Hospital Call Follow Up

[SoMinty]

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I’m in a position where I’m interested in taking hospital call to augment income. I’ve done this in the past but was at a different practice with more resources. How do others handle ED patient follow up for problems that they don’t treat/specialize in? If I see a patient with acute glaucoma, uveitis or a retina problem in the ED I can temporize/stabilize but I don’t want this coming to my private practice long term. If you take primary call in the ED how do you handle this? Do you just give the patient phone number of local practices and tell them to call after discharge or come back to the ED? What about uninsured/under insured patients? I’m fine working the odd hours and dealing with ED type issues but the follow up issue is something I haven’t been able to figure out. I was speaking with the hospital that I’m thinking of contracting with and they don’t know how the existing call docs handle it. For context my practice does not take insurance and does not have slit lamps or other equipment that you would want to long term follow patients with.

 

[eyeeye_captain]

Need more info on the variables. How big/busy a hospital, trauma level, and expectations for response time and floor consults? The hospital has no clue how the current system works? What’s the pay?

Also… you don’t take insurance, don’t do long term follow up, and don’t even have a slit lamp? So I’m guessing you’re some kind of plastics/aesthetics doc. Honestly I’m not sure your practice/skill set fits the job, no offense.

If your local folks are willing to have you be a triage person and are extremely kind enough to accept your potential disaster referrals, that’s probably the only way it works. If you weren’t sending me normal stuff on a regular basis, I’d have you on the blacklist for my front desk.

 

[SoMinty]

It’s a level 2 trauma center, you sign up for week blocks at a time. Currently four other people so in theory I’d do roughly 1/5th the year. It is ED only so no floor coverage. They currently transfer globes, pay is 500 daily plus you get some special additional reimbursement for specific insurances (I don’t want to get into specific details).

To be honest I’m taken aback by your second paragraph. Across the country 1st year ophthalmology residents routinely take ED call with little to no supervision. You’re suggesting that a fully credentialed ophthalmologist can’t provide at a minimum the same level of care? My question is regarding follow up, not appropriate care within the ED. Would you question a retina specialist taking call because they don’t want to follow cornea ulcers or lid lacerations (in my experience two of my most common calls)? The third paragraph is essentially my question - how are people handling this currently? What is the standard for follow up? I’ve taken ED call in the past but at the time I had a different practice environment where it was more feasible to see follow ups.

 

[Slide]

It’s a level 2 trauma center, you sign up for week blocks at a time. Currently four other people so in theory I’d do roughly 1/5th the year. It is ED only so no floor coverage. They currently transfer globes, pay is 500 daily plus you get some special additional reimbursement for specific insurances (I don’t want to get into specific details).

To be honest I’m taken aback by your second paragraph. Across the country 1st year ophthalmology residents routinely take ED call with little to no supervision. You’re suggesting that a fully credentialed ophthalmologist can’t provide at a minimum the same level of care? My question is regarding follow up, not appropriate care within the ED. Would you question a retina specialist taking call because they don’t want to follow cornea ulcers or lid lacerations (in my experience two of my most common calls)? The third paragraph is essentially my question - how are people handling this currently? What is the standard for follow up? I’ve taken ED call in the past but at the time I had a different practice environment where it was more feasible to see follow ups.

IMO best thing to do is see what the other four ophthalmologists are doing for follow-up and see if an arrangement can be worked out. The issue is that once you've seen the patient in the ER you've established a relationship with them, and you're on the hook to see them if you can't get someone to follow-up with them. If you don't have a formal plan you're legally responsible if you don't arrange for follow-up; not saying you have to force them to show up, you have to have some certainty for someone to see the patient for follow0up care

The guy you responded to was a bit blunt but he has a point. If you don't have the resources to see a follow-up from the ER and if if you can't get someone else to see them, you're kinda putting yourself at a massive liability risk. Some of the biggest lawsuits in ophthalmology that have been successful haven't been from the actual care administered, but failure to follow-up from the ER/hospital afterwards or not being able to manage them in such a setting. The massive payouts from ROP lawsuits weren't from the care itself but from lack of appropriate follow-up after discharge. Is this really worth 500 a day? Surely there's something else you could do that's less of a headache. Personally I wouldn't take any sort of primary ophthalmology call for less than 1K a day.

 

[RetinaDude]

From what I’ve heard from ophthalmologists covering ERs, $500/day seems extremely low…….but it is nice to not have to cover ruptured globes since you said those are sent out. As Slide mentioned, I would not even consider doing this unless it was $1000+/day.

Ask the other docs what they do for follow up. Another consideration is if this hospital has ever used Locum ophtha for coverage? Because if they have, ask what those docs did for follow up after the patient was discharged?

 

[4ophtho]

first check your hospital bylaws. My hospital requires on call MDs to follow up patients.
secondly, if you don’t have a slit lamp you can’t call yourself an ophthalmologist.
Lastly OMIC has a good published guidance on your responsibilities as an on-call ophthalmologist, including your responsibility for providing follow up and your liability if you do not.

 

[dantt]

You’re suggesting that a fully credentialed ophthalmologist can’t provide at a minimum the same level of care?

You can't without a slit lamp!

 

[eyeeye_captain]

Across the country 1st year ophthalmology residents routinely take ED call with little to no supervision. You’re suggesting that a fully credentialed ophthalmologist can’t provide at a minimum the same level of care?

I didn’t, but since you made the point, I’ll actually get behind it. Those residents generally have more resources at hand than a community hospital and can call a senior and work it up the chain even to subspecialty attendings if necessary. It’s built in. Even the most malignant programs have some guardrails, and they have baked in follow-up. You’re… just you, unless you have a strong network willing to pick up the phone and/or evaluate a patient. Residents are also not potentially conflicted about canceling their cash pay clinic to see emergencies.

It would appear I’m not the only one with concerns about your overall setup here.

 

[Rhexis]

You can't without a slit lamp!

Exactly. I get tons of ED follow ups for people with corneal FBs that they couldn't get out that they send to my office for me to remove. Can't do that without a slit lamp. Tons of other examples where an actual slit lamp is necessary (uveitis, corneal edema, etc...)

 

[eyeeye_captain]

I see only 3 pros to the job itself, and those have caveats - paid (albeit poorly), no globes (are you still required to evaluate them prior to transfer?), no inpatient (although if your patient is admitted, I’m guessing you’re on the hook for rounding?).

The cons are many. Admin is opaque. The call roster seems small for what I would think is a good size hospital. Q5 as the primary call. Unclear resources. Unclear backup. Trauma leans towards un- and underinsured patients.

You would really need to know what’s kosher in the bylaws for response time and distance from the ED. You’d be canceling clinics on occasion if they’re sticklers for under an hour or something.

If the other 4 docs are in competing practices, there could be friction, especially with scheduling your weeks. I’m guessing the reason there’s so few is they take some insurance that can only have surgery there and are required by the hospital to take call to use the OR.

All this for a whopping $35k/year pre-tax. For your own sake, run, then run faster.

 

[TheLesPaul]

first check your hospital bylaws. My hospital requires on call MDs to follow up patients.
secondly, if you don’t have a slit lamp you can’t call yourself an ophthalmologist.
Lastly OMIC has a good published guidance on your responsibilities as an on-call ophthalmologist, including your responsibility for providing follow up and your liability if you do not.

I'm plastics and I don't have a slit lamp. I do (unfortunately) have to take call but most emergencies you can see with a penlight and or an indirect. I do have a tonopen but it's been a long time since I've used it. You can usually palpate rock hard eyeballs.

Most ER stuff that needs intervention is plastics-related so I handle that and freely refer the rest to colleagues. I handle their lid lacs/orbital abscesses/look at scans for them etc when they are on call so it is a beneficial arrangement. I don't do their canthotomies in the middle of the night.

But my board certification is in ophthalmology and I don't have a slit lamp....so I disagree with your statement.

 

[SoMinty]

The concern about adequate follow up is appropriate, hence my post. The comments about slit lamps etc are beside the point, the emergency department has that equipment, my practice does not. Appreciate the responses, I've gotten the information I was requesting.

 

[Slide]

The concern about adequate follow up is appropriate, hence my post. The comments about slit lamps etc are beside the point, the emergency department has that equipment, my practice does not. Appreciate the responses, I've gotten the information I was requesting.

Just to add - I take call due to my responsibilities at an academic institution and take it from me, you'll get sick of it quickly; I've done it for 10 years and I'm about done with it. I don't know how badly you need the money but the amount of work and time expended, as well as the stress and hassle dealing with it, is rarely worth it unless you can take a few days off from clinic from the reimbursement.

I did some back of the envelope math and to you'd have to see maybe 10-11 extra patients a month to make up the revenue lost from call. You do you but I know what I'd do instead.

 

[4ophtho]

Yep took me about 10 years to completely burn out from it.