Taking call: Find satisfaction among the risks
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Taking call, an arrangement in which employees can be called during certain periods of time to work, is generally expected among health care workers, including orthopedic surgeons.
Because some amount of training is subsidized by the government and aided by patients, being on call “fulfills part of the social contract that orthopedic surgeons have with society in general,” according to David M. Brogan, MD, MSc, associate professor of orthopedic surgery at Washington University in St. Louis.
Source: Washington University Orthopedics
While the responsibilities for being on call vary by subspecialty and by institution, Brendan M. Patterson, MD, chair of orthopedic surgery at the Cleveland Clinic Health System and professor of orthopedic surgery at Case Western Reserve University School of Medicine, noted that, in general, being on call for a practice means being available to answer and manage patients’ problems after hours, while being on call for a hospital involves answering all requests for orthopedic input, both for inpatient and the ED, during a 24-hour period.
“You advise the ED where the patient can follow up after they are discharged from the ED or you may need to go into the ED to assess the patient and/or perform a procedure, such as reducing or putting a fracture that is out of alignment back in alignment,” Patterson told Healio/Orthopedics Today.
Personal risks
Although J. Benjamin Jackson III, MD, MBA, FAAOS, FAOA, professor at the University of South Carolina - Prisma Health, agreed with the social obligation that surgeons have to the community, he said it poses risk to the orthopedic surgeon who still has to deliver a high-quality product to patients the next day on minimal hours of rest.
“There is a lifestyle and practical component to it, too,” Jackson said. “I, as well as most physicians, do not drink alcohol when they are on call and need to be immediately available via phone. Additionally, you have to be 15 or 30 minutes from the hospital with most hospitals having bylaws regarding that. So, it is not like you can just do what you want.”
Brogan added families can also feel the burden of being on call when the orthopedic surgeon may have to miss personal or family events.
“[Taking call] can lead to fatigue, it can lead to disruption of personal schedules and missing personal events, which can have an impact on your loved ones and that is a real and not insignificant burden at times,” Brogan told Healio/Orthopedics Today.
Professional risks
In addition to personal life, being on call can also impact an orthopedic surgeon’s professional life, according to sources who spoke with Healio/Orthopedics Today.
“If you are stuck in the operating room performing a call case, you may not be able to perform your elective cases,” Brogan said. “They may have to be canceled or delayed, and that is a burden on your elective practice patients.”
Published research has shown that the rate of burnout is higher among physicians who take a lot of call, according to Daniel A. Osei, MD, hand and upper extremity surgeon at Hospital for Special Surgery. He added that taking call may also lead to financial disincentives, because “a lot of emergency care happens in patients that do not have insurance.”
“The more time one spends taking care of uninsured patients, the less time a physician has available to provide care to insured patients. While the financial side of medicine is not what drives most of us, it is still an important issue that affects the financial viability of one’s practice or department,” Osei said.
Compensation
One way to offset the financial disincentives associated with being on call is for orthopedic surgeons to be compensated for their time, sources noted.
“For providers who have a practice that is independent of the hospital and the hospital is in a situation where it requires those services to keep the doors open and the hospital is a resource for the community, I think the hospital has an obligation to compensate physicians because a disproportionate amount of the revenue that flows in from an episode of care goes to the hospital relative to what goes to the doctor,” Patterson said.
Brogan said receiving compensation may lessen the burden of being on call and signals to surgeons that the institution values their time.
“I think there is something to be said for, if not just the money itself, the signal that it communicates in terms of the value of the person being on call,” Brogan said.
However, Stephen Warner, MD, PhD, an orthopedic trauma surgeon at UTHealth Houston and Memorial Hermann, said compensation for call depends on the clinical practice setting and what the compensation model is for those settings. While practices where not all orthopedic surgeons may be on call may have a separate compensation plan, Warner said practices where all orthopedic surgeons are on the call schedule may have compensation plans built into their salary.
According to Brogan, the compensation model that seems to be most common is a stipend in which orthopedic surgeons receive a flat fee for being on call overnight.
“It might be [a different fee schedule] for the weekdays and a different fee schedule for the weekends, depending on the relative time required to be on call,” Brogan said.
Positive impacts on practice
Although being on call can lead to an increase in stress among orthopedic surgeons, Warner said it can be an avenue to build a practice by making new connections with patients that may not have been made through a more traditional outreach system.
Osei said he believes being on call brings a level of legitimacy to the specialty.
“Our patients can have any number of different types of conditions, problems and injuries. I think to be a complete orthopedic surgeon you should be able to provide care for the whole gamut of issues that affect the musculoskeletal system,” Osei told Healio/Orthopedics Today. “If we as a specialty were uncomfortable or unable to take care of these traumatic injuries, then I think that we run the risk of failing to uphold the standards and vocational responsibilities of our profession.”
In addition, Jackson said being on call can widen a surgeon’s skillset by providing difficult cases to work through, as well as routine cases.
“[Being on call] makes you a better surgeon by keeping that skillset,” Jackson said. “That is why it is important in the first 5 years to be able to keep that skillset and be able to take care of those complex trauma patients. That is why I think it is important to not lose the skillset that you spent so long working and training to be able to learn.”
‘Know your skillset’
But John Cherf, MD, MPH, MBA, an orthopedic surgeon in Chicago, said subspecialization within orthopedics may cause difficulties being on call if surgeons receive a case that is “out of their comfort zone or subspecialty.”
“Is it good for society if you have a sports medicine doctor who is on call treating pathology that is not their everyday practice?” Cherf, who is a member of the Board of Councilors and Evidence-Based Quality and Value Committee of the American Academy of Orthopaedic Surgeons, told Healio/Orthopedics Today. “Or does that doctor just bed down that case and give it to his partner who might be the hip and pelvis or hand expert?”
Jackson said it is important for orthopedic surgeons to know where their skillset is at and what they are not able to do. When orthopedic surgeons believe they are not comfortable with treating a case they were called in on, Jackson said they should call on their partners for help.
“I have gone in several times on nights and weekends I was not on call to take care of a difficult problem [that one of my partners] needed help with,” Jackson said. “I commend my partners for saying that they needed help, and they needed a certain level of expertise that they did not feel like they had as much as they wanted in that certain situation.”
Complex trauma cases
Depending on where the practice or hospital is located, Brogan said it might be possible to transfer the patient to a nearby facility with an orthopedic surgeon who can take care of the case. However, he added that not all cases may be easily transferred.
“There are certain cases that cannot be transferred and still result in good outcomes and those are the true emergencies, such as compartment syndrome,” Brogan said. “So, that speaks to the need for surgeons to be comfortable with some of those basic emergencies that do not lend themselves to being easily transferred and still have an acceptable outcome for the patient.”
Major centers may often have skilled trauma surgeons who can handle most complex trauma cases that come in, according to Osei. In those cases, Osei said the on-call orthopedic surgeon may be able to urgently manage the patient.
“If you have a bad pelvic fracture that comes in on a call, even a non-trauma specialist should be able to stabilize the fracture and make sure the patient is hemodynamically stable. In doing so, the on call surgeon can take what was an emergent situation and turn it into a semi-urgent situation that can be handled the next day by the specialist trauma surgeon,” Osei said.
On-call rotation schedule
One way to lessen the burden of being on call is by employing an on-call rotation schedule that allows surgeons to see who is on call when and to make sure the task of being on call is evenly distributed, according to Brogan.
“Without some sort of schedule, it becomes too easy to have one person either intentionally or unintentionally shoulder a disproportionate share of the load,” Brogan said.
Brogan added creating an on-call rotation schedule far enough in advance can also reduce the stress associated with the uncertainty that being on call brings.
“By having a schedule, and we try to schedule call relatively far in advance, then you know that you can certainly make plans when you are not on call and be able to live up to those obligations and if you are on call, then try to avoid making any critical plans for that day,” Brogan said. “Similarly, if there are critical life events or activities that I know that I have to be present for, then I make every effort to block those dates off from call.”
In addition to personal plans, Warner said having an on-call rotation schedule can help with planning outpatient or elective cases.
Some hospital systems and institutions may employ a backup call system, in which the general orthopedic surgeon call schedule is supplemented with a call pool of specialist trauma surgeons who the surgeon on call can reach out to if there is a case they are uncomfortable handling, according to Osei.
“Oftentimes you do not need to come in when you are on backup call, but having that assurance that if you are in over your head there is somebody with expertise who you can call on, ... that can decrease anxiety when you are going in to take care of something complex,” Osei said.
Mitigate on-call stress
Cherf said many hospitals and orthopedic groups have physician assistants, residents or fellows field some of the calls.
“There is a tiered approach to treating a lot of these patients, which can decompress the orthopedic surgeon,” Cherf said.
Patterson said having time off after being on call may help mitigate some negative impacts of call, while Brogan said regular exercise can be good for both mental and physical health.
“I try to participate in regular exercise, which is good for my mental health. It is good for my physical health, and it certainly makes it easier for me to deal with some of the long nights and long hours that being on call can lead to,” Brogan said.
Continuing medical education by reading trauma literature, attending trauma meetings and reviewing cases with trauma partners is also important for surgeons to stay up to date on the latest techniques and maintain their skillset, according to Jackson.
However, Patterson said mitigating the stress associated with being on call has a lot to do with the support orthopedic surgeons receive from family, friends and colleagues.
“There is a certain professional burden that comes with being on call and having to reserve time that you cannot be spending with your family, where you cannot have a beer or a cocktail with colleagues because you are the person who could be answering the phone at any minute,” Patterson said. “But there is also the perspective that call, especially in orthopedics and especially for some emergent conditions, is an opportunity to be a hero. You can save someone’s life, or you can save someone’s limb because you responded to the call.”
- References:
- Derman PB, et al. HSS J. 2015;doi:10.1007/s11420-015-9441-0.
- Gupta CC, et al. Ind Health. 2022;doi:10.2486/indhealth.2021-0124.
- Lundy D. Clin Orthop Relat Res. 2021;doi:10.1097/CORR.0000000000001930.
- Sprajcer M, et al. PLoS One. 2021;doi:10.1371/journal.pone.0259035.
- Stella JJ, et al. Cureus. 2018;doi:10.7759/cureus.2823.
- Tucker DW, et al. Orthopedics. 2022;doi:10.3928/01477447-20220511-01.
- For more information:
- David M. Brogan, MD, MSc, of Washington University in St. Louis, can be reached at brogand@wustl.edu.
- John Cherf, MD, MPH, MBA, of Advocate Health and the American Academy of Orthopaedic Surgeons Committee on Evidence-Based Quality and Value, can be reached at jcherf@cioo.org.
- J. Benjamin Jackson III, MD, MBA, FAAOS, FAOA, of the University of South Carolina – Prisma Health, can be reached at jbenjackson@gmail.com.
- Daniel A. Osei, MD, of Hospital for Special Surgery, can be reached at rennichr@hss.edu.
- Brendan M. Patterson, MD, of Cleveland Clinic Health System, can be reached at lesleyt@ccf.org.
- Stephen Warner, MD, PhD, of UTHealth Houston, can be reached at caitlin.b.barkley@uth.tmc.edu.
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