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Who the ED calls, and how long the answer takes(4 min read)

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Deepesh Arora

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This is post 4 of 10 in the series “FabrixMed learnings”

  1. The referral is where healthcare goes to die
  2. The ED doesn’t just need more hands. It needs faster answers.
  3. The government keeps a map of where healthcare is missing
  4. Who the ED calls, and how long the answer takes(4 min read)
  5. We ration specialists by zip code
  6. Screening is a logistics problem, not a medicine problem
  7. Stop selling the device, sell the outcome
  8. Independence needs shared support Scheduled for November 7, 2026
  9. Pay for the answer, not the appointment Scheduled for November 14, 2026
  10. Healthcare’s last mile runs on fax machines Scheduled for November 21, 2026

Who the ED calls, and how long the answer takes

In my last two posts I argued that the emergency department’s problem isn’t just missing hands — it’s missing answers. Decision delay, not just doctor shortage. This week I found the data. It says I’m right, and it’s more specific than I expected.

Here’s the setup. When an ED doctor hits a case she can’t resolve alone, she calls a specialist — a consult. Nationally, the CDC’s emergency department survey found a consulting physician was seen in 11.6% of ED visits in 2018, 13.5% in 2019, and 15.7% in 2020 — trending up. Studies that count consults requested (not just completed) put it at 20–40% at teaching hospitals. So somewhere between one in eight and one in three ED visits waits on a specialist’s answer.

Now the part nobody talks about: who gets called, and how long each one takes. A 2026 study out of the University of Virginia tracked roughly 35,000 consults over a year and measured the one thing that matters — minutes from “we need you” to an answer the ED can act on. It is, as far as I can tell, the only detailed breakdown of its kind in the US. The CDC doesn’t record consult specialty nationally. Read that again: the country obsessively measures door-to-doctor time in every ED, but nobody nationally measures consult-to-answer time. We clock how fast a doctor arrives. We don’t clock how fast the answer arrives.

Here is what the study found:

Specialty called Share of consults Median wait for an answer
Internal medicine 26.8% 90 min
Cardiology 8.2% 164 min
Psychiatry / behavioral health 6.7% 196 min
Neurology 5.6% 178 min
General surgery 5.2% 144 min
Orthopedic surgery 4.9% 154 min
ICU 4.0% 60 min
Neurosurgery 2.9% 155 min
ENT 2.4% 153 min
Ophthalmology 2.3% 160 min
Toxicology 0.9% 92 min

Overall median: 108 minutes. Nearly two hours, every time, just waiting for the answer.

A few things jump out.

First, the psychiatry paradox. Behavioral health is only about 7% of consults — yet it has the longest wait of any specialty: 196 minutes, over three hours. And this is the specialty with the worst boarding crisis in the country: roughly 1 in 10 mental-health ED visits among Medicaid-covered youth ends in boarding for 3–7 days. The patients who wait longest for an answer are the ones who then wait longest for a bed. The delay compounds.

Second, the pattern in the slow list. Cardiology, neurology, neurosurgery, ENT, ophthalmology, orthopedics — the longest waits cluster around exactly the specialties that hospitals struggle most to keep on call. Three out of four ED directors say their specialist on-call coverage is inadequate, and the worst gaps are neurosurgery, hand surgery, orthopedics, ENT, ophthalmology, dermatology. These are the 2am specialties: the ones nobody staffs at night because the volume doesn’t justify a full-time body. So the ED calls, and waits.

Third — and this is the one I keep coming back to — one in five of these waits is a number the system chose not to measure. Nationally. The measurement gap is the story. You manage what you measure, and American emergency medicine has spent decades optimizing everything up to the consult order, then shrugging at the 108 minutes after it.

I’m not pretending the data is perfect. This is one academic hospital where every admission requires a consult, which inflates the internal-medicine share. Other studies put orthopedics as high as 25% and psychiatry as high as 15% of consults. But directionally it holds: a large share of ED visits stall on a specialist’s answer, the answer takes hours, and the slowest answers belong to the hardest-to-staff specialties.

Which brings me back to the geometry question from my last post. Every shortage program tries to move the doctor to where the patient is. But the doctor isn’t the bottleneck in this table — the answer is. A cardiology consult that takes 164 minutes doesn’t need a cardiologist relocated to the county. It needs the question to reach a cardiologist faster and the answer to come back sooner. The specialist stays put. The patient stays put. Only the consult moves.

That’s the shape of what I’m building with FabrixMed — e-consult infrastructure that moves answers, not people, into the places and moments where the wait is longest.

I’m still learning this world. If you run an ED, staff one, or study consult patterns — tell me what these numbers get wrong. The map is better when more people draw it.

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