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Rethinking ED Call: How to balance physician, hospital and community needs

Rick Sheff, MD, for HealthLeaders Media, November 14, 2008

As I write this, I am saddened by my recent visit with a hospital and medical staff that are struggling with the challenge of physician coverage of unassigned patients for the emergency department and inpatient consultations. Discussions between some physician groups and the hospital degenerated into anger, threats, and broken trust. The physician demands for ED call compensation easily outstrip the hospital's entire bottom line. Yet some of the physicians have stated that if their compensation demands aren't met, they will stop taking call at the end of the month regardless of what the bylaws require. Why did this happen, and what can be done by hospital and medical staff leaders to prevent a similar experience in your hospital (or turn it around if it's already happened)?

Physicians are unhappy about providing coverage for unassigned patients for many legitimate reasons, including:

  • Growth in ED volumes
  • Rise in the uninsured
  • Reduced physician reimbursement
  • Greater practice disruptions from patients acquired while on call
  • Increased liability
  • Desire for a better work-home balance

These changes and others have led to a dramatic shift in physician expectations regarding coverage of unassigned patients. In the past, when a colleague called a fellow physician with a patient who needed that physician's expertise because of an emergency, the response from the other end of the phone was usually, "How soon do you want me there?" Today, the response is far more likely to be sullenness, resentment, perhaps even overt anger, often directed at their fellow physician, or even a refusal to care for the patient. Every time this happens in your community, it undermines collegiality of the medical staff, creates an EMTALA compliance risk, and drives a deeper wedge between physicians and your hospital.

In response to the changes in healthcare and medical practice, physicians in many communities across the nation are demanding compensation to provide coverage services they have previously provided for free. Given the pressures on the practice of medicine and the rising burden of ED call, this is an understandable demand. (To be fair, a number of other physician dissatisfiers are driving physician unhappiness that have nothing to do with coverage of unassigned patients, but which further fuel demands for compensation for coverage services previously provided for free.) But what has taken many by surprise is the tenor of discussions between physicians and hospitals over call. Physicians, especially in some surgical specialties, have presented ultimatums, demanding large sums just to carry the beeper for unassigned call. Even when these amounts are larger than the hospital's entire bottom line, some of these physicians respond to hospital management with harshness, anger, name calling, and threats. What's going on here?

Is ED Call an Unsolvable Problem?

If you ask many physicians for a solution to the ED call problem, they have a simple solution. This is a hospital obligation, not a physician obligation. Therefore, if the hospital wants physicians to do this work, they should pay them. What's the problem?

If you ask many hospital administrators and governing board members for a solution to the ED call problem, they have an equally simple solution. Every physician on the medical staff should be required to take call as a condition of medical staff membership. What's the problem?

The problem is they can't both be right. They have fallen into the trap, well described by American writer H.L Mencken when he said, "For every complex problem there is an answer that is clear, simple, and wrong."

Many of us like to be challenged by problems, and to try to solve them. Crossword puzzles come to mind. The latest craze with Soduku, the Japanese math puzzle game, does as well. We like the challenge and the satisfaction of discovering the right solution. For physicians, coming up with the right diagnosis for each patient—how they spend much of their professional time—is about solving problems. Doing this well provides great professional satisfaction. For a surgeon to do the right procedure well to cure the patient is about solving a problem. For an internist to select the right drug to cure a patient's condition is also about solving a problem.

So, what is the right solution to the ED call problem faced by hospitals and communities across the country? Your physicians are great problem solvers. Your hospital administrators are great problem solvers. Your board members are great problem solvers. They don't get to the top in their fields without being a great problem solver. So why can't they solve the problem of ED call?

It's not because they haven't tried. The CEO has negotiated individual deals with each physician specialty that forced the issue of compensation for call. Does this feel like a solution? Perhaps to the physicians, but not the CFO, who sees a never ending spiral of costs for ED call, costs nobody is paying the hospital more to take on and which will eventually bankrupt the hospital if allowed to continue unchecked. And even for the physicians, what felt like an acceptable solution the previous year somehow seems not enough compensation for the same work this year, so they go back asking for more, sometimes a lot more. And for any specialty that didn't get in on the initial deals for compensation for call, it certainly doesn't feel like a solution, at least not until their specialty gets in on the dealing as well.

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