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

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

The difficulty is that ED call is not, at least at this time, a solvable problem. Instead of finding one right answer, it is about understanding, honoring and finding a way to support the needs of physicians, the needs of the hospital and the needs of the community all at the same time. This is not a problem to solve, but a dilemma that must be managed, even if it has no solution. Problem solving thinking, which is about "either/or" thinking, is not designed to manage a dilemma of this nature. A dilemma like ED call requires "yes/and" thinking. In fact, applying typical problem solving to managing a dilemma fulfills H.L. Menken's observation, and eventually makes the problem worse.

There is not enough money in healthcare today to reimburse every physician for every night on call, even if they deserve it. Until recently, especially in the eyes of many physicians, the situation regarding ED call has been unbalanced. Physician needs have been disproportionately sacrificed by the rising burden of call, while their hospital and community have not taken on their fair share of this burden. Requesting (or demanding) reimbursement for coverage services they've been providing for free is one way to redress this imbalance. This is not an unreasonable request. It can become unreasonable if it is expressed with the level of physician hostility seen in many medical staffs today. It can also become unreasonable if the physicians' demands come at the expense of the hospital's ability to meet the challenges faced by hospitals today. In The Greeley Company's work with hospitals and medical staffs, we have found the most constructive and effective way to address ED call is to ask both physicians and hospital leaders, "How can we best balance the need to achieve physician success, hospital success and good care to our community at the same time?"

Einstein taught us that a difficult problem cannot be solved at the same level of thinking that created it. So developing a practical, fair, and sustainable approach to ED call requires bringing physicians and hospital leaders together to develop fair and balanced strategies that will help both physicians and the hospital succeed. Do all physicians owe some amount of uncompensated ED call or must every physician be paid for every moment of ED call? How should we establish the value of what physicians do when on call (fair market value) across different specialties in a way physicians will perceive as fair and equitable? How can we establish the criteria for which physicians will be paid for call and how much they will be paid in a manner that is fiscally responsible and sustainable for the hospital, rather than using a quick fix, "finger in the dike" approach that puts the hospital on an unsustainable slippery slope.

There is no "solution" to these difficult questions that will make all parties happy. In fact, the best framework for tackling ED call may be the wisdom of a marriage and family counselor who stated, "Couples fight over one thing and one thing only... How will we share the pain?" Whether couples are fighting over money, kids, sex, or the house, the underlying problem is that there is pain on both sides. They are arguing over how much of this pain each of them will take. That is exactly what is happening regarding ED call. For physicians, the pain of ED call is personal. They have disrupted sleep and fatigue, lost income, increased liability, lost time with families, and significant practice disruptions. For the hospital, they have the pain of potential EMTALA violations, investigations and fines, the cost of paying up to millions of dollars for call that will have be carved out from other important and worthy expenses, and the problems resulting from poor physician-hospital relations with some of their most important and busiest doctors.

We have found that both physicians and hospital leaders respond well to this language of sharing the pain. This allows us to facilitate the "crucial conversations." How much pain will be taken on by the hospital and how much by each specialty? How we will value what physicians in different specialties do when on call? At the end of the process, we still have to answer the question every physician wants to know: What's the number? How much will I be paid for ED call? When this question is asked and answered through a process that helps physicians and the hospital agree on how to share the pain, a fair and sustainable outcome is possible. We can then focus on gathering data to measure what physicians do when on call to establish the true burden of call, which provides as accurate a picture of their pain as possible. The data is also critical for establishing fair market value for physician ED call services and creating fairness in compensation levels across the different specialties. At the end of the day, each physician, each specialty, and the hospital has to take on some of the pain, usually more than they want to. But that's what being in healthcare requires of us today.

So many forces, including the pressures around ED call, are pulling medical communities apart. A thoughtful and effective process to address ED call can start to bring your medical community together. One of the lessons we can learn from understanding ED call as an unsolvable problem is that if we over focus on one side—physician success at the expense of the hospital or hospital success at the expense of physicians—bad things will happen. For healthcare to work for everybody, we must come together and find ways to manage ED call that help physicians succeed and hospitals succeed while giving good care to our communities.

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Rick Sheff, MD, is chairman and executive director with The Greeley Company, a division of HCPro. Dr. Sheff has more than 25 years of healthcare management and leadership experience as a physician leader, consultant, author, and lecturer. If you have questions or comments regarding ED Call or medical staff leadership, please contact Stacey Koch at 888/749-3054, ext 3193 or email skoch@greeley.com.

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