Overnight call rate

[Cath Up]

-90 bed freestanding psych hospital
-shift is 1700-0800 remote phone coverage with verbal orders, very occasional non-MD question about admit/not admit from other EDs
-3-12 calls per shift average 8, most are in the evening, though usually woken up from 2-6am with one call
-no documentation, no need to go in to sign anything
-say you enjoy the work, have no kids or serious discomfort from the sleep disruption

What rate range is reasonable? How low would you go?

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[Sushirolls]

I don't enjoy the IP/ED call work. I have kids. And don't like being woke up.

You aren't just covering the new calls/admits, but you are the liability target as physician of record for the whole 90 beds.
Chances are you could likely be technically called, and requested to also show up in person by individual X and the hospital bylaws will say, yes, you must, and the perception that it is a strictly phone call only gig, is very, very low odds. Rare for hospital bylaws to designate a specific "phone call only" specialty. I'd bite for $300/hr, so $3900 per shift. Unlikely any entity will pay that, unless its the locums agency they find, because they baulked at paying you that. So they'll pay it, just not you, the person who could be the long term, quality, reliable coverage... Big Box shops...

My younger, less experienced, perhaps naive self, would do it for $125/hr in today's dollars.

These days the only thing I want waking me up in the middle of the night are kids issues, danger to home/family, or a toothy animal trying to get my livestock in need of their lead deficiency treatment.

 

[ObsequiousAplomb]

-90 bed freestanding psych ED
-shift is 1700-0800 remote phone coverage with verbal orders, very occasional non-MD question about admit/not admit
-3-12 calls per shift average 8, most are in the evening, though usually woken up from 2-6am with one call
-no documentation, no need to go in to sign anything
-say you enjoy the work, have no kids or serious discomfort from the sleep disruption

What rate range is reasonable? How low would you go?

I don't think it's remotely reasonable to entertain an idea that people without children deserve lower pay. that being said, since I do have children, maybe I should go around demanding more pay for things?

I agree with Sushi's rates. Doctors that fill these roles are liability sponges. Non-MDs constantly putting in orders under the doctor's name, making decisions on their own because they know better than to ask the doctor who will say no.

 

[Cath Up]

I don't think it's remotely reasonable to entertain an idea that people without children deserve lower pay. that being said, since I do have children, maybe I should go around demanding more pay for things?

I agree with Sushi's rates. Doctors that fill these roles are liability sponges. Non-MDs constantly putting in orders under the doctor's name, making decisions on their own because they know better than to ask the doctor who will say no.

I guess my sense is that sleep feels a lot more valuable for young parents so a job like this would not be desirable and they’d have to make a lot more to go through it. Not knocking having kids at all… everyone I know who’s had that says it changes calculations for work life balance at least a little.

Your point about liability is well taken.

 

[calvnandhobbs68]

who covers seclusion/restraints?

 

[Jules A]

very occasional non-MD question about admit/not admit

Careful not to minimize this “non-MD question”. If the answer is “not admit” whoever you spoke with just discharged a patient on your behalf.
How much are they paying you? Or are you just guessing about how many calls you might receive?

At the hospitals I work offsite call same hours 12-18 beds $850 psychiatrist. So yeah Sushi’s number is on target.

 

[Celexa]

I just cannot imagine taking a job like this from a liability standpoint. You have no defense if something goes wrong, not even your own documentation, just what other people have put in the chart? There's no amount of money that would make me feel comfortable with that.

 

[Bartelby]

I wonder if it would work like resident supervision. You discuss the case, make the final call, and write an addendum as needed. If so it could be okay re: liability if the staff are good, but even if so the sleep disruption alone would push me away unless they would offer a ridiculous amount (maybe like what Sushi referenced $300/hr).

 

[Candidate2017]

-90 bed freestanding psych ED
-shift is 1700-0800 remote phone coverage with verbal orders, very occasional non-MD question about admit/not admit

-no documentation, no need to go in to sign anything

Let's ignore the fact that you will covering 4-6 times the average inpatient census, and let's play a game:

A person shows up to a psych "ED" seeking help, SW or RN tells you they're fine, so you approve discharge home, then bad outcome happens. Please convince 12 random people you should not be liable for millions of dollars because you adhered to the standard of care (i.e., psychiatrists routinely send people home via phone, without examining them, relying solely on the assessment of a non-physician). Go ahead, I'll wait.

Let's play another game: What are the odds this is a for-profit hospital?

-say you enjoy the work, have no kids or serious discomfort from the sleep disruption

This isn't work. This is just letting The Man use your license, insurance, and current and future assets. Seriously, how can someone complete a legit psych residency and think this proposition is ok.

 

[splik]

This would fall below the acceptable standards for a freestanding psych ER. They need to have 24/7 psychiatric coverage (which could include using residents or psych NPs). telephone coverage not acceptable. It would be acceptable if it were an inpatient psych unit or consultation to a medical ER.

 

[Bartelby]

This would fall below the acceptable standards for a freestanding psych ER. They need to have 24/7 psychiatric coverage (which could include using residents). telephone coverage not acceptable. It would be acceptable if it were an inpatient psych unit or consultation to a medical ER.

Good point. What if the on site provider is an NP? Thinking more about it though I am coming around to the "too much liability" camp too.

 

[Cath Up]

This would fall below the acceptable standards for a freestanding psych ER. They need to have 24/7 psychiatric coverage (which could include using residents). telephone coverage not acceptable. It would be acceptable if it were an inpatient psych unit or consultation to a medical ER.

My bad, it is a psych hospital not ED.

 

[Cath Up]

who covers seclusion/restraints?

That’s a good question, as this requires an in person eval. Not sure it is legally viable with this model. The hospital seems to have low acuity.

 

[Cath Up]

Careful not to minimize this “non-MD question”. If the answer is “not admit” whoever you spoke with just discharged a patient on your behalf.
How much are they paying you? Or are you just guessing about how many calls you might receive?

At the hospitals I work offsite call same hours 12-18 beds $850 psychiatrist. So yeah Sushi’s number is on target.

The non admits are bed searches from other hospitals so fortunately the liability is not your own I believe. This is a hospital not ED- I mis-typed.

 

[Cath Up]

Appreciate the thoughts from everyone-

Yes, obviously this setup is at a for profit hospital. I agree it appears sub standard though I know of >5 medical EDs in my region that have mental health techs present patients at night to phone attendings to decide disposition. I don’t agree this is adequate care for EDs to provide in general- thoughtful disposition is why I enjoy ED work, and that is informed by training.

Learning about this setup was born from reaching out to dozens of facilities across 3 states looking for moonlighting opportunities with this being the only durable responder (I understand fully why they might be hiring at all times).

Universally and without exception I’ve had attendings recommend moonlighting to me for several reasons. It’s really disappointing that my region has few options and my residency has nothing substantial set up, yet allows moonlighting.

 

[splik]

My bad, it is a psych hospital not ED.

Oh that's totally different then. I think there is relatively low liability if the pts are tucked in on a locked unit and your review of admissions was really about their medical and psychiatric suitability for the unit. I cant imagine it would be very attractive job but if you are in interested and the volume of calls is not too onerous and it wouldn't impact your sleep or your quality of life, then go for it. These things usually do not pay well and do not command an hourly fee. There is usually a fee by the night, weekend, or week.

 

[Cath Up]

Oh that's totally different then. I think there is relatively low liability if the pts are tucked in on a locked unit and your review of admissions was really about their medical and psychiatric suitability for the unit. I cant imagine it would be very attractive job but if you are in interested and the volume of calls is not too onerous and it wouldn't impact your sleep or your quality of life, then go for it. These things usually do not pay well and do not

I am so sorry for wasting everyone’s energy on ED, not hospital, though I wonder if some people would still feel similarly.

Perhaps I shouldn’t start new posts in bed before I fall asleep!

 

[Celexa]

I am so sorry for wasting everyone’s energy on ED, not hospital, though I wonder if some people would still feel similarly.

Perhaps I shouldn’t start new posts in bed before I fall asleep!

Knowing how many absolute medical disasters I have walked into in the mornings on inpt units, and how the nursing skill seemingly everywhere has declined post Covid retirements and increasing reliance on travelers, I wouldn't feel differently. I assumed you were talking about inpt coverage from the start.

But also, the reason moonlighting is encouraged for residents (on an educational level) is to gain experience by seeing more patients and stretching your wings making independent clincial decisions. This isn't a very good job for that part. Money is certainly reason enough to take an extra gig but don't expect this type of job to do much for your skills. Something like covering a unit on the weekends, where you are doing quick but in person evals, would be different.

 

[Stagg737]

As others have said, if it were a psych ED this should not even be a consideration.

For general inpatient coverage it could be. That’s a lot of beds to cover by yourself. Average of 8 calls doesn’t sound like a lot, but if 2-3 comes after midnight it starts to wear you down. What you’re talking about I probably would have considered for $1000/night as a resident, but would recommend it for anything less than $1500. As an attending I wouldn’t even discuss this position for less than $2k/night and still probably would walk at anything less than $2500/night.

 

[comp1]

I don't like setups like this where there is someone separate from the day system entirely. It's much, much better to have a call pool of outpatient providers who work within the same system or, even better, primarily day inpatient providers participate in a call pool. You don't really have much of an incentive overnight to not just admit everything. Definitely agree with others that the liability is low and that this sort of coverage is absolute community standard, generally throughout the country, for freestanding inpatient psychiatric hospitals. However, I think pay for this is going to be extraordinarily poor. I had a job like this when I was a resident moonlighter. I was paid the equivalent of $130 per night in today's dollars. There was additional stuff like if I had to go in and see a patient, it was an extra $200 or $300 if I discharged the patient AMA (all night discharges being AMA). It's hard to negotiate these positions and it's why they're generally built into other positions instead, outside of resident moonlighting. The reason is because they only view you as "working" when you're answering the call which might add up a full hour of talking on the phone the entire night and possibly much less. You aren't even generating billing for that hour. Obviously you can't just turn your brain off immediately and fall back asleep after answering the call, but it's hard for people to wrap their head around that. I'm not sure what to tell you in terms of price, I just don't like the setup of hiring someone specifically for this only by phone. I'd take a dedicated on site or even video remote NP over this kind of on call coverage in a heartbeat. At least the morning people would come in to admit notes being done.

 

[psych_0]

To the folks here suggesting you should be paid $1500+ per night to give phone orders and respond to average 8 calls/night without having to go in....is this a thing? I have never seen anyone getting close to that at any job I have interviewed or worked at either as a resident or an attending? Do the math. $1500/night * 7 days a week * 47 weeks/year....That's a $493k job (with 5 weeks vacation). Are there really people getting paid anywhere close to that? Even with young kids, that is not a horrific gig. If anyone is getting paid this amount of money to do that easy of a job, I doubt they are letting go of that any time soon.

Shoot, even a 7 on 7 off scenario pays $273k. There's no way this is a real expectation. This forum has lost its mind lol.

 

[Celexa]

To the folks here suggesting you should be paid $1500+ per night to give phone orders and respond to average 8 calls/night without having to go in....is this a thing? I have never seen anyone getting close to that at any job I have interviewed or worked at either as a resident or an attending? Do the math. $1500/night * 7 days a week * 47 weeks/year....That's a $493k job (with 5 weeks vacation). Are there really people getting paid anywhere close to that? Even with young kids, that is not a horrific gig. If anyone is getting paid this amount of money to do that easy of a job, I doubt they are letting go of that any time soon.

Shoot, even a 7 on 7 off scenario pays $273k. There's no way this is a real expectation. This forum has lost its mind lol.

People aren't naming what they think people are actually paid; they're naming the amounts it would be personally worth it to them to take on the aggravation and liability. And some of us are saying there's no amount of money that would be worth it.

 

[Bartelby]

Exactly. I hate getting up through the night, it would take a silly number to get me genuinely interested.

 

[Jules A]

I average 4-6 calls and 1-2 admits on fairly well run units with census <20. I can’t imagine there are only ~8 calls with 90 beds. And calls are never spaced to enhance my quality of life or sleep.

 

[Wheatbread]

We get $500 for 24 hours on call. 65 bed inpatient + ED calls. Usually from 8-5pm I don’t get any calls as we have ED providers and floor calls go to pts attending. From 5pm-12am usually get one page an hour and after midnight it’s maybe 3-6 pages. It’s absolutely horrible and they refuse to increase the stipend. I like money but this is 100% not worth it but it’s mandatory. It’s only about once per month though.

 

[Merovinge]

I did Q7-8 call for around 150 beds. Averaged 5-6 admissions from 2100-0700 plus the additional PRNs. Was required and without pay but it specifically made the job untenable for me for the long run as the next day was brutal and adding that to trying to have children was not sustainable for me. As I tell my patients, humans are awful at understanding the costs of sleep deprivation, they are always more than you think they are.

 

[ObsequiousAplomb]

To the folks here suggesting you should be paid $1500+ per night to give phone orders and respond to average 8 calls/night without having to go in....is this a thing? I have never seen anyone getting close to that at any job I have interviewed or worked at either as a resident or an attending? Do the math. $1500/night * 7 days a week * 47 weeks/year....That's a $493k job (with 5 weeks vacation). Are there really people getting paid anywhere close to that? Even with young kids, that is not a horrific gig. If anyone is getting paid this amount of money to do that easy of a job, I doubt they are letting go of that any time soon.

Shoot, even a 7 on 7 off scenario pays $273k. There's no way this is a real expectation. This forum has lost its mind lol.

as others have said, we are naming our personal price. We haven't lost our minds. The fools who accept peanuts for terrible quality of life are the ones who have lost their minds.

 

[comp1]

You aren't getting paid $1500 a night. This honestly is not a job. It's a small part of a job that's shared amongst many people in addition to day work. I'm very confused about how it even came up as it's not practical. Is it like a new medical director?

 

[Stagg737]

You aren't getting paid $1500 a night. This honestly is not a job. It's a small part of a job that's shared amongst many people in addition to day work. I'm very confused about how it even came up as it's not practical. Is it like a new medical director?

Could be a contracted group who came together and said FYPM for overnight coverage and now the hospital is trying to fill in that hole for cheaper than what they're paying the group. Saw it happen with a local hospital when I was in med school and the whole group eventually got replaced. Kicker is the hospital still only runs at ~60% potential capacity 7-8 years later because the group they hired was just 4 psychiatrists (now 3 MDs and 2 NPs I believe) and the previous group had 8.

 

[Merovinge]

You aren't getting paid $1500 a night. This honestly is not a job. It's a small part of a job that's shared amongst many people in addition to day work. I'm very confused about how it even came up as it's not practical. Is it like a new medical director?

I am sure IP units are looking for ways to decrease the call burden on their day staff so they can continue to recruit people to these jobs and residents/fellows are the perfect target to pay a peanuts to. A very small portion of my fellows are going into IP work these days when they can do PHP/IOP for similar acuity without call or classic OP work. I certainly don't see NPs or PAs clamoring to take these shifts which tells you something...

 

[randomforensic]

i'm a resident. i have the option to pick up these overnight shifts when the staff psychiatrists can't work their mandatory (roughly 6 per month) ones for whatever reason. i get paid $350. similar hours of coverage as OP, similar number of beds. i've averaged 10-16 calls a night. i don't like doing it but some months i need more money.

 

[Sushirolls]

10+ years ago as resident was getting $100/hr for similar beds. No ED consults, but doing the H&P of the patients admitted by phone from on call staff. I.e. Resident was warm body in hospital fielding in hospital issues, so staff docs only had to get ED call to then say yes, admit.

Psych ED then was $90/hr.

$350 for what you are doing is just not worth it.

 

[Sushirolls]

The most ideal set up for IP units is the following:

-Patient presents to ED.
-ED&SW see, want admit, from same hospital or an outside hospital.
-Records faxed to the unit charge nurse who does first review of labs/records, and urges correction of routine issues. Like where's the CMP? TSH? UDS? etc.
-Charge nurse presents patient to on call Psychiatrist by phone. Who fields these calls only until 10PM. Admit orders are also provided then, for once the patient gets on unit.
-After 10PM, charge nurse makes pile of outside hospital inquires, to be addressed again at 7, or 730AM, or 8AM, whenever the IP doc roles into the unit in AM to present those cases to the doc. Charge nurse calls back those OSH to see if patient still need admit, and then accepts, if unit has open beds. Patients in the ED of the hospital with the IP unit, will have the unit charge nurse present those patients to the hospitalist team after 10PM. They decide to accept admit or not, and the patients are admitted to the hospitalist service on the unit, who has admitting privileges to the psych unit. They do a garden variety medical H&P, and will put in the A/P MDD severe, consult psych in AM and change primary service to psych in AM. So a few short hours of the night, the IM hospitalist service is the admitting doc, and doc of record for the psych patient. Psychiatry flips the primary service over to psych in AM once seen. IM then follows as consultatnt if necessary, or signs off. This is how IP units reduce paging psych in evening.
-Hospitalists play along with this setup because they are going to already get reflex consulted by Psych anyways, and still see the same patients in middle of night anyways, but at least now admitting, they (might) get higher billing charge by being the first admit H&P. They know they are helping psych out, and get a tit/tat tradeoff of psych not pushing back during day time when they want the C/L consult for what we know is complete waste of our time. Win/Win.

 

[Merovinge]

Makes sense, but no for-profit psych hospital is telling an ED at 2230h to call back in 9 hours for an admission. They are fighting to make as few barriers as possible for the money machine, I mean patient, to come to the unit. I am not sure what percent of beds are in academic hospitals/multispecialty hospitals versus stand alone psych IP, but there certainly is a significant percentage in the latter. In my geography they certainly make up well north of 50%.

 

[ridethecliche]

OP, are you a resident? It sounds like that from some of these posts. If so, this sounds like a totally terrible opportunity.

All these posts make me thankful that my fellowship moonlighting experiences were plentiful after not being allowed to moonlight at all as a resident.

 

[Cath Up]

OP, are you a resident? It sounds like that from some of these posts. If so, this sounds like a totally terrible opportunity.

All these posts make me thankful that my fellowship moonlighting experiences were plentiful after not being allowed to moonlight at all as a resident.

Yes I am a resident.

I’ve been taking overnight call for a little while now. I had them increase my rate. I probably have averaged 5 calls per shift. There is no seclusion or restraints at the facility. It is mostly to cover admissions so I check withdrawal risk, vitals, home meds, agitation and sleep meds, current behavior status, acute suicide/aggression risk typically. I also work there some weekends inpatient, which pays $150/hr with more if I see a lot of patients and is exposure and autonomy I enjoy- more of the spreading my wings type autonomy I was looking for. They want me to see too many patients so I see as many as I feel safely able to see and work very long hours, which I don’t really mind as I’m away from home for the weekend regardless, to spend enough time with people and still hit the minimum. There is a psychiatrist available for backup if I need it.

There is also crisis work at another hospital that pays more. It is under staffed, but this is the work I most enjoy at this point as it is more intense and dispositioning I find to be important work that I want to obtain experience with. Seeing as I don’t really need the money, if I feel uncomfortable with what the facility tries to get me to do, I will stop. For example, I started turning down patients that I’m “not supposed to turn down per support staff” because I didn’t like the nurse staffing ratio. If the facility tells me I can’t do this, I’d probably quit.

My biggest concern remains liability that I may or may not be aware of- I know others feel this is too much liability for them. I know I am a sponge for the system in that sense, but haven’t detected anything egregious like staff putting my name on things they didn’t tell me about. I am considering obtaining my own liability insurance in addition to the policy that the hospital has for me. I don’t know if this is a smart thing to do though.

The issue of being a cog in a low-quality machine does get to me. I think everyone has a different tolerance for this kind of thing. I am rendering the best care in person that I know how, but obviously there are issues with every other step of things- access to long term therapy, the right meds, PHP, IOP, rehabs. Most people in this population are low SES with little buy-in into their health as it is and getting everyone the case management and peer support they’d need to improve is definitely unrealistic. I think the local county health psych access remains underfunded and under staffed with frankly has similar problems and I’m not convinced it does much of a better job. Two wrongs don’t make a right but when the field is littered with **** tier care and access all over the place it is difficult to avoid, at least in my area. Long term I would like to have my own practice where I can give good longitudinal care or work in a private group that does so. Maybe some community health system work.

 

[Therapist4Chnge]

I just cannot imagine taking a job like this from a liability standpoint. You have no defense if something goes wrong, not even your own documentation, just what other people have put in the chart? There's no amount of money that would make me feel comfortable with that.

Well said. No documentation and phone only sound like bait to be a Meat Shield. There are very solid reasons for documentation.

 

[Therapist4Chnge]

who covers seclusion/restraints?

I’d want to review the restraints policy first and then make sure everyone has been trained on it (in writing) before i’d remotely feel comfortable signing off on anyone as it relates to use of restraints.

OP, I say this as someone very familiar w restraint policies. I had to work w nursing & legal at multiple rehab hospitals on them bc of high-acuity TBI cases. I also do med mal cases, and “standard of care” might be the comparison, but a halfway decent cross by the other side would flay you open if they knew just the basics of how they overnight coverage. Run from that position, and if they ask why, it’s all about the liability.

FWIW, I wouldn’t invite added stress and liability for less than $350/hr, not that they would even pay that unless desperate. Being a psych hospital and not ED def is a better option, but the number of beds and “Meat Shield” considerations still apply.

OP, I’m not sure if you have the training or interest, but doing (certain) legal work is a far far better option to make excellent side $ once out of fellowship and fully on your own. You’ll want mentorship for a bit, but the hourly is far better than any clinical work. It can be done on your own time (mostly), and after the learning curve it can provide a much better work/life balance than taking overnight call. Doing IMEs for civil cases, not child custody (run!!) or criminal work (can be good, but a forensic fellowship would be preferred).

 

[Merovinge]

I did weekend IP rounding as a fellow (but in adult psych) and found it good work. I was also paid $150 hour, although adjusted for inflation that would be at least $200 in today's dollars (boy am I old...). I could always get the work done and more complicated cases I was getting paid the same hourly rate to handle so it never felt dumpy. I was never on call or a meat shield for liability for anything out of hours, I have seen what lawsuits early in a career do to doctors, and boy it has never been pretty.

 

[ridethecliche]

@Cath Up

I would make damn sure that the facility is paying your tail coverage while you're working there. When it was the only way to pick up hours, I did ED dispo stuff for a similar rate and don't regret it. I'm in my last year of fellowship now, allegedly, and often work overnights on weeknights. There's definitely a chance that I get slammed and totally screwed when it comes to overnight responsibilities so I've turned it down a tad while I'm coming into boards prep and will likely start things over again a week or two after that's done.

I'm really trying to avoid working weekends even if it means being pretty busy during the week. I've done a few home call telepsych things that are paid less than the crisis call, but it's only for 7hrs a night and I'm done by midnight. I did it once from 5pm to 8am and it was possibly one of the worst call shifts I've ever had so it's going to be a minute before I sign up for that again... but I'm a glutton for punishment so it'll probably happen.