Pain Relief for Scheduling On-call

How to Care for Patients After Hours

By Susanna Donato
Susanna Donato is a writer for Physicians Practice

Whether you’re a by-the-numbers, one-in-four doc, or a small-town lone ranger who is on call all night, every night, you can improve the way your office handles being on-call.

Not simple math
Many practices dole out call duty on a rotation — one in four nights, one in four weekends on call (or one in seven, one in 10, one in two).

“This sounds very equitable, but inevitably … one physician travels a lot or can never work Fridays or decides to cut back hours. The pie sometimes doesn’t get divided evenly,” said Pamela L. Moore, a practice management consultant and senior editor for Physicians Practice, Inc. “Some practices try to level the playing field by paying physicians for extra call duty. The trouble with this plan is that physicians hate call so much that you can’t pay them enough to take it.”

Moore pointed out that an April 1999 Medical Group Management Association (MGMA) Information Exchange survey found that 85 percent of primary care physicians would not take more call, even for more pay.

Physicians also throw a wrench in the schedule system when they want to be home in the evenings, come into the office late or spend weekends with their kids.

“More physicians are going along with what we call the Generation X school of thought: ‘I want to practice good medicine, I will work hard, but I also want to have a life,’” noted Germaine Lorbert, a senior search consultant with Cejka Search in St. Louis, Mo.

Build your equity
As a result, practices across the country have developed sophisticated systems to track call. Allen Daugird, M.D., uses relative value units (RVUs) at the University of North Carolina at Chapel Hill’s Department of Family Medicine.

To establish the system, group members assigned specific numerical values to various types of call. Using a spreadsheet, the practice calculates full-time and part-time schedules, after-hours activities and office responsibilities. After some adjustments, each physician receives an equitable call schedule.

Other practices can imitate Daugird’s spreadsheet, purchase software (see “Additional Resources”) or create their own systems.

“The RVU idea works, but so does weighting call days more simply,” Moore observed. “For instance, say taking call on a holiday is worth two days of call, or that taking call Saturday night is worth one weekday call.”

A few practices allow physicians to opt out of taking call in exchange for a chunk of their income. Another Information Exchange, conducted by MGMA in December 2002, found call typically valued at one-quarter to one-third of a physician’s pay.

Before giving up call, however, try to think of some creative solutions, starting with patient communication.

“Physicians are vehemently complaining that patients abuse call,” said Jayne Oliva, a principal with Burlington, Mass.-based Croes-Oliva Group. “Patients complain, ‘I can’t find my doctor all day, he never calls me back, so of course I call.’” In consumer-driven health care, patients feel they have the right to call. Managing patient expectations is essential to making [call] work.”

Moore echoes that theory. “You can reduce the literal number of calls you get by proactively educating patients about issues they tend to call about after hours,” she said. “Give new parents handouts about what to do about fever or vomiting and when to consider it serious, for example, and review it with them, and they are less likely to call in the middle of the night.”

Muster your resources
In addition to communication, ensure patients receive the care they need. Some hospitals help with this effort by developing full-time or night and weekend hospitalist programs — with physicians who care for all patients in a facility. One New Hampshire practice took that idea a step further and hired their own hospitalist to reduce demand on staff during daytime hours.

“We used to rotate one internist a week to go to the hospital, but physicians still had to deal with office issues, like making phone calls from the hospital,” said Steve Paris, M.D., a pediatrician and medical director for the Manchester community practice of the Dartmouth-Hitchcock Clinic.

“Today, people are pretty acutely ill when they are hospitalized,” Paris added. “We had a general sense that we probably should upgrade the quality of hospital care we provided. So, a year ago, we hired a person who works days in the hospital as his primary responsibility, and everyone is happier. Internists know they’re in the office. The hospitalist is always there at the hospital to take care of patients. He isn’t conflicted because he has no other responsibilities.”

Paris’ practice relies on the local hospital’s nighttime hospitalist program for overnight coverage. Pediatricians get some call relief, as well. “We’re fortunate that the hospital has a Level III nursery, so there always is neonatal coverage,” Paris said.

Before you dive into a hospitalist partnership or call-sharing with other local providers, review your managed care contracts. Check the definitions of credentialed providers and stay in compliance to make sure you’ll be reimbursed for care provided by a physician from outside your group.

Delegate call
Lorbert has seen specialty groups expand their call group — and thereby reduce call — by sharing duties with internists. The internists take first call and contact specialists, such as gastroenterologists and oncologists, when needed. “That is a great solution, but only for nonsurgical subspecialists such as gastroenterologists and endocrinologists,” Lorbert said.

Yet another option is handing over first-call responsibilities to nursing staff or physician assistants.

“This works best in practices that get middle-of-the-night calls for the same, fairly nonemergent issues over and over,” said Moore. “OB and pediatrics are good examples. A first-time mother will panic in the middle of the night when her baby has a fever. This usually doesn’t require physician intervention.”

Moore pointed out a few keys to success. “First, you’ve got to have a well-trained staff. They need to follow protocols and understand their function is not to protect physicians from calls at all costs.” She also noted that practices should expect to pay staff for taking on the additional burden, and practices should review the program after the first couple of months to make sure it’s working well.

Remember call’s roots
When you move away from ratios and toward solutions, you can begin to address the reason why call exists in the first place.

“It’s less about ‘I don’t want to take call every night,’” said Oliva. “Instead, it emanates from a conversation that says, ‘What’s the best way to manage this patient population?’ Solutions come when you talk about patient care delivery instead of call because that’s what call is. It’s about how we service our patients when the office isn’t open.”

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