Strategies For Reducing The Burden Of Call (1 of 2)

After catching my recent interview on the White Coat Investor podcast (thanks for the opportunity, Jim!), a like-minded reader wrote in asking if I had suggestions on how he might reduce or eliminate call responsibilities.

Except for a year of failed experimentation in ER surge call (don't ask), I never take call working in emergency medicine, so I'm a definite outsider approaching an interesting puzzle. Still, I feel excited to pitch in, if only to brainstorm strategy as someone who empathizes with a desire to cut back and soften the most dreadful parts of medicine.

Before we continue, a public service announcement from your friendly neighborhood ER doc: Thank you, on call specialists, for rising to the occasion to help patients in need. Despite a broken system, you come in and do the right thing, often at odd hours for society's disenfranchised and unloved. We now return to our regular programming.

Let's call our physician Dr. Slowburn. He's fallen for the concept of Financial Independence, but is not sure about Retiring Early. Given the option, he'd prefer to reduce the aggravations of his existing job and increase his career longevity within it rather than grinding it out until he can't take it any more and quitting medicine completely.

Pertinent details follow. Identifying information has been scrubbed to preserve our doc's anonymity:

• Surgical sub-specialist in a suburban, low cost of living region of the U.S.
• Call burden for two hospitals is shared among private practices in the area
• Hospital bylaws allow docs to opt out of call after 20 years of service or 60 years of age
• 2 senior docs just opted out of call, leaving each remaining doc to work 9-10 weeks of call per year (an increase of 30% per doc over last year)
• Hospital A, recently certified as a level 2 trauma center, pays approximately 3 hours' multiple of the average specialist's hourly rate per 24 hours of call. So if your hourly is $100, the hospital pays $300 per on call shift. (This is paid whether the specialist gets called 20+ times or not at all.)*
• Hospital B pays nothing for taking call*

*Pay for taking call, it should be noted, is the type of debate that elicits heated opinions on both sides. Exploring the ethics of pay for call is beyond this post.

Now that we understand the lay of the land, let's consider those variables that will influence any proposed strategy.

What's the age distribution of the on call pool of physicians?

The age of the remaining physicians who share the call burden is one important factor in determining how to proceed given the legacy exemption after  20 years of service / 60 years of age currently honored by the hospitals.

A seniority-based on call system that depends on under-compensated or uncompensated goodwill of young physicians is inherently flawed. The legacy system Dr. Slowburn inherited relies on a stable inflow and egress of physicians over time. It also assumes all new physicians are young (a mid-career doc would disrupt the assumed equilibrium) and all exiting physicians are old.

The baby boomers exposed this flaw for Social Security, with a large number of folks making a simultaneous withdrawal from the system in excess of the contribution. Those physicians who have already "paid in" to the call system (the 2 docs opting out of call) are the boomer equivalent, while the incoming younger physicians who "pay in" are told they will receive a future benefit that is uncertain at best.

Physician age is unlikely to reflect an even distribution. If the physician ages are skewed, any proposed solution must be able to withstand scenarios like the present one, where multiple physicians become eligible to opt out at once, placing a strain on the remaining physicians.

Bottom line: legacy exemptions from call are unlikely to solve Dr. Slowburn's call problem, and furthermore, are unlikely to withstand the test of time as call nights demand more of the specialists on duty.

How much does the gorilla in the room weigh?

It's important to understand the position of the two hospitals in the system to know Dr. Slowburn's true negotiating power.

If all the specialists in the area rely on hospital privileges to perform surgery, the hospital is negotiating from a position of strength.

On the other hand, if the surgical specialists can confine their cases to those performed at an outpatient surgery center owned and operated by these same independent physicians, they might find themselves in a strong position to negotiate with the hospital, or even eliminate call completely like the GI doc who spun turds into gold.

The hospital is under legal obligation to have available specialists on call under EMTALA, and may make a specialist's hospital privileges contingent on serving on the call panel. Hospitals often follow Center for Medicare Services guidelines to maintain their eligibility to treat Medicare patients, and those guidelines do not appear to require a specialist to serve on a call panel for a hospital where he or she operates.

Do the benefits of uniting the specialists in the region outweigh the risks?

A medicine sub-specialist I know was recruited to a desirable region as a W2 employee of a health system to treat in-network patients. After he'd fulfilled his contractual obligations (working 1 or 2 years), the remaining regional specialists recruited him to join their independent group practice, increasing his (and their) control over their business. The W2 employee saw his income go up on joining the independent group.

By banding together in a region where hospitals lack another viable alternative, the sole regional specialist group was able to negotiate favorable reimbursement rates with insurers.

If you live in a 2 horse town, becoming part of the only hay concession around is one way to maintain the upper hand on the horses.

This strategy should be weighed against any potential retaliation that could occur. If the hospitals hire a couple of employee specialists, it could have negative repercussions for the remaining specialists in the area (at least for those years until these employees can be recruited to once again join the independent specialists).

Can the on call specialists entice a physician transitioning to retirement to help relieve their call burden?

Dr. Cory Fawcett has written on this blog about his glide path out of general surgery, where he took call but did not follow clinic patients for several weeks at a time at different critical access hospitals as part of several years working in locum tenens positions.

While Dr. Fawcett worked at smaller, lower volume critical access hospitals providing respite to the sole surgeons in the area, perhaps lessons learned from his positive experience could lead to an analogous position at a larger or busier suburban facility.

Perhaps the on call specialists, the hospital, or some combination thereof can be persuaded to jointly fund a position for a retiring surgical sub-specialist who might enjoy occasional cases obtained on call without clinic responsibilities, while living rent-free and getting to know a charming area she might not otherwise have enjoyed.

Dr. Slowburn and colleagues could try to reverse engineer a position that would appeal to this theoretical retiring doc by using their experiences to understand what would make it sufficiently enticing. Maybe they target someone who sold their practice but misses medicine and wants a couple of weeks a month of on-again, off-again work for a few years.

Maybe this is pie-in-the-sky thinking, as what made Dr. Fawcett amenable to taking call was the low volume of the small hospitals her worked at, but it only takes finding the right fit for an appropriately appealing position.

It is more realistic to seek someone providing a partial offset of call duties than to expect to find a physician interested in working exclusively on call shifts.

Recruit A Jolly Good Fellow

While Dr. Slowburn's geography may or may not be close to an academic medical center, finding the closest training program and identifying the Fellows in your subspecialty who might be looking to moonlight is a strategy worth considering.

Moonlighting during fellowship is another way to earn money at a time when folks might have started a family or be deeply motivated to pay down high interest rate educational debt. With the collective financial support of the other specialists in the region, flying out a Fellow from the nearest program and offering to pay a supplement if she'll take your weekend call could be part of a longer-term solution.

It is advisable that the Fellow be treated collegially by the peers she is protecting, and that the remuneration be generous. This person is making your life better, and she will be very hard to replace if she feels disrespected or skimped on. I'd approach this similar to how I regarded getting help when our children are young: We never regretted spending the money, and we never replenished the sanity we lost whenever we tried to pinch pennies.

Show this Fellow your gratitude is by making it the moonlighting gig all the other Fellows compete to obtain. Better yet, let several Fellows participate!

A Fellow can also use the experience to test drive Dr. Slowburn's area as a potential region to open a practice or seek employment in the future, which may add to the mutual appeal of the arrangement beyond income alone.

If several specialists buy into this idea, they might persuade the hospital to expedite accreditation or provide perks like on-site housing (i.e., the call room) free uniform (scrubs) and free food at the cafeteria. One should never underestimate the power of free for a physician in training.

In the next installment of this 2 part series, we'll explore options for surviving as a surgical subspecialist outside of the hospital ecosystem. We'll also consider how we might devise a free market solution for picking up and giving away call shifts among specialists, and how we can establish market rates.