis to see these patients regardless of their ability to pay. I was on staff in many non-academic hospitals that required neurology ER services, which I performed when I was on call. In head trauma cases in some hospitals the neurosurgeons would not see the case unless a neurologist saw them first and decided that a neurosurgeon was needed.

Why did I see these patients on ER call? First, it was a given responsibility, and many of the referrals were from general physicians who also sent patients to my office. Not seeing their patients in the ER when needed would certainly not have been a positive thing for my practice.

In the early 1990's the neurology section at one of the larger hospitals where I was on staff enacted a rule that a neurologist could not be on active staff of the hospital unless he took ER call. This was not paid call. In 2000 I left my group practice and went solo but still took ER calls for nine more months. This was the beginning of the era of hospitalists in Houston, and they were a part of the majority of the hospitals where I was on staff. I believe they were essential and beneficial for my emergency room call. They were immediately available, and when I got called by one of them from the ER, we discussed many cases over the phone. If the patient was stable and I was comfortable with the hospitalist taking care of the patient, he or she was admitted to the hospitalists, and I would consult them the next morning.

In the middle of 2000, I stopped hospital work for an office practice only. I no longer go to ERs. Many neurologists, young and old, I have spoken to appreciate the proliferation of hospitalists and now, neurohospitalists. However, not all hospitals have stroke units and administer TPA. I have been and will always be in favor of reimbursement for ER call even though it no longer applies to me. If neurologists on call have to go to the ER to give TPA and take care of a stroke patient, that is a big plus for the patient.

Before TPA was available we did not have much to offer for acute stroke patients, but still had to take care of them. With more neurointensivists trained and becoming part of many hospital staffs, and also the advent of telemedicine for hospitalists, the need for ER call for many private practice neurologists will likely decrease. The best of times for a neurologist on call is beginning.

—Ronald DeVere MD, FAAN
Austin, Texas