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Managing the call schedule

By Carolyn Rogers

Challenge is to balance the needs of patients, physicians

Throughout the nation, patients are finding it difficult and sometimes impossible to obtain emergency care services in a timely manner. At the same time, physician practices are finding it difficult—and sometimes impossible—to provide the depth of emergency care services that are required. Balancing the needs of patients and the needs of physicians is a challenge that must be met, says Jeffrey Mark Smith, MD, an orthopaedic traumatologist in private practice in San Diego, and a former full-time faculty member at the University of California, San Diego.

“Currently there is no consensus on whether to pay physicians for call. The central issue is how to maintain call coverage.”

The call schedule and the trauma lifestyle
Managing the call schedule is a key factor in improving the trauma lifestyle, according to Dr. Smith.

“The call schedule matters,” he says. “At one time, physicians took call to help grow or support their practices, or as a rite of passage as they rose in seniority in a given practice. But when managed care organizations began directing insured patients away from the on-call physician to other physicians, they also took away a major incentive for physicians to take call.”

Also, as residency and fellowship graduates become more subspecialized and much more opposed to taking call, the number of more senior surgeons wanting to go off the call panel has also slightly increased, Dr. Smith reports. As a result, on-call participation has declined and, in some locations, is at or near crisis level.

Loss of paying patients to other physicians isn’t the only reason for the declining participation in call. The perceived increase in medical liability risk, the growing number of uninsured, the impact that taking call has on a physician’s regular practice, and other quality-of-life issues also contribute to the problem. Other factors include inefficient access to operating rooms, unavailability of support staff, normal fatigue, interference with elective cases (or those of a colleague), and the unpredictable delays of on-call cases related to equipment availability, associated injuries, and anesthesia issues.

Uninsured patients, physician shortages
The proportion of uninsured patients visiting emergency departments (EDs) is growing along with the overall uninsured population, Dr. Smith says. “Both hospital and ED capacity have contracted over the last decade while the sheer volume of ED visits has actually increased by 20 percent, according to 2003 data from the National Center for Health Statistics.

Recent studies also show that uninsured and underinsured patients are relying more heavily on EDs because physician office appointments have become more difficult to obtain.

High demand for specialty services—such as orthopaedics, neurosurgery, and otolaryngology—combined with relative shortages in key specialties exacerbates the problem in both academic and private centers. Plus, “Reductions in resident support due to work-hour limits place the direct-response burden back on the staff physician,” he says.

Call conflicts
“Many orthopaedists and other specialists find that the unpredictable demands of call are often too detrimental to the efficiencies required to survive in a private practice,” Dr. Smith says. “No physician wants to neglect scheduled office patients or delay scheduled procedures.”

Because many ED calls occur at night or on weekends, many physicians—who are placing greater emphasis on time with their families—perceive call coverage as too much strain on their personal lives and well-being.

Professional liability turmoil
The perception of increased liability risk for on-call activities also influences surgeons’ willingness to take call. Patients who have sustained complex injuries, but have no established physician relationships (and are therefore less likely to follow-up on care) present a high-risk liability scenario for surgeons.

“To make matters worse, this scenario is often coupled with no compensation from the patient or insurance to help offset the physician’s higher premiums,” Dr. Smith adds.

Orthopaedists: “Take the lead” in finding solutions
To maintain call coverage and improve the “trauma lifestyle,” Dr. Smith urges orthopaedic surgeons to work within their communities to develop a proactive strategy that addresses medical staff structures, hospital support, emergency care operations, and payment. “If the on-call physicians are well-supported in all these ways, patients will definitely benefit,” says Dr. Smith. “As the providers of acute musculoskeletal care, we should be the leaders in determining the solution to on-call problems.”

Successfully managing the call schedule
Keep in mind that there is no one plan or solution to managing the call schedule, Dr. Smith cautions.

“Ensuring that patients have adequate access to emergency care in the safest possible environment is of primary importance,” he says. A successful plan compensates surgeon participants for the care and services provided and balances the pros and cons of subspecialization.

“Any on-call solution should focus on the goal of providing the best quality care with optimal efficiency for a reasonable period of time, at the least cost,” he says. “If the plan is fair, these goals are achievable most of the time.”

Fairness
Under a fair plan, call isn’t used as a way to pass on “bad” cases and keep “good” ones.

“Transfer agreements are acceptable, but ‘dumping’ cases is not,” he explains. “If the ED refers funded cases to your service when you’re not on call, but transfers unfunded cases, that’s a violation of the Emergency Medical Treatment and Active Labor Act (EMTALA).”

When developing a plan for an institution, the planning team should keep in mind that each call participant has his or her own concept of “fairness” as it relates to equal share of call (weekends, nights, holidays) and seniority issues.

Compensation levels
Settling on an appropriate compensation plan can be problematic, Dr. Smith warns. (See “Getting paid for taking call” on page 1 for more information on this topic.)

“Too much compensation might lead to interest in call solely for financial reasons,” he says. “And if one service or specialty is paid for taking call, other services will also expect to be paid, even if their work demands might be less.”

If too little compensation is offered, however, too few people will be interested. As a result, those surgeons left to provide the call coverage not only carry a disproportionate share of the burden—they’re also inadequately compensated for that time,” he says.

Alternatively, providing no call pay—while referring all complex traumas to a regional center—may decrease the incentive for institutions and physicians to keep “funded” complex cases.

“Referring centers and orthopaedic surgeons can, and should, continue to care for funded and unfunded straightforward cases, while sending patients with more complex injuries to the regional center,” he says.

According to Dr. Smith, one consideration would be to require the on-call specialist to do the following:

See and evaluate (not just by remote imaging) all transfers, except where transfer agreements have been already worked out; or

Communicate personally, rather than through the ED physician, the reason for transfer to the regional center.

Subspecialization levels
The on-call solution will also vary based on the level of subspecialization at your institution, Dr. Smith says. “If there’s too much subspecialization, it can be harder to fit generalists into the schedule, or to find a “fair” balance of general, hand, spine, and trauma call.”

When too few specialists are on staff, the medical center may have difficulty treating complex injuries (i.e., acetabular fractures) or too much burden may be placed on the few available specialists. In this instance, “shared call, with hand-offs from the generalist of all or a certain balance of nonemergent trauma and fracture cases to the few trauma or fracture specialists, may be the answer,” he says.

More solutions
Orthopaedic generalists who provide on-call services should be supported in maintaining their skills in basic fundamentals, and should not be held to the standard of care provided by a subspecialist. They should have an avenue to refer or hand-off more complex cases.

The specialists who provide support for referral or hand-off of complex cases should also have access to an appropriate volume of less-complex funded cases, or access to some of the stipend monies to support a financially viable practice.

Lastly, “We need to educate and encourage all our patients and communities to support for medical liability reform,” says Dr. Smith.

Carolyn Rogers is a staff writer for AAOS Now. She can be reached at rogers@aaos.org

AAOS Now
September 2008 Issue
http://www.aaos.org/news/aaosnow/sep08/managing2.asp