Faced with a growing revolt of specialists against on-call duties, hospitals have been luring them back with sizeable payments and, failing that, reporting them to the authorities and threatening to remove them from staff. If hospitals do not have physicians on call around the clock, they are in violation of federal law and could lose status as trauma centers, says George Lee, M.D., vice president of medical affairs at California Pacific Medical Center in San Francisco.
Lee says California Pacific, the largest hospital in northern California with more than 600 beds, pays doctors $200 to $900 a day for on-call work. The payments, which began in 1991, amount to $2 million dollars a year and most likely will never go away, he says.
"Once you start paying, taking it back is very, very difficult," Lee explains.
California's on-call crisis is more advanced than in the rest of the nation, but hospitals everywhere are feeling the pinch. Eventually, paying for call "will become standard practice across the country," Lee predicts.
Specialists least likely to take call are plastic surgeons, otolaryngologists, psychiatrists, neurosurgeons and orthopedic surgeons, according to a recent survey of California hospitals cited in a May report on the problem by the California Senate Office of Research.
"Evidence is systematically mounting that gaps and problems with on-call coverage are contributing to delays in treatment and growing costs to hospitals across the state," the report says, adding that hospitals in other states have similar problems.
Challenging California doctors about their call responsibilities "has been the chief cause of hospital administrators losing their jobs," says Loren Johnson, M.D., chief medical officer for Sutter Emergency Medical Associates, an independent company that contracts exclusively with Sutter Health in Sacramento, Calif.
Johnson says in some cases, on-call doctors simply don't respond to requests from the emergency room, forcing patients to transfer to another hospital.
Refusing to respond to assigned call, Johnson says, is a violation of federal law and carries fines of as much as $50,000 per case. Several times he has personally reported doctors who have done so, he says.
In contrast, refusing to sign up for call does not violate the law, and more doctors are taking this option, Johnson says.
Call duties have become more time-consuming, and specialists no longer need the work to get new patients, says Lowry Jones, M.D., who serves on a task force at the American Academy of Orthopaedic Surgeons that monitors on-call problems.
"I don't know of any orthopedic surgeon who is very hungry for patients," Jones says. "Everybody is busy."
John Feldenzer, M.D., a neurosurgeon in Roanoke, Va., says he got so fed up with call duties at Roanoke Memorial Hospital, part of Carilion Health System, that he resigned from the hospital in 2000.
Though Roanoke pays for call duties, an operation can take up much of the day and "I have to drop what I am doing," Feldenzer says. "It doesn't matter if I have 10 people coming into my office that day, I have to tell them to go home."
But departures and retirements of several local neurosurgeons in addition to Feldenzer only exacerbated the on-call problems for the three remaining neurosurgeons at Roanoke Memorial. Two of them, Edgar Weaver Jr., M.D., and James Vascik, M.D., told the hospital they would no longer do any cranial work while on call, according to their attorney, Roberts Moore.
Moore says the hospital insisted that the doctors perform all neurosurgery cases or be removed from staff, and his clients, who refused to be interviewed, filed a lawsuit against the hospital last October to stop the new policy.
Shirley Holland, spokesperson for Roanoke Memorial, says most of the on-call neurosurgery work at the hospital is cranial. All of it would have to be done by just one remaining neurosurgeon, and "we couldn't put that burden on one physician," she says.
Both sides had reached a temporary truce in November. Weaver and Vascik agreed to postpone narrowing their on-call duties, and the hospital lured back Feldenzer and another neurosurgeon in undisclosed arrangements and began trying to recruit two more neurosurgeons to the area by Sept. 1, when the agreement runs out.
At first recruitment prospects looked grim, but by July the hospital had two serious prospects, Moore says.
The lawyer says both sides still have to meet to extend the deadline, but "we're optimistic that we can work this out."
Most likely to refuse callEmergency rooms report the greatest problem getting a response from physicians in the following specialties:
|Specialty||% of ERs|
Source: California Senate Office of Research, May 2003