Paying Doctors to be on Call

Doctor on callAn article published in the December issue of Academic Medicine highlights the increasing shortage of doctors who are willing to be on-call, even for pay, and the reasons for and solutions to the crisis.

On-call duties were traditionally performed without pay by doctors in exchange for hospital admitting privileges. Today, residents at Academic Health Centers (AHCs) carry a disproportionate amount of on-call responsibilities, generally uncompensated, with an increasing amount performed by trained physicians for pay. The article, titledPaying Physicians to Be on Call: A Challenge for Academic Medicine,” suggests that this is partly the result of socialization at AHCs, where residents learn from observing other physicians that on-call duty post-training is merely optional. The centers also teach trainees that during practice they should limit work hours and get adequate rest. In medical education, there is a new emphasis on the role that lack of sleep plays in medical errors and physician health. In 2003, the Accreditation Council for Graduate Medical Education restricted the number of hours a resident could work weekly to 80, including on-call time. The article cites a number of studies that demonstrate the negative effect of a lack of sleep on cognition, mental and physical health, and even frequency of motor vehicle accidents after an on-call shift. Another reason for the change is a generational shift in attitudes regarding work/life balance. Recent and new graduates are determined to spend more time at home and with family than their parents did, and to avoid the high divorce rates of older doctors.

A 2006 survey found that 73 percent of emergency departments (ED) and 57 percent of trauma centers had inadequate on-call specialist coverage, “owing in part to the growing demand for ED care.” In 2002, the Center for Disease Control found that 21 percent of emergency department sentinel events, including deaths and permanent disability, could be attributed to a lack of specialty physician services. The shortage is most severe in urban areas.

Over the past decade, hospitals have increasingly been paying specialty physicians for on-call services. Some feel that it is fair for physicians to charge for being on call; others fear the practice will bankrupt AHCs. The article asserts that physicians in training are getting inconsistent messages about their future on call responsibilities. AHCs must “develop and implement specialty shift-work models that offer predictable and safe work hours, compensation for services at fair market value, and adequate time for rest between shifts.” What do you think should be done about the shortage?

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