call schedule

[shoal]

sorry if this has been posted before.

but how does your group handle call?

we do 1 week at a time, no reimbursement. doesnt matter if youre scheduled for vacation or are working everyday of that time period.

i imagine there are better ways to handle this.

thx

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[BoardingDoc]

we do 1 week at a time, no reimbursement. doesnt matter if youre scheduled for vacation or are working everyday of that time period.

This makes absolutely no sense. The way my attendings have described it is basically for any given week, there are several doctors not working on a given day. One of those docs is on call for that day (or a run of days when they're not working). As such, it is almost never 1 doc who is on call for an entire week as they will likely be working themselves during that week.

Doing it your way, it sounds like it's possible for you to work a shift (lets assume it's 8 hours long to make this less horrible) and then get called in to stay an additional 8 hours if the next doc calls in sick... meaning you're working 16 hours straight at a minimum. That does not seem remotely safe. Granted, I'm not an attending yet, but I wouldn't take a gig that allowed for that possibility.

 

[shoal]

yes, you're correct. its even possible to be working a shift get called in (18 hours straight) then return in 7 hours...

im not sure if its ever happened, but the setup doesnt make sense.

we're a pretty small group ~18 docs. so theres not a ton of flexibility for coverage.

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[WilcoWorld]

We each take call on a day that we are not otherwise working about once/month. We only get called in when someone can't make it in for a shift (influenza, appendicitis, kid got hospitalized). We do not call people in for high census.

In 4 years I've been called in 2-3 times.

 

[GeneralVeers]

That sounds terrible. Whenever I've worked job with call, I was paid $500 for the day plus regular hourly if called in. That encouraged people to pick up call shifts and trade. A week for no pay? Seriously?? Get away from that job. I couldn't imagine doing a week of call with no drinking, going out to dinner or even just able to relax.

 

[Daiphon]

We do quarterly schedules, with 2 docs on as backup any given week - we don't take backup on weeks we're scheduled zero shifts.

We get one shift worth of time to be on 1st and a half shift when batting second; if we're called in, then we get that + however many hours we're needed. Effectively, 3 shifts/year to simply be available & with an understanding that the others on the schedule may be jostled to accommodate short bouncebacks (e.g. I worked the overnight, so if the 10a doesn't show up, the 2p will come in early to minimize the effects of circadian reversal).

3rd backup is always the department head.

Semper Brunneis Pallium

 

[tkim]

Used to work a place with scheduled call - 2 days a month. Used to get called in for high census far more often than illness. Job I have now does not have call. May not be great for the person calling in, but not having to take call is awesome.

 

[deleted77919]

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[emergentmd]

EM docs? Call? Isn't that one reason we went into EM?

I am highly against call. In the 15 yrs in my 100 doc group, the amount of time someone really needs to be called in is not worth having 1-2 docs on call all the time. Paying them to take call is meaningless as it all comes from our billing anyhow. So what if we all did 1% call, getting paid doesn't affect our bottom line b/c there is no mysterious extra money to pay call.

We beg and if that doesn't work, just make the docs working work a few extra hours. There is always a way to get it covered.

 

[GeneralVeers]

EM docs? Call? Isn't that one reason we went into EM?

I am highly against call. In the 15 yrs in my 100 doc group, the amount of time someone really needs to be called in is not worth having 1-2 docs on call all the time. Paying them to take call is meaningless as it all comes from our billing anyhow. So what if we all did 1% call, getting paid doesn't affect our bottom line b/c there is no mysterious extra money to pay call.

We beg and if that doesn't work, just make the docs working work a few extra hours. There is always a way to get it covered.

I don't agree. Call is good, but it needs to be reimbursed. Yes it comes out of the bottom line, but if people want to take more call, and others want to take less then it should be reimbursed appropriately.

At one of my gigs, there is no call schedule and a chronic shortage of doctors. Many times shifts are not completely filled from the start. In a place with 50K annual volume (180 pts/day) it really sucks to have your 10 hour shift expanded to 12, and be down an extra doc for the day. Instead of 2 pts an hour for 10 hours, now I'm seeing 3+ for 12. It's exhausting and bad for doctor and nursing morale. The company is cheap and won't offer more than $100/hour bonus, which explains why they can't fill empty shifts.

 

[emergentmd]

I don't agree. Call is good, but it needs to be reimbursed. Yes it comes out of the bottom line, but if people want to take more call, and others want to take less then it should be reimbursed appropriately.

At one of my gigs, there is no call schedule and a chronic shortage of doctors. Many times shifts are not completely filled from the start. In a place with 50K annual volume (180 pts/day) it really sucks to have your 10 hour shift expanded to 12, and be down an extra doc for the day. Instead of 2 pts an hour for 10 hours, now I'm seeing 3+ for 12. It's exhausting and bad for doctor and nursing morale. The company is cheap and won't offer more than $100/hour bonus, which explains why they can't fill empty shifts.

Different environments require different solutions.

CMG with chronic coverage issue = $$$$ Whip. Im doing this now and it eventually gets covered when the whip gets big enough.
SDG just needs to make calls and someone will usually cover it. It happens so rarely that having 1-2 doc on Call all the time SUCKS. If I work 14 dys, being on call for another 2 dys would suck. We tried it for a few months, no one ever got called in, and everyone who was on call hated it. Scheduling docs for 14 dys/mo is already hard. Add another 2 call days makes everyone's lives worse with very little benefits IMO.

 

[The White Coat Investor]

EM docs? Call? Isn't that one reason we went into EM?

I am highly against call. In the 15 yrs in my 100 doc group, the amount of time someone really needs to be called in is not worth having 1-2 docs on call all the time. Paying them to take call is meaningless as it all comes from our billing anyhow. So what if we all did 1% call, getting paid doesn't affect our bottom line b/c there is no mysterious extra money to pay call.

We beg and if that doesn't work, just make the docs working work a few extra hours. There is always a way to get it covered.

We don't have call. When we have a need, we step up and get it done. For example, a partner's family member goes into the hospital yesterday. Text message and email goes out. We come up with a plan to split the shift. In the end, a doc that was off just volunteered to do the whole shift. That has happened every time it has been needed for decades. The people you work with matter. Because we care about each other, we take care of each other in situations like this. Because we care about each other, we don't take advantage so it remains a pretty rare thing. We also overstaff ourselves a bit and only work a limited number of 8 hour shifts a month so that covering these sorts of things is easier. Maybe it's a "unicorn" job, but if so, that's sad.

 

[Apollyon]

EM docs? Call? Isn't that one reason we went into EM?

I am highly against call. In the 15 yrs in my 100 doc group, the amount of time someone really needs to be called in is not worth having 1-2 docs on call all the time. Paying them to take call is meaningless as it all comes from our billing anyhow. So what if we all did 1% call, getting paid doesn't affect our bottom line b/c there is no mysterious extra money to pay call.

We beg and if that doesn't work, just make the docs working work a few extra hours. There is always a way to get it covered.

We don't have call. When we have a need, we step up and get it done. For example, a partner's family member goes into the hospital yesterday. Text message and email goes out. We come up with a plan to split the shift. In the end, a doc that was off just volunteered to do the whole shift. That has happened every time it has been needed for decades. The people you work with matter. Because we care about each other, we take care of each other in situations like this. Because we care about each other, we don't take advantage so it remains a pretty rare thing. We also overstaff ourselves a bit and only work a limited number of 8 hour shifts a month so that covering these sorts of things is easier. Maybe it's a "unicorn" job, but if so, that's sad.

See, these are the fundamental differences. The first is the lean, parsimonious/frugal yet solvent, "show me the money", with outsize, Texas-sized wages, yet, with 100 docs, people won't help out others just by being available officially for the crunch, then, there is the fat, arms open group, kumbaya, "whatever it is, everything, immediately, you got it", abstractly optimized, but reality, nearly utopian. For the vast number of the rest of us, is is somewhere between those on the spectrum - one end is the "Thunderdome", "every man for himself", and the other is the communal, mutualistic, "kibbutz" sort. Who is right? As it always comes out in the end, "all politics is local". My first job, 10 years ago, 60 docs total, the EM partners/pre-partners would be on call 1x/month, for ill/census, for a 10 hour period for the day, only paid if you got called in, and this didn't chafe anyone. I guess this is the obligatory shrug.

 

[shoal]

surges and people forgetting or screwing up then delay showing up have been the reasons ive been called in thus far. it really hasnt been -- im deathly ill, or i have a funeral i need to attend.

Unforunately, the later 2 are easier to plan for. the oppps i slept in, my drive is 2hrs or we have 20 in the waiting room, could you please help --- seem to be the reason ive been called in.

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[The White Coat Investor]

surges and people forgetting or screwing up then delay showing up have been the reasons ive been called in thus far. it really hasnt been -- im deathly ill, or i have a funeral i need to attend.

Unforunately, the later 2 are easier to plan for. the oppps i slept in, my drive is 2hrs or we have 20 in the waiting room, could you please help --- seem to be the reason ive been called in.

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That's a function of too lean staffing in my opinion.

 

[RustedFox]

That's a function of too lean staffing in my opinion.

This.

Every winter here on the gulf coast, we have asked for the CMG to bolster staffing during the (snowbird) season months of November to "Easter". They him and haw and haw some more, and the "SURGE PROTOCOL! LOLZ!" results in us being called in all too frequently. I quit that (HCA) job last season. Faaaar happier with my new place, where the staffing flexes with ease, and the D2D times aren't insane (10 mins).

 

[BoardingDoc]

surges and people forgetting or screwing up then delay showing up have been the reasons ive been called in thus far. it really hasnt been -- im deathly ill, or i have a funeral i need to attend.

Unforunately, the later 2 are easier to plan for. the oppps i slept in, my drive is 2hrs or we have 20 in the waiting room, could you please help --- seem to be the reason ive been called in.

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Agree with WCI. Surges should be something that can be planned for by looking at your historical data. Yes, if there's a mass shooting or something, you'll have an unexpected spike. Otherwise, managers should see this coming and staff accordingly.

 

[Janders]

Even with intelligence and historic data, it can be difficult to plan for surges.

For example, I can show you data from last year where our mean daily volume was 83 patients, but some days were as high as 115 and some as low as 57. within the same week. At this wasn't necessarily predictable Mondays-are-busy variance. With that high of a percentage of swings, and overall small size of an ED, it can be tough to appropriately staff without just overstaffing all the time.

We tend to prefer calling people in early, having them stay late, or just giving up on charting to handle the surges and charting later, versus having someone on-call and twiddling thumbs just to try and drive in for a couple hours. But like WCI, we are structured democratically and with lean overhead, so people have a significant incentive to play nicely together.

 

[Hercules]

We don't have call. When we have a need, we step up and get it done. For example, a partner's family member goes into the hospital yesterday. Text message and email goes out. We come up with a plan to split the shift. In the end, a doc that was off just volunteered to do the whole shift. That has happened every time it has been needed for decades. The people you work with matter. Because we care about each other, we take care of each other in situations like this. Because we care about each other, we don't take advantage so it remains a pretty rare thing. We also overstaff ourselves a bit and only work a limited number of 8 hour shifts a month so that covering these sorts of things is easier. Maybe it's a "unicorn" job, but if so, that's sad.

Similar scenario here. We're an 8 doc SDG in a 55k community ED. FT for us is ~115 hrs/month so people have room to flex and help each other out. We have a pretty physically active group with 3-4 ankle/clavicle fractures in the past two years. We also have a birth rate that rivals most third world countries. We don't use a call schedule but in every scenario we have always stepped up to cover each other and make things work. I would personally hate a call schedule but I'm sure it would sound nice the first time I got hosed by a no-show. I just haven't experienced that in my current group.


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[The White Coat Investor]

Even with intelligence and historic data, it can be difficult to plan for surges.

For example, I can show you data from last year where our mean daily volume was 83 patients, but some days were as high as 115 and some as low as 57. within the same week. At this wasn't necessarily predictable Mondays-are-busy variance. With that high of a percentage of swings, and overall small size of an ED, it can be tough to appropriately staff without just overstaffing all the time.

We tend to prefer calling people in early, having them stay late, or just giving up on charting to handle the surges and charting later, versus having someone on-call and twiddling thumbs just to try and drive in for a couple hours. But like WCI, we are structured democratically and with lean overhead, so people have a significant incentive to play nicely together.

Guess what we would do in that situation? We would staff ourselves for 100-110 patients a day. Then most days feel pretty laid back and occasionally people get sent home (with pay) when it is really slow.

There's no reason you HAVE to staff "appropriately" when you own the group. You can overstaff if you want.

 

[gman33]

Guess what we would do in that situation? We would staff ourselves for 100-110 patients a day. Then most days feel pretty laid back and occasionally people get sent home (with pay) when it is really slow.

There's no reason you HAVE to staff "appropriately" when you own the group. You can overstaff if you want.

Yes, you can staff anyway you want in that situation. But you may end up working 20% more for the same pay.

 

[Hercules]

Yes, you can staff anyway you want in that situation. But you may end up working 20% more for the same pay.

Good points by both gman and WCI. We choose to staff relatively lean and all of us are ok with picking up the pace on high volume days. As a result we have a pretty high $$/hr but we work hard while we are there. I think the key is that it doesn't feel bad when it's your choice. If at any point we decide we want to have a more relaxed pace at work we can just add coverage or hire another doc. Our model would feel completely different to me if some outside party were telling us we had to staff lean and suck it up during the surges.


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[GeneralVeers]

We had 30+ docs and 3 sites, so it was common for a doc to get sick or have to call in. The call doc was expected to come in at 4PM at our busiest site for a couple hours. If not busy they would stay home. We were also overstaffed a bit, and it was common to send docs home early if needed.

I'd rather have that system than one where I have to work longer and harder if someone drops a shift.

 

[The White Coat Investor]

Yes, you can staff anyway you want in that situation. But you may end up working 20% more for the same pay.

Absolutely, or the same amount for less pay. But you'd be surprised how much pay there is sloshing around there when you get to keep the CMG's 30%.

 

[The White Coat Investor]

Good points by both gman and WCI. We choose to staff relatively lean and all of us are ok with picking up the pace on high volume days. As a result we have a pretty high $$/hr but we work hard while we are there. I think the key is that it doesn't feel bad when it's your choice. If at any point we decide we want to have a more relaxed pace at work we can just add coverage or hire another doc. Our model would feel completely different to me if some outside party were telling us we had to staff lean and suck it up during the surges.

Exactly. Ownership....it's a beautiful thing. You still get the poison, but at least you get to pick your poison.

 

[Birdstrike]

I can only think of one thing to make Emergency Medicine more burnout inducing than it already is: Making EM physicians be "on call" when they're not working. Ever.

Since >75% of patients presenting to EDs are neither urgent nor emergencies, you're taking "call" not to cover emergencies, but to make sure metrics please hospital administrators.

I had an ED job once where every shift you worked, you were on "call" for volume surges the first few hours before every shift. It was especially soul-crushing, because even though getting called wasn't often, when you were called in, not only did it lengthen your shift 2 or so hours, it guaranteed it was going to be an extra brutal level of volume on top of it combined with being 2 or so hours short on sleep. Also, the call never came for some mass casualty incident or actual unavoidable crisis, but for dealing with volume surges of typical non-emergent patients that weren't sick. It was put in place to prop up an ED that was purposefully staffed short, to get supra-maximal productivity out of the nurses and doctors.

Who said that in EM, "when you're off you're off"?

Yeah. Not true. I learned that one the hard way. I had no SDN at prior that point (well, only in its infancy) to easily read called out specialty myths and recruiting lies.

If EM "call" is getting more prevalent, which its sounds like maybe it is based on these thread comments, I find that very ominous but not surprising. I do like the double-pay idea for any unscheduled shift worked, but that's far from standard.

I proposed on this forum several years ago, having an "Emergency Physician Bill of Rights And Responsibilities To Self " with rules like this to promote EM physician wellness and to reduce burnout (and others such as maximum recommend hours per month, maximum patients/MD/hr, minimum time between changes in circadian rhythms to reduce EP burnout) to be backed up, published by, and at least recommend as specialty standard by ACEP but no one took it seriously, here or anywhere else, so I gave up on it. (I even deleted the post and I just searched for it on the internet archive and it's not there, so it's gone).

Like someone else posted recently, EM leadership is so much in bed with the CMGs, hospital administrators and corporate interests of EM, that anything that might impair the sacred and untouchable ED metrics and patient satisfaction movement, gets and will get, no traction without a massive grassroots revolt.

 

[GeneralVeers]

I proposed on this forum several years ago, having an "Emergency Physician Bill of Rights And Responsibilities To Self " with rules like this to promote EM physician wellness and to reduce burnout (and others such as maximum recommend hours per month, maximum patients/MD/hr, minimum time between changes in circadian rhythms to reduce EP burnout) to be backed up, published by, and at least recommend as specialty standard by ACEP but no one took it seriously, here or anywhere else, so I gave up on it. (I even deleted the post and I just searched for it on the internet archive and it's not there, so it's gone).

That is the beauty of locums. I can work as much or little as I want. If a site gives my crappy scheduling I can go elsewhere. At one of my sites I refuse to do day shifts because the nurses suck. At my other I refuse to do nights because it's too much single coverage.

 

[Birdstrike]

That is the beauty of locums. I can work as much or little as I want. If a site gives my crappy scheduling I can go elsewhere. At one of my sites I refuse to do day shifts because the nurses suck. At my other I refuse to do nights because it's too much single coverage.

Good. You found a way to maintain control rather than be controlled.