No relief

[bky3c]

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I’m working a 12-hour overnight shift tomorrow as an independent contractor for a CMG in a single coverage shop. So far, they have been unable to cover the Friday day shift, so no one is scheduled to relieve me. If they don’t fill in the schedule, I’m stuck working a 24, right? Do I have any options at all?

This is already scheduled to be my last shift at this ED and for this CMG, for numerous reasons. It’s so bad that the above comes as no surprise. Any advice would be appreciated. Thanks.

 

[EctopicFetus]

I would call you contact on your way in. Say I have to be someone 30 mins after shift. If my relief doesn’t show up I’m calling hospital ceo, house supervisor etc and telling them to shut the emergency department. I am leaving.
If you can not find someone I can rearrange my plans but I will need $1,000 per hour and I will be here for the full shift. I need a response about coverage at the end of my shift before 4pm. If I fail to hear from you I will plan on leaving. I will call hospital admin and let them know they need to plan to shut their ed at the end of my shift.

 

[RuralEDDoc]

There’s no good option. I’ve been in an extremely similar situation. I emailed the medical director and regional director and said I would be unavailable to work without scheduled relief. Guess what? Relief was found in less than 2 hours.

 

[RuralEDDoc]

I like Ectopics answer better than my own.

 

[cyanide12345678]

I like ectopics answer. It's your last shift. I guess it doesn't matter then if you burn some bridges on your way out. But they better pay you a lot more than your usual rate if they are going to make you stay.

 

[bravotwozero]

Agreed with above. Not sure if you realize it, but they need you more than you need them, and you have all kinds of leverage, to either avoid the double shift altogether or get paid handsomely to do it.

 

[DO3]

I’m working a 12-hour overnight shift tomorrow as an independent contractor for a CMG in a single coverage shop. So far, they have been unable to cover the Friday day shift, so no one is scheduled to relieve me. If they don’t fill in the schedule, I’m stuck working a 24, right? Do I have any options at all?

This is already scheduled to be my last shift at this ED and for this CMG, for numerous reasons. It’s so bad that the above comes as no surprise. Any advice would be appreciated. Thanks.

Know someone in a situation like this except CMG couldn’t fill 3 night shifts. Jokingly, this person said, $600/hr and I’ll cover them. They said ok w/o negotiation. $18k over 3 days isn’t a bad haul. The money is there...like someone else said, they need you way more than you need them. If you work that extra 12 you should be paid handsomely. Do not give in or be guilt tripped in to doing it.

 

[cyanide12345678]

I know my contract says that I'm only required to work the time that i am scheduled. But how does emtala work if the doors of the ER are closed because there is no ER doctor?

Can an ER truly close it's doors and turn away patients because a doctor is not available from an emtala perspective?

 

[DO3]

I know my contract says that I'm only required to work the time that i am scheduled. But how does emtala work if the doors of the ER are closed because there is no ER doctor?

Can an ER truly close it's doors and turn away patients because a doctor is not available from an emtala perspective?

Hospital could lose all its Medicare funds. But it’s not the your/docs problem. It’s the hospital’s/cmg’s. That’s why they will pay almost an unlimited price to someone to keep the doors open.

 

[GonnaBeADoc2222]

All great answers so far.

Isn't it the medical director's responsibility to cover this shift if can't find coverage?

 

[Birdstrike]

I would call you contact on your way in. Say I have to be someone 30 mins after shift. If my relief doesn’t show up I’m calling hospital ceo, house supervisor etc and telling them to shut the emergency department. I am leaving.
If you can not find someone I can rearrange my plans but I will need $1,000 per hour and I will be here for the full shift. I need a response about coverage at the end of my shift before 4pm. If I fail to hear from you I will plan on leaving. I will call hospital admin and let them know they need to plan to shut their ed at the end of my shift.

This is the perfect response. Again and again, we (physicians) let our good intentions and desire to help people allow us to be used, suckered and abused like chumps. "I have to do it, cuz I'm a 'good guy.'" It takes its toll, day by day, hour by hour, minute by minute, until we find we're burned out and at a point of emotional exhaustion we can't take anymore. But, no more.

You think the ----ing CEO of the hospital is ever gong to "pull a 24" because admin is staffed short? No ----ing way! Not twice, no once, not ever. But that we even considering doing it, because some admin ----ed up and didn't do their job of getting coverage, is a personal tragedy.

If we don't change our mindset, our profession is doomed. If we do, great things without limit are waiting for us.

 

[BoardingDoc]

I would call you contact on your way in. Say I have to be someone 30 mins after shift. If my relief doesn’t show up I’m calling hospital ceo, house supervisor etc and telling them to shut the emergency department. I am leaving.
If you can not find someone I can rearrange my plans but I will need $1,000 per hour and I will be here for the full shift. I need a response about coverage at the end of my shift before 4pm. If I fail to hear from you I will plan on leaving. I will call hospital admin and let them know they need to plan to shut their ed at the end of my shift.

If they take you up on you staying late at 1k/hr, you need to stipulate that this also be given to you in writing (email is fine).

 

[Birdstrike]

If they take you up on you staying late at 1k/hr, you need to stipulate that this also be given to you in writing (email is fine).

Yes. Good point!

Never forget, these are business people, and business is what they care about. They don't care about our wellness, circadian rhythms, level of job-related emotional exhaustion or peace of mind. They don't. At all.

 

[bky3c]

All great answers so far.

Isn't it the medical director's responsibility to cover this shift if can't find coverage?

Generally, yes, but in this case the medical director is physically unable to practice clinical medicine... hence the admin position. I suppose they could go farther up the chain...

Thanks for the helpful answers so far. I'll update when there's anything to say.

 

[Vandalia]

1. I would make sure there is a clear, documented (e.g., email) statement to them that you will not work after your shift ends. Absent this, they could state that they "reasonably relied" on you to work the next shift. Of course, this would be ridiculous, but they have bigger pockets for litigation.

2. In my eyes, the primary liability for you would be a claim for "patient abandonment" either in a civil malpractice suit or an action by the state medical board. The fact that one's shift has ended is generally not an adequate defense to such claims; you may have coverage for malpractice liability from the hospital or the locums company or your own insurer, but they will not take the hit for a board action. If you have independent malpractice coverage, I would definitely talk with them beforehand about how to handle this situation. If the game of chicken does not work, it can get very complicated very fast. My gut reaction would probably be to shut down triage an hour before the shift ends, or at the very least when your shift ends and clean up what is left. But there is a reason people don't pay me for my gut reaction.

 

[Pigg-O-Stat]

I would keep it simple. Email the scheduler and ask for double time (or whatever rate you want) for the second 12. They'll probably say yes. If not, you can escalate things.

 

[Groove]

I’m working a 12-hour overnight shift tomorrow as an independent contractor for a CMG in a single coverage shop. So far, they have been unable to cover the Friday day shift, so no one is scheduled to relieve me. If they don’t fill in the schedule, I’m stuck working a 24, right? Do I have any options at all?

This is already scheduled to be my last shift at this ED and for this CMG, for numerous reasons. It’s so bad that the above comes as no surprise. Any advice would be appreciated. Thanks.

Hmm, that's a tough one. I would have probably manufactured an emergency that couldn't be disproven so that I didn't have to work that shift. That doesn't sound like a "pit doc on his way out" problem but more like a "medical director" problem. I.E. He/She should be the one dealing with it, not you.

Any chance a malignant hospital CMO/CEO could orchestrate any punitive measures for leaving your shift and/or "egregious" salary demands? That's probably the only thing I would be nervous about... It would be just my luck to have my hospital privileges revoked or suspended for no other reason than to punish me for leaving the ED unstaffed knowing that I'd have to report that in the future. I'd probably sue them if that happened, but it just sounds like a potential mess. If something like that is a long shot then I think @EctopicFetus response is a good one. Otherwise, I'd probably just put my head down and muscle through the shift and never look back.

Have you contacted your CMG brass? I have a hard time thinking they would officially support you working a 24h shift with no chance of rest d/t all the legal ramifications if something bad happened. I can't imagine they wouldn't ask your director to relieve you. What a sh** show. Keep us updated.

 

[CajunMedic]

Can an ER truly close it's doors and turn away patients because a doctor is not available from an emtala perspective?

We had one in Mississippi that did this all the time when no MD/PA/NP was available. They’d notify the state and the ambulance services, lock all the ED entrances, put a sign on the door that they were temporarily closed and the next closest hospitals were 60 miles one direction and 66 miles the other. Never heard of them getting an EMTALA violation.

 

[betamale]

I’m working a 12-hour overnight shift tomorrow as an independent contractor for a CMG in a single coverage shop. So far, they have been unable to cover the Friday day shift, so no one is scheduled to relieve me. If they don’t fill in the schedule, I’m stuck working a 24, right? Do I have any options at all?

This is already scheduled to be my last shift at this ED and for this CMG, for numerous reasons. It’s so bad that the above comes as no surprise. Any advice would be appreciated. Thanks.

Med director usually comes in

 

[bky3c]

I just fired off three texts and an email to the scheduler, the medical director, and the regional director. Turns out they've roped some poor soul into covering the shift. Poor guy now has 5 on, 1 off, 4 on, and he (like everyone else there) lives out of town. I hope he demanded a pretty penny from them.

Thank you all for your suggestions. I've been in this situation unexpectedly a few times (once on Christmas morning, no less), but never "expectedly." One more shift at this place, and five more elsewhere, till early retirement. I'm out. This is just a tiny slice of all of the BS I've put up with over the years, and I'm sure it's no different from the rest of you.

 

[DrGasPasser]

1. I would make sure there is a clear, documented (e.g., email) statement to them that you will not work after your shift ends. Absent this, they could state that they "reasonably relied" on you to work the next shift. Of course, this would be ridiculous, but they have bigger pockets for litigation.

2. In my eyes, the primary liability for you would be a claim for "patient abandonment" either in a civil malpractice suit or an action by the state medical board. The fact that one's shift has ended is generally not an adequate defense to such claims; you may have coverage for malpractice liability from the hospital or the locums company or your own insurer, but they will not take the hit for a board action. If you have independent malpractice coverage, I would definitely talk with them beforehand about how to handle this situation. If the game of chicken does not work, it can get very complicated very fast. My gut reaction would probably be to shut down triage an hour before the shift ends, or at the very least when your shift ends and clean up what is left. But there is a reason people don't pay me for my gut reaction.

Absolutely do not follow this advice. The OP is an employee or contractor for a CMG, not the hospital. As such, they should not be inserting themselves into the hospital operations or trying to shut down any portion of the hospitals property. If the OP tells the charge nurse to to do this and they comply, the OP will have a giant EMTALA target on their back for any patient who presents to the hospital for a MSE and is then turned away - especially in that last hour when the OP is contractually obligated to perform MSEs.

At the very least, the OP should remain on the property, performing MSEs to anyone who arrives, and providing stabilizing care during their entire shift. Absolutely do not tell hospital employees to shut down anything unless you want to spend the rest of your life waiting tables. What happens after the shift is highly dependent on what is in their employment contract and the steps that were taken to provide reasonable accommodations to insure patient safety. If the OP simply walks out of the hospital 1 minute after their shift ends without handing off their patients, they should expect to get a call from the state medical board regarding patient abandonment and CMS investigators for failing to stabilize any patient still in the ED with an EMC. On the other hand, if they document efforts to insure safe handoff to hospital providers, then the risk of adverse action from regulatory bodies is mitigated. I say mitigated, but not zero.

Finally, anytime a facility is left without coverage there is a ton of liability for anyone involved - hospitals, administrators, doctors, nurses, etc. Keep in mind that CMS investigators and state medical boards will not give 2 ****s about the OP’s pay. That CMS investigator will have no compunction about crawling so far up a doctors ass that a bronchoscope will be needed to pull them out. They will be looking to see if a provider met their obligations under the provisions of their medical license and EMTALA. While it’s important to be fairly compensated for the extra work caused by these situation, affected EPs would be wise to spend the same effort appearing reasonable and focused on patient safety when these situations arise. Otherwise, expect to pay all that over time in legal fees defending their ability to practice medicine.

 

[GonnaBeADoc2222]

Absolutely do not follow this advice. The OP is an employee or contractor for a CMG, not the hospital. As such, they should not be inserting themselves into the hospital operations or trying to shut down any portion of the hospitals property. If the OP tells the charge nurse to to do this and they comply, the OP will have a giant EMTALA target on their back for any patient who presents to the hospital for a MSE and is then turned away - especially in that last hour when the OP is contractually obligated to perform MSEs.

At the very least, the OP should remain on the property, performing MSEs to anyone who arrives, and providing stabilizing care during their entire shift. Absolutely do not tell hospital employees to shut down anything unless you want to spend the rest of your life waiting tables. What happens after the shift is highly dependent on what is in their employment contract and the steps that were taken to provide reasonable accommodations to insure patient safety. If the OP simply walks out of the hospital 1 minute after their shift ends without handing off their patients, they should expect to get a call from the state medical board regarding patient abandonment and CMS investigators for failing to stabilize any patient still in the ED with an EMC. On the other hand, if they document efforts to insure safe handoff to hospital providers, then the risk of adverse action from regulatory bodies is mitigated. I say mitigated, but not zero.

Finally, anytime a facility is left without coverage there is a ton of liability for anyone involved - hospitals, administrators, doctors, nurses, etc. Keep in mind that CMS investigators and state medical boards will not give 2 ****s about the OP’s pay. That CMS investigator will have no compunction about crawling so far up a doctors ass that a bronchoscope will be needed to pull them out. They will be looking to see if a provider met their obligations under the provisions of their medical license and EMTALA. While it’s important to be fairly compensated for the extra work caused by these situation, affected EPs would be wise to spend the same effort appearing reasonable and focused on patient safety when these situations arise. Otherwise, expect to pay all that over time in legal fees defending their ability to practice medicine.

Pretty terrifying stuff.

Prudent course of action in future may be just to call out of shift and let them deal with it. Money negotiations and potential fallout may not be worth it.

Cudos to you OP for having the ability to get out of the game early.

 

[thegenius]

I think if you warn all appropriate people (your CMG, ER medical director, ER charge nurse, etc), at the beginning of your shift that there may be a problem, that there is no coverage after you after your 12 hr shift, and your intent is to leave, I'm not sure you are exposing yourself to legal action. EMTALA doesn't necessitate that an ER is staffed with a medical personnel 24/7, it just says that if a person shows up to an ER (assuming it's open) with a medical complaint and asking for an MSE, that they get one. That doesn't mean it has to be you. If it did, then every single ER doctor employed at an ER would be liable for EMTALA violation 24/7 if a patient doesn't get an MSE.

Plus EMTALA violations are applied to a hospital, not to doctors.

The original response is still the best one. Demand 4x payment for your unscheduled time or you leave. And make sure you have a paper trail of all of this as well.

 

[thegenius]

I just fired off three texts and an email to the scheduler, the medical director, and the regional director. Turns out they've roped some poor soul into covering the shift. Poor guy now has 5 on, 1 off, 4 on, and he (like everyone else there) lives out of town. I hope he demanded a pretty penny from them.

Thank you all for your suggestions. I've been in this situation unexpectedly a few times (once on Christmas morning, no less), but never "expectedly." One more shift at this place, and five more elsewhere, till early retirement. I'm out. This is just a tiny slice of all of the BS I've put up with over the years, and I'm sure it's no different from the rest of you.

This sounds like a great example of why locums jobs can suck (I presume this is locums)

 

[bky3c]

Nope, not locums. This was the closer-to-home job part time, permanent, independent contractor job I took after several years of 100% locums to try to cut down on time spent traveling. Boy, did that backfire. My locums jobs have generally been fine.

 

[deleted109597]

Absolutely do not follow this advice. The OP is an employee or contractor for a CMG, not the hospital. As such, they should not be inserting themselves into the hospital operations or trying to shut down any portion of the hospitals property. If the OP tells the charge nurse to to do this and they comply, the OP will have a giant EMTALA target on their back for any patient who presents to the hospital for a MSE and is then turned away - especially in that last hour when the OP is contractually obligated to perform MSEs.

At the very least, the OP should remain on the property, performing MSEs to anyone who arrives, and providing stabilizing care during their entire shift. Absolutely do not tell hospital employees to shut down anything unless you want to spend the rest of your life waiting tables. What happens after the shift is highly dependent on what is in their employment contract and the steps that were taken to provide reasonable accommodations to insure patient safety. If the OP simply walks out of the hospital 1 minute after their shift ends without handing off their patients, they should expect to get a call from the state medical board regarding patient abandonment and CMS investigators for failing to stabilize any patient still in the ED with an EMC. On the other hand, if they document efforts to insure safe handoff to hospital providers, then the risk of adverse action from regulatory bodies is mitigated. I say mitigated, but not zero.

Finally, anytime a facility is left without coverage there is a ton of liability for anyone involved - hospitals, administrators, doctors, nurses, etc. Keep in mind that CMS investigators and state medical boards will not give 2 ****s about the OP’s pay. That CMS investigator will have no compunction about crawling so far up a doctors ass that a bronchoscope will be needed to pull them out. They will be looking to see if a provider met their obligations under the provisions of their medical license and EMTALA. While it’s important to be fairly compensated for the extra work caused by these situation, affected EPs would be wise to spend the same effort appearing reasonable and focused on patient safety when these situations arise. Otherwise, expect to pay all that over time in legal fees defending their ability to practice medicine.

Hard no
MSE has to be performed by qualified medical personnel. It does not have to be a physician. Cover up the sign and you're no longer an ER. Trust me, we know how it works. FSEDs and hospitals close every day now.
Your perspective could be taken to mean the OP is responsible ad infinitum if no relief shows up. Not just the next shift, but essentially forever.
Yeah, I play hardball with the staffing company. And if they blink, the AOC/CMO/news get called. End of story.

 

[RustedFox]

We had one in Mississippi that did this all the time when no MD/PA/NP was available. They’d notify the state and the ambulance services, lock all the ED entrances, put a sign on the door that they were temporarily closed and the next closest hospitals were 60 miles one direction and 66 miles the other. Never heard of them getting an EMTALA violation.

Jeeeezus, man.

I like you a lot; but where in east Skynyrd did you live that you saw this?

(I say this as a boy from Pennsyltucky that grew-up turbo-rurally; so I know how it is to have a hunting injury and wonder where the nearest "big town" is".)

 

[Fox800]

$1,000 per hour until relief shows up. Hard stop. They'll find someone, or the medical director will come in.

 

[anonperson]

Absolutely do not follow this advice. The OP is an employee or contractor for a CMG, not the hospital. As such, they should not be inserting themselves into the hospital operations or trying to shut down any portion of the hospitals property. If the OP tells the charge nurse to to do this and they comply, the OP will have a giant EMTALA target on their back for any patient who presents to the hospital for a MSE and is then turned away - especially in that last hour when the OP is contractually obligated to perform MSEs.

At the very least, the OP should remain on the property, performing MSEs to anyone who arrives, and providing stabilizing care during their entire shift. Absolutely do not tell hospital employees to shut down anything unless you want to spend the rest of your life waiting tables. What happens after the shift is highly dependent on what is in their employment contract and the steps that were taken to provide reasonable accommodations to insure patient safety. If the OP simply walks out of the hospital 1 minute after their shift ends without handing off their patients, they should expect to get a call from the state medical board regarding patient abandonment and CMS investigators for failing to stabilize any patient still in the ED with an EMC. On the other hand, if they document efforts to insure safe handoff to hospital providers, then the risk of adverse action from regulatory bodies is mitigated. I say mitigated, but not zero.

Finally, anytime a facility is left without coverage there is a ton of liability for anyone involved - hospitals, administrators, doctors, nurses, etc. Keep in mind that CMS investigators and state medical boards will not give 2 ****s about the OP’s pay. That CMS investigator will have no compunction about crawling so far up a doctors ass that a bronchoscope will be needed to pull them out. They will be looking to see if a provider met their obligations under the provisions of their medical license and EMTALA. While it’s important to be fairly compensated for the extra work caused by these situation, affected EPs would be wise to spend the same effort appearing reasonable and focused on patient safety when these situations arise. Otherwise, expect to pay all that over time in legal fees defending their ability to practice medicine.

So the current physician is essentially a slave until another physician relieves them? That doesn't make sense. So if the CEO decides they don't want to pay for coverage for 3 days, the OP is responsible? No way.

That's the medical director and CEOs problem, not the problem of the employee who is being paid a set amount to work a set number of hours.

"I am leaving at the end of my shift as contractually obligated and you have to get coverage for YOUR patients in YOUR ED"

This is supposed to be the benefit of being an employee/IC. We have no ownership and no long term skin in the game.

 

[thegenius]

A urogynecologist chiming in! Love it.

 

[CajunMedic]

Jeeeezus, man.

I like you a lot; but where in east Skynyrd did you live that you saw this?

(I say this as a boy from Pennsyltucky that grew-up turbo-rurally; so I know how it is to have a hunting injury and wonder where the nearest "big town" is".)

Port Gibson, MS. Halfway between Vicksburg and Natchez. Far enough East in Claiborne county, I could transport you to Jackson faster. Our station was in the ED Parking lot. Retired plastic surgeon 1 night out of every 3, PA/NP the rest, closed if none of them would come in.

 

[emergentmd]

As the Only Doc in the ER, you can not morally or professionally leave. It sucks but if you leave, every inpatient and ER pt will be abandoned by you. If I left, and someone died b/c there was no doc in the area I would not be able to forgive myself. Place on top of this, the book will be thrown at you. You will be reported to the Board and would likely lose your license. At best, you will be reported and will have to explain this at every hospital you try to get credentials. Likely you will never be credentialed at any decent hospital again. I know I would never vote to credential you.

As this is your last shift, the best thing is to fire off emails requesting 3-5x rate. If they refuse, fire of an email stating that you are endangering pts working over 12 hrs. Likely they will find someone or pay your ransom.

BUT whoever told you to leave without coverage just gave the worse advice I have read on here.

 

[turkeyjerky]

As the Only Doc in the ER, you can not morally or professionally leave. It sucks but if you leave, every inpatient and ER pt will be abandoned by you. If I left, and someone died b/c there was no doc in the area I would not be able to forgive myself. Place on top of this, the book will be thrown at you. You will be reported to the Board and would likely lose your license. At best, you will be reported and will have to explain this at every hospital you try to get credentials. Likely you will never be credentialed at any decent hospital again. I know I would never vote to credential you.

As this is your last shift, the best thing is to fire off emails requesting 3-5x rate. If they refuse, fire of an email stating that you are endangering pts working over 12 hrs. Likely they will find someone or pay your ransom.

BUT whoever told you to leave without coverage just gave the worse advice I have read on here.

Really? That seems rather harsh. I haven't been in this situation, but I think I would inform the charge nurse and hospital admin that I would stay to dispo all my remaining patients, but would not pick up any new patients. I'd advise them to stop accepting ambulances and inform walk-ins that there is no doctor on duty (presumably most patients would decide to leave at that point).

I would argue that there's no abandonment once you've dispo'd a patient, and that merely being present in the ED does not constitute a patient-physician relationship, and hence there's no duty to see new patients. Similarly, if I walked through the ED on my day off to go to a meeting, I'm not available for patient care.

 

[gro2001]

Hard no
MSE has to be performed by qualified medical personnel. It does not have to be a physician. Cover up the sign and you're no longer an ER. Trust me, we know how it works. FSEDs and hospitals close every day now.
Your perspective could be taken to mean the OP is responsible ad infinitum if no relief shows up. Not just the next shift, but essentially forever.
Yeah, I play hardball with the staffing company. And if they blink, the AOC/CMO/news get called. End of story.

Somewhere out there is an ER doc who lost the game of chicken to the most stubborn hospital admin ever and is stuck working in the ER for years without relief. Surviving on Shasta cola and Graham crackers. Nobody answering his increasingly pleading emails.

 

[d2305]

Wonder what happened?

 

[WilcoWorld]

Somewhere out there is an ER doc who lost the game of chicken to the most stubborn hospital admin ever and is stuck working in the ER for years without relief. Surviving on Shasta cola and Graham crackers. Nobody answering his increasingly pleading emails.

And he never returned, no he never returned
And his fate is still unlearned
He may ride forever 'neath the streets of Boston
He's the man who never returned

 

[DrGasPasser]

Hard no
MSE has to be performed by qualified medical personnel. It does not have to be a physician. Cover up the sign and you're no longer an ER. Trust me, we know how it works. FSEDs and hospitals close every day now.
Your perspective could be taken to mean the OP is responsible ad infinitum if no relief shows up. Not just the next shift, but essentially forever.
Yeah, I play hardball with the staffing company. And if they blink, the AOC/CMO/news get called. End of story.

No, my perspective means that a EP who is not a hospital employee telling hospital staff to shut down triage an hour before their shift is over is cruise’n for a bruise’n. If you disagree, by all means go right ahead and do that.

 

[DrGasPasser]

So the current physician is essentially a slave until another physician relieves them? That doesn't make sense. So if the CEO decides they don't want to pay for coverage for 3 days, the OP is responsible? No way.

That's the medical director and CEOs problem, not the problem of the employee who is being paid a set amount to work a set number of hours.

"I am leaving at the end of my shift as contractually obligated and you have to get coverage for YOUR patients in YOUR ED"

This is supposed to be the benefit of being an employee/IC. We have no ownership and no long term skin in the game.

No, the Medical Board and CMS investigators will want to see that reasonable steps were taken to insure patient safety. It is highly unlikely that they will view an EP instructing the staff to shut down triage an hour early (presumably so they will not have to work a second beyond their shift) as reasonable. There is no finite answer here. It all depends on how much risk you want to take with your license. Feel free to walk out a second after your shift, but I’d argue that is on the higher end of the risk spectrum. Moreover, I’d be surprised if the OP’s contract doesn’t have some language as to their requirements during these situations.

 

[DrGasPasser]

I think if you warn all appropriate people (your CMG, ER medical director, ER charge nurse, etc), at the beginning of your shift that there may be a problem, that there is no coverage after you after your 12 hr shift, and your intent is to leave, I'm not sure you are exposing yourself to legal action. EMTALA doesn't necessitate that an ER is staffed with a medical personnel 24/7, it just says that if a person shows up to an ER (assuming it's open) with a medical complaint and asking for an MSE, that they get one. That doesn't mean it has to be you. If it did, then every single ER doctor employed at an ER would be liable for EMTALA violation 24/7 if a patient doesn't get an MSE.

Plus EMTALA violations are applied to a hospital, not to doctors.

The original response is still the best one. Demand 4x payment for your unscheduled time or you leave. And make sure you have a paper trail of all of this as well.

Physicians (including EPs) are absolutely subject to EMTALA violations. It still happens with some regularity. Here is how it works, hospitals are required to establish who will perform MSEs and maintain on-call lists for purposes of EMTALA. The hospital’s contract with the CMG generally delegates the performance of MSEs in the ED to its employees or independent contractors. That is why the EP’s contract with a CMG has language that they will, among other things, provide MSEs and stabilizing care during their shift. Those other things almost always involve obeying hospital bylaws which set standards for physician conduct and inevitably include language about hand off and abandonment. EPs are usually added to the institution’s list of providers allowed to perform MSEs when they credential.

So, it’s not hard to see where an independent contractor can land themselves in a world of stuff by telling hospital employees to shut down triage (ie turn people away) 1 hour before their shift ends, or anytime for that matter. This becomes very problematic if the hospital or CMG is actively trying to find relief which arrives on time or let’s say 30 min late. Any patient who presented to the hospital property and is turned away during that 60-90 min period may pose a problem.

I say “may” because EMTALA and medical Board investigations are like a box of chocolate...you never know what you are going to get. My advice to an independent contractor is to stay for their entire shift, do not insert themselves into hospital operations by trying to close facilities or care spaces (a smart charge nurse would tell you to f-off), work with the hospital admin and CMG to insure safe handoff, document these efforts, and then look for a new job once it’s all over...😉.

 

[anonperson]

No, the Medical Board and CMS investigators will want to see that reasonable steps were taken to insure patient safety. It is highly unlikely that they will view an EP instructing the staff to shut down triage an hour early (presumably so they will not have to work a second beyond their shift) as reasonable. There is no finite answer here. It all depends on how much risk you want to take with your license. Feel free to walk out a second after your shift, but I’d argue that is on the higher end of the risk spectrum. Moreover, I’d be surprised if the OP’s contract doesn’t have some language as to their requirements during these situations.

So what is reasonable?
2 hours?
6 hours?
24 hours?

I could just live there and then there won't be any risk.

Once the shift is done, it's done.

I am not an ED physician but I cover labor and delivery for 24 hours so deal with the active labor part of EMTALA.

Our hospital has bylaws that forbid greater than 24 hours for a single physician to cover labor and delivery.

Regarding reasonable steps to ensure coverage. How is that the problem of the employee? This is the problem of the owner/ leader.

 

[DrGasPasser]

So what is reasonable?
2 hours?
6 hours?
24 hours?

I could just live there and then there won't be any risk.

Once the shift is done, it's done.

I am not an ED physician but I cover labor and delivery for 24 hours so deal with the active labor part of EMTALA.

Our hospital has bylaws that forbid greater than 24 hours for a single physician to cover labor and delivery.

Regarding reasonable steps to ensure coverage. How is that the problem of the employee? This is the problem of the owner/ leader.

There is no firm definition of reasonable and the individual circumstances will dictate how it is defined. Interestingly, I’m sure that all of us have had to stay after our shifts because a colleague over-slept or forgot they were on the schedule. Did anyone peace-out as soon as their shift ended? Who here has walked off after a shift, leaving their ED uncovered when their relief no-showed?

So, why the recommendations to treat this situation in a different manner? Do you really think the fact that the staffing issue was known ahead of time is going to change much when it comes down to being decredentialed?

Bottom line - these staffing issues where nobody is on the schedule happen all the time in this industry. In the vast, vast majority of cases the CMG or hospital is able to make reasonable accommodations to get the doctor relief but that may involve someone staying late after a shift. That is EXACTLY what happened in this case and the OP is off to greener pastures. However, the internet is never short on digital muscle that is willing to tell people to do all manner of reckless crap that they themselves have never none or would never do.

 

[GonnaBeADoc2222]

There is no firm definition of reasonable and the individual circumstances will dictate how it is defined. Interestingly, I’m sure that all of us have had to stay after our shifts because a colleague over-slept or forgot they were on the schedule. Did anyone peace-out as soon as their shift ended? Who here has walked off after a shift, leaving their ED uncovered when their relief no-showed?

So, why the recommendations to treat this situation in a different manner? Do you really think the fact that the staffing issue was known ahead of time is going to change much when it comes down to being decredentialed?

Bottom line - these staffing issues where nobody is on the schedule happen all the time in this industry. In the vast, vast majority of cases the CMG or hospital is able to make reasonable accommodations to get the doctor relief but that may involve someone staying late after a shift. That is EXACTLY what happened in this case and the OP is off to greener pastures. However, the internet is never short on digital muscle that is willing to tell people to do all manner of reckless crap that they themselves have never none or would never do.

Yeah I gotta say I would have to err on the side of caution here.

 

[anonperson]

There is no firm definition of reasonable and the individual circumstances will dictate how it is defined. Interestingly, I’m sure that all of us have had to stay after our shifts because a colleague over-slept or forgot they were on the schedule. Did anyone peace-out as soon as their shift ended?

So, why the recommendations to treat this situation in a different manner? Do you really think the fact that the staffing issue was known ahead of time is going to change much when it comes down to being decredentialed?

Bottom line - these staffing issues where nobody is on the schedule happen all the time in this industry. In the vast, vast majority of cases the CMG or hospital is able to make reasonable accommodations to get the doctor relief but that may involve someone staying late after a shift. That is EXACTLY what happened in this case and the OP is off to greener pastures. However, the internet is never short on digital muscle that is willing to tell people to do all manner of reckless **** that they themselves have never none or would never do.

A colleague sleeping in or late to traffic is entirely different than a greedy CEO trying to underpay a physician and subsequently having difficulty covering a shift.

I don't recommend telling the hospital to shut down the ER etc. for the very reason that you/I are employees and are not owners or leaders of the health system. That is for the CEO and CMO to worry about.

The problem is physicians in general are good people and don't want patients to suffer. This comes to our detriment because the corporate side exploits this to no end.

This isn't charity, it's a job.

 

[thegenius]

Physicians (including EPs) are absolutely subject to EMTALA violations. It still happens with some regularity. Here is how it works, hospitals are required to establish who will perform MSEs and maintain on-call lists for purposes of EMTALA. The hospital’s contract with the CMG generally delegates the performance of MSEs in the ED to its employees or independent contractors. That is why the EP’s contract with a CMG has language that they will, among other things, provide MSEs and stabilizing care during their shift. Those other things almost always involve obeying hospital bylaws which set standards for physician conduct and inevitably include language about hand off and abandonment. EPs are usually added to the institution’s list of providers allowed to perform MSEs when they credential.

So, it’s not hard to see where an independent contractor can land themselves in a world of stuff by telling hospital employees to shut down triage (ie turn people away) 1 hour before their shift ends, or anytime for that matter. This becomes very problematic if the hospital or CMG is actively trying to find relief which arrives on time or let’s say 30 min late. Any patient who presented to the hospital property and is turned away during that 60-90 min period may pose a problem.

I say “may” because EMTALA and medical Board investigations are like a box of chocolate...you never know what you are going to get. My advice to an independent contractor is to stay for their entire shift, do not insert themselves into hospital operations by trying to close facilities or care spaces (a smart charge nurse would tell you to f-off), work with the hospital admin and CMG to insure safe handoff, document these efforts, and then look for a new job once it’s all over...😉.

Nope.

“Only hospitals can be sued for EMTALA violation in federal court (although physicians can have civil monetary penalties levied against them by HCFA—see under EMTALA Violations).”

The Emergency Medical Treatment and Active Labor Act (EMTALA): what it is and what it means for physicians

Now...the hospital might not like you leaving the ED, they might terminate your contract, or do other things. But EMTALA is a federal statute, only tried in federal courts and the defendants are hospital systems, not physician(s).

 

[thegenius]

There is this notion people are arguing here that a doctor just gets up and leaves at the end of the shift without talking to anybody and says peace out.

In reality the opposite would occur.

Hours and perhaps days before the shift, once the doc knows there is nobody on the schedule, the doc starts making phone calls and emails asking hospital and CMG admin to find relief. And indicating he will want 3x pay to stay for an entire extra shift. Or warning everyone that he will not see new patients at the end of the shift.

Then when he is on shift...the doc continues to make phone calls and emails to those in charge that something has to happen and he needs coverage. The doc would be telling nurses about the staffing problem.

People would come to the aid of the doc. This wouldn’t fall through the cracks.

Heaven forbid if this would happen. I doubt this ever would. But at the end of my shift I would stop seeing patients unless you basically come in almost dead, and yes i would consider leaving at or after the end of my shift, after days of asking and warning hospital admin about that forthcoming problem with a paper trail to back this up.

 

[DrGasPasser]

Nope.

“Only hospitals can be sued for EMTALA violation in federal court (although physicians can have civil monetary penalties levied against them by HCFA—see under EMTALA Violations).”

The Emergency Medical Treatment and Active Labor Act (EMTALA): what it is and what it means for physicians

Now...the hospital might not like you leaving the ED, they might terminate your contract, or do other things. But EMTALA is a federal statute, only tried in federal courts and the defendants are hospital systems, not physician(s).

I specifically said “subject to” and not “sued for.” Words matter and do not try to twist mine. As I said in previous posts and consistent with your linked article, physicians are absolutely subjected to violations of EMTALA which can include fines of up to $50K per violation as well as termination of their ability to bill Medicare. From your article :

“Participating hospitals and physicians who negligently violate the statute are subject to a civil monetary penalty not to exceed $50,000 (or $25,000 for hospitals with <100 beds) for each violation. Because a single patient encounter may result in >1 violation, fines can exceed $50,000 per patient. It is important to note that most physician malpractice policies will not cover such administrative penalties...”

Any physician who tells their hospital to close triage an hour early because they do not think that their relief will show up puts that facility at risk for an EMTALA violation for any patient who is turned away without a MSE and stabilizing care. That physician stands a reasonable chance of picking up a $50K fine as well for each patient who does not get a timely MSE. I can almost promise you that the hospital’s legal counsel will draft their own complaint depicting a rouge independent contractor physician to mitigate their exposure.

 

[GeneralVeers]

I'd get it in writing that they would pay me $1000/hr to stay or i would peace out at the end of my shift. I seriously doubt any legal trouble could arise if you leave at the end of your scheduled shift. I just don't agree with the legal intepretations on here.

 

[VA Hopeful Dr]

I'd get it in writing that they would pay me $1000/hr to stay or i would peace out at the end of my shift. I seriously doubt any legal trouble could arise if you leave at the end of your scheduled shift. I just don't agree with the legal intepretations on here.

Its not abandonment if they aren't your patients, and they aren't your patients until you've done something - history, physical, labs, something

 

[GeneralVeers]

Its not abandonment if they aren't your patients, and they aren't your patients until you've done something - history, physical, labs, something

Correct. No court in the land would force you to work for free as an indentured services. At 7AM I would immediately stop seeing any new patients, dispo or discharge any that were remaining, and walk out the door.

 

[DrGasPasser]

Correct. No court in the land would force you to work for free as an indentured services. At 7AM I would immediately stop seeing any new patients, dispo or discharge any that were remaining, and walk out the door.

You are probably pretty safe doing that unless a patient presents in extremis after 0700 while you are still in the ED. Then, I’d say that all bets are off - your license and ass are on the line if you do not render aid.

On the other hand, telling your charge nurse to shut down triage an hour early is really bad advice.

It’s all a game of risk management. In the end, we are all adults and probably shouldn’t need the internet to tell us how to act in any given set of circumstances.