In another sign of the pressure facing Cincinnati's medical system, the Mayfield Clinic neurosurgery group has sharply reduced the number of hospitals where it provides 24-hour emergency coverage.

        Effective Sept. 1, Mayfield, the area's largest neurosurgery group, has limited its coverage of emergency consultations and services to four hospitals: Christ, Good Samaritan, University and St. Elizabeth South.

        The group has stopped providing “on call” service to seven other hospitals: Jewish, Bethesda North, Mercy Anderson, Mercy Fairfield, St. Luke East, St. Luke West and St. Elizabeth North.

        A letter informing hospitals of the change was sent Aug. 23.

        Emergency neurosurgery is performed mostly to treat trauma from car wrecks, falls and attacks; for strokes caused by bleeding in the brain; and for a variety of complex medical situations.

        Mayfield was down to asking 10 specialists to provide round-the-clock care at 11 hospitals.

        “There is a neurosurgical manpower shortage in the Tristate area. In the very near future, a critical number of the neurosurgeons in our community will reach retirement age and/or the age at which they no longer take emergency night call,” according to the letter from Mayfield.

        “Also, it has become increasingly difficult to recruit new neurosurgeons to this area. This is primarily due to the lower-than-average reimbursement from managed care companies, along with the skyrocketing medical malpractice insurance premiums that exist in this area. There are also legal considerations that necessitate this change,” the letter states.

        Mayfield's change has far-reaching implications for the community because the group is by far the largest neurosurgical group in town. Mayfield includes 14 neurosurgeons, 10 of whom take emergency calls.

        Greater Cincinnati has six other neurosurgeons, three with Riverhills Healthcare group, two in Middletown and an independent surgeon, Westwood-based Dr. Set Shahbabian, who performs surgery mostly at Good Samaritan Hospital.

        Not only is the overall number of neurosurgeons down from 30 a decade ago, six of the 20 still practicing are in their 60s and considered within five years of retirement.

        Among the issues raised by Mayfield's decision:

        It further exposes what doctors have been saying for months about a “brain drain” of specialist physicians affecting medical care in the area.

        It is an exception to a trend of high-tech care expanding in the suburbs.

        The change complicates plans to convert Bethesda North Hospital in Montgomery to a high-level trauma center that would improve service to the fast-growing northern suburbs.

        It raises questions about how hospitals will deal with orthopedic surgeons and other specialties considered in short supply. Traditionally, hospital bylaws have required surgeons to be on call for emergency cases in return for permission to perform elective, or nonemergency surgeries.

        “Hospitals are going to have to adapt to the times, just as physicians have had to adapt to the times. Neurosurgery is not going to be the only subspecialty making these kinds of changes,” said Dr. Thomas Saul, a neurosurgeon with the Mayfield Clinic.

        So how does all this affect care to people who suddenly need brain or spine surgery? At worst, it openly acknowledges limitations in care that have existed for several years. At best, it could improve care, doctors and hospital officials say.

        “What we've done here is consolidate high-tech services in high-tech hospitals. And that is really what the payor community has been pushing for,” said Carol King, vice president of emergency services for the Health Alliance of Greater Cincinnati.

        In many fields of medicine, such as organ transplantation and cardiac surgery, bigger has proven to be better because experienced staffs tend to report the lowest complication and death rates. In Greater Cincinnati, Mayfield is trying to send patients to the hospitals best-equipped to handle neurosurgery, said Mike Gilligan, Mayfield's president and chief executive.

        For adults, University, Christ and Good Samaritan are the only hospitals in town with neurosurgical intensive-care units and support from neurosurgical residency programs. In many cases, other suburban and rural hospitals were scrambling to transfer neurosurgery cases to the better-equipped central-city hospitals anyway, Mr. Gilligan said.

        In Northern Kentucky, the situation is somewhat different. Three Mayfield doctors who live in Northern Kentucky have agreed to cover emergencies at St. Elizabeth South in Edgewood, the most sophisticated hospital in Northern Kentucky. But unlike the three Cincinnati hospitals on Mayfield's list, St. Elizabeth does not have a neurosurgery intensive-care unit nor a related residency program.

        St. Elizabeth, which has no other surgical residency programs, is not planning to add one for neurosurgery. Instead, it hopes to train nurse practitioners and physician assistants to serve as “first responders,” similar to the role played by resident physicians in other hospitals, said Marc Hoffman, executive vice president and chief operating officer at St. Elizabeth.

        It plans to use its general intensive-care units to care for neurosurgery cases until patient volume grows enough to justify a dedicated unit, Mr. Hoffman said.

        The bottom line for the community, however, is that Cincinnati continues to lose neurosurgeons. Mayfield has been trying for months without success to fill three open positions, Mr. Gilligan said. But with Cincinnati insurers paying below-average rates, recruiting has been a challenge.

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