Concern remains over lack of solutions to worsening on-call dilemma

In 2006, the American Academy of Orthopaedic Surgeons published a position statement regarding growing concern over the lack of proper acute trauma care and urgent general orthopedic care.

In what has since been termed the ‘on-call dilemma,’ physicians are finding it more difficult — given a potential lack of reimbursements, increasing practice costs, increasing uncompensated care, worsening paperwork and the medical liability climate — to provide proper on-call hours. Some regions are more troubled than others, but it has become obvious that a problem still exists and must be corrected.

Correcting that problem is difficult, however, and this difficulty is rooted in the multivariate nature of the issue itself. According to Paul Tornetta III, MD — a member of the American Academy of Orthopaedic Surgeons (AAOS) Trauma/On-Call Project Team that put together the 2006 position statement — there is little if any sign that the situation is actually getting any better.

Through AAOS and the Orthopaedic Trauma Association (OTA), work is being done to provide a voice for physicians in the ongoing debate on how to rectify the on-call dilemma. Still, some are concerned nothing definitive is on the horizon.

Part of the problem as sources for this article noted, is a lack of willingness on the part of younger surgeons to take call hours.

Paul Tornetta III, MD, said the on-call issue is not improving and may get to the point where patients may not be able to access care. Image: Shaughnessy L

“As residents now are being trained to work 80 hours a week – as opposed to some of us who were trained to work 120 hours a week — they come out not really anticipating that they are going to have to take that much call,” Tornetta said. “With the 80-hour work week, we are graduating residents with far less experience than they used to have. Despite how bright and accomplished they are … they are simply not as well prepared as they were 10 years ago.”

Lisa K. Cannada, MD, a former fellowship committee chair with OTA and current chair of the AAOS Match Oversight Committee member, agreed with the sentiment that younger orthopedic surgeons are displaying less willingness to take call.

“It is hard to say if it is the generation itself, but it is a definite byproduct of the 80-hour work week,” she told Orthopedics Today. “The residents go home and we are still staying and working.”

Cannada, an Orthopedics Today Editorial Board member, noted that many residents, during their training, will witness patient dumping or attendings who actively try to avoid call. Being witness to this kind of behavior could negatively impact their habits in the future.

“It is really important to those of us who are training the new physicians that we never set a negative call example, because [the residents] are going to remember the negative,” she said.

Incoming residents, she added, are seeking jobs where they have limited or no call responsibilities.

“No new hire should ever be told they do not have to take call,” she said. “I am hearing that residents choose jobs where they do not have to take call. You have to earn that right.”

Tornetta added it is more common now for physicians to come out of residency with less experience – and be less comfortable entering practice right away. This leads them into fellowships to advance their training and experience, which can shrink their “comfort zone” and make them less willing to take call hours.

However, some physicians do not see the younger generation as a significant part of the issue.

“There are some data that suggest the younger orthopedic surgeons are doing at least as much call work as they have done in the past,” said David C. Templeman, MD, an OTA past president.

Importance of core competency

Core competency is seen as another issue, and physicians claim that only part of what needs to be done is actually getting done.

“My belief is that general acute trauma care should be a core competency for any orthopedic surgeon,” Tornetta said. “Just getting through the night, getting the patient to the next step, is something that an orthopedic surgeon should be able to do … but after that, it is the hospital system that needs to create the opportunity for definitive care. That is currently not really being done.”

“Orthopedic surgeons need to step up and recognize that emergency and urgent care of patients is part of our job,” he added.

Wade R. Smith, MD, said that education is a large part of making sure newer surgeons are prepared – not just in core competency, but also in differing systems.

“We teach them how to do things, and then they find themselves somewhere and they do not know how to do things in that system,” he said. “I do not think there has been a lot of emphasis on that. I think there needs to be – and it is teachable stuff.”

Cannada noted that core competency has been brought up as an issue in the past, with talk of making it mandatory for orthopedic surgeons to be able to take care of certain orthopedic conditions. She said soft positioning from the AAOS is partially to blame for the continued issues.

“What the academy position statement essentially said is, there should be no mandate and we should be able to solve this crisis ourselves,” she said. "So, without mandates from multiple areas, it is going to remain a problem.”

A large part of the problem in determining any solution for the on-call dilemma is that some communities – larger cities with more orthopedic surgeons – are not experiencing any on-call issues.

Tornetta said, “It is easy for a physician who is on call in one of the affiliate hospitals or one of the smaller hospitals in Boston without resources to refer a patient to a tertiary care center like Boston Medical Center, but if you are at a smaller community hospital where there is no referral tertiary care facility and you are not comfortable taking that problem, what happens?”

Smith said the variation between regions has to do with numerous factors, ranging from the amount and age of orthopedists in the area to reimbursement guidelines and malpractice laws.

He said a fundamental decision has to be made in regards to pushing for centralized care locations. This, however, would involve curtailing the rights of community surgeons and hospitals – making it a difficult venture.

Tornetta suggested a trauma care system wherein smaller issues get handled in smaller centers and larger issues get handled in the larger, with a certain number of trauma centers that are well supported for a certain population of patients in each region – a system he says would increase efficiency.

“You can support a smaller number of systems or places with whatever dollars are available, and that would help fund the uncompensated care,” he said, adding that such changes would be “a big process” that could not be changed in 1 year or one term of office. “But that is the only way to make the regionalization more consistent throughout the country,” he added.

According to Cannada, “In smaller communities, you do not have large groups. There may be one orthopedic surgeon, and he/she really cannot take call 30 nights a month. When you have a state like Massachusetts, which is populous, and you look at the density of orthopedic surgeons, that is not going to be an issue, but when you get to South Dakota, Wyoming, Nebraska … the density of orthopedic surgeons decreases.

“Nonetheless, we should come up with minimal levels of care which are acceptable for everyone in the United States,” she added.

Working for free?

Templeman told Orthopedics Today that with 20 to 30 million uninsured people in the country, it is remarkable that the on-call dilemma is not more of a crisis.

“There are some data that suggest the younger orthopedic surgeons are doing at least as much call work as they have done in the past. ” — David C. Templeman, MD

“I really think the reason … is that physicians have been so great historically about providing uncompensated care,” he said. “But it’s a double-edged sword. It perpetuates the problem because government and other people have the problem taken care of for them, so they do not need to address it immediately.”

The attitude that uncompensated care should be expected of physicians is seen as troubling, especially as public debate among nonclinicians and nonphysicians makes the position of the orthopedic surgeon asking for compensation increasingly difficult to defend.

“We are not going to solve the on-call crisis by telling orthopedic surgeons they are bad people because they do not want to take call,” Smith said. “People say, ‘well, you live in a community.’ I have never run into orthopedic surgeons who are not willing to serve their community, be it day or night … if you are a non-clinician or a nonorthopedist and you have never had to take care of patients or take call, it just seems so easy to say ‘well, listen, do your duty.’ It is also easy to demonize the orthopedic surgeons who do not.”

Regardless, Tornetta said, it should not be difficult for a physician to support their side of the debate, as payment is hardly the only aspect of the issue.

“I am happy to speak with anyone and say it is inequitable that you do work and do not get paid for it,” he said. “I think it is reasonable to expect that physicians, along with hospitals, insurance companies and everybody else, share the burden. Right now we are working in a situation where not only are we not reimbursed fairly, but we do not even have the resources to manage the patients equitably. It is far worse than the payment issue.”

Don’t give up the bone

According to Cannada, uniting to combat the on-call dilemma is one of the only ways progress can be made.

“We never want to give up the ‘care of the bone,”’ she said. “We need to maintain a solid front so we can continue to negotiate in the hospitals for on-call pay, adequate support staff and adequate [OR] time. We don’t want the hospitals to set the rules without our input.”

Smith said the AAOS and OTA are having discussions about the issue, with each trying to take the lead. He added however, that it is hard for large organizations to do much more than establish general guidelines. The conflict may come down to economics.

“I am a little concerned that this, like all other crises, will be solved through economic balancing,” he said.

Some worry, however, that a solution may be a long way off – if it even exists.

“There is not a lot of activity now to improve the situation,” Cannada said. “If you are looking at our leadership in the AAOS, this is a non-issue in their minds. It is not being addressed anywhere.”

Smith, a member of the American College of Surgeons’ Subcommittee on Orthopedic Trauma, said he thinks most legislatures are reluctant to get involved – but may have to eventually.

“If call is not affordable for hospitals or doctors, then over time there will be less call,” he said. “When this becomes a crisis … it moves up to the level of government issue. That is unfortunately what may happen before this is solved. It is hard to see a voluntary solution.”

“Right now, the problem is not getting better,” Tornetta said. “What you are going to see eventually is that this on-call problem will become drastic enough that people are no longer going to be able to get care. When that happens, there is going to be a whole bunch of politicians who put Band-Aids on the problem and do not solve it. It is going to get worse, and there is nothing on the horizon I am aware of that is going to change this for the positive.” – by Robert Press

References:

• Leahy M. Easing the burden of on-call coverage. Published in the June 2010 issue of AAOS Now. Accessed Sept. 16, 2010. http://www.aaos.org/news/aaosnow/jun10/managing2.asp.
• American Academy of Orthopedic Surgeons. Emergency orthopaedic care position statement: Position statement 1172. Published Sept. 2006. Revised Dec. 2008. Accessed Sept. 17, 2010. http://www.aaos.org/about/papers/position/1172.asp.

• Lisa K. Cannada, MD, can be reached at St. Louis University School of Medicine, Department of Orthopedics, Desloge Towers, 3635 Vista Ave., 7th Floor, St. Louis, MO 63110; 314-577-8850; e-mail: lcannada@slu.edu.
• Wade R. Smith, MD, can be reached at wrsmith@geisinger.edu.
• David C. Templeman, MD, can be reached at Hennepin County Medical Center, Department of Orthopaedic Surgery, 701 Park Ave. 862B, Minneapolis, MN 55415; e-mail: templ015@umn.edu. He receives royalties from Zimmer, and is a consultant for Stryker.
• Paul Tornetta III, MD, can be reached at 850 Harrison Ave., 3rd Floor, Boston, MA 02118; 617-414-5212; e-mail: ptornetta@gmail.com. He is a consultant for, and receives royalties from Smith & Nephew.

Does the current malpractice environment impact the on-call dilemma?

Some marginal risk to taking call

As a non-physician, I have always thought that the risk of making a mistake that permanently harmed a patient and taking call were two of the biggest downsides of being a physician. While I believe that call is a significant burden on a physician and that physicians should be compensated for it, I would not let the risk of a malpractice claim be a significant factor influencing whether to take call or not.

David M. Glaser

A physician in private practice faces any number of potential legal risks: The government seeking to recover alleged overpayments or claim fraud; employees may claim harassment or discrimination; colleagues may sue for defamation; and patients may sue for malpractice. While all of these risks are real, malpractice typically garners a wildly disproportionate share of physician attention and worry. However, it is important to remember that malpractice is the liability most likely to be insured. For any of the other situations, it is likely that the physician will incur out of pocket expenses to defend a claim, even if the claim is entirely unfounded. By contrast, in a malpractice case, even if the physician is ultimately determined to be negligent, the physician is unlikely to face direct personal financial liability. I don’t mean to minimize the psychological aspect of a malpractice case; presumably the reason any allegation of malpractice is so troubling is that all professionals want to be confident that they are providing the best care. However, from an economic analysis, I believe that many physicians perceive the economic harm of malpractice to be much larger than it is and underestimate the other risks.

There may be some marginally higher risk that a physician on-call will face malpractice liability. There is certainly a possibility that some element of the patient’s history will complicate care. However, that risk exists for every patient encounter. The risk of missing a drug allergy or a pre-existing condition is simply a risk of medical practice.

I believe that the biggest risk associated with providing care while on-call is a mistake caused by fatigue — which seems unavoidable; emergencies happen, and someone needs to provide care, even in the middle of the night.

A physician should consider the impact of call on the physician’s life. But I would advise that the malpractice risk should not be a significant factor in their decision.

David M. Glaser, JD, is a health care attorney at Fredrikson & Byron, P.A.

Surgeons must assess risk-reward of call

Orthopedic surgeons, like other medical specialists, are increasingly reluctant to volunteer for on-call service, particularly in community hospital ERs where the surgeon must treat previously unknown or indigent patients presenting with injury and unaddressed co-morbidities.

B. Sonny Bal

Some say the fear of professional liability exposure while providing on-call service is unfounded; data may show that ER coverage does not increase liability exposure, or that if a physician is sued, the odds are overwhelming that he or she will prevail. However persuasive, these arguments fail to convince; the decision to provide on-call service ultimately rests on a risk-reward analysis that all rational beings make daily.

While physicians prevail in the majority of lawsuits alleging professional negligence, such claims by plaintiff-patients are hardly benign. A professional negligence lawsuit can be an unforgettable event; an allegation of professional misconduct can be very unsettling. Aside from the emotional toll, a lawsuit will typically consume an overwhelming amount of time in preparation, meetings, research, and investment in playing the role of patient adversary. Years of uncertainty and investment ultimately go unreimbursed, and there is little to show for in the end, even if a jury rules in the defendant doctor’s favor.

In the animal kingdom negative stimuli reinforce avoidance behavior. With that in mind, and given the intensely negative experience that a lawsuit brings and the ease with which overzealous attorneys can file a lawsuit and roll the legal dice hoping for a settlement before trial, surgeons can be reasonably expected to avoid those behaviors that increase the odds of legal exposure, while emphasizing activities that reduce that risk.

Given the scenario of negligible or non-existent reward, and the small, but finite possibility of a career-shattering negligence claim, on-call service, despite the altruistic charm of a professional calling, becomes an activity that a rational being will instinctively avoid. Unless this reflexive risk-avoidance behavior is modified by corresponding changes that alter the risk-reward equation, the fear of medical malpractice litigation will continue to dampen physicians’ enthusiasm to volunteer on-call service.

B. Sonny Bal, MD, JD, MBA, is Associate Professor of Hip and Knee Replacement, at the Department of Orthopaedic Surgery, University of Missouri School of Medicine.