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Multi-pronged approach eases on-call challenge
Offering stipends is not always best solution
Hospitals in Boston, like facilities in many other major cities, are paying $1,000 or more to lure specialists to be on-call for ED coverage, according to a recent article in the The Boston Globe.1
"You can find stipends of $2,000 or more across the country," notes John Benanti, MD, FACEP, chairman of the Department of Emergency Medicine at South Shore Hospital, Weymouth, MA, and president of the Massachusetts chapter of the American College of Emergency Physicians.
However, while South Shore must compete with other facilities and pays some specialists to take calls, Benanti says that money is not always the answer. His facility pursues several strategies to fill this critical need. "There are a lot of [specialist] groups that are not asking for money; they are asking the hospital to hire PAs [physician assistants] to do a lot of their work, so they can just come in and do their surgery," Benanti says.
Several other groups ask for hospitalists or generalists to handle a number of surgeries, he says. "We have one of the largest hospitalist programs in New England, and they do take on surgery cases," says Benanti. If there is an elderly patient with a hip fracture, for example, there are often a lot of comorbidities that the hospitalist can address, while the surgeon can focus on operative care.
Paid, unpaid call
On-call coverage at South Shore can be compensated or uncompensated. The physician has to be a beeper or a phone call away, says Benanti. "On-site overage is compensated, but they must be on campus," he says.
At his facility, OB/GYN and general surgeons are on-site, as are anesthesiologists and anesthesia intensivists. Neurosurgeons, orthopedics, and interventional cardiologists "all are on-call to the ED," he says.
At present, says Benanti, general, trauma, and orthopedic surgeons are paid to take calls. "Other groups are asking," he says, noting that decisions are made one group at a time. He predicts the request for paid call will happen more and more.
The hospitalist program, which started in 2000, includes 25 full- and part-time staff. The PA program, which started in 2004, includes 14, nine of whom (all full-time employees) are assigned to the ED. There are also three part-timers.
This option, too, costs the hospital money. "PAs cost money, as do hospitalists, when you have an employed model like us," Benanti says.
Approach makes sense
A multi-pronged approach such as the one adopted by South Shore makes sense to K. John McConnell, PhD, assistant professor at the Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health and Science University, Portland. McConnell is lead author of a recent paper that studied the on-call crisis in Oregon.2
"A good example [of why such an approach is needed] might be a smaller hospital that has maybe just two orthopods or OB/GYNs, and they do not want to take call every other night; it's not even a matter of money," he asserts. "So, some of the other things we're seeing here in Oregon involve the hospital telling a surgeon they will give him or her privileges, but they will also contract with locum tenans surgeons to take three calls a week."
What about offering PA or hospitalist support instead of pay, as South Shore is doing? That probably works, "but my sense is it is different for every hospital and specialty," McConnell says. There are major issues with radiology, for example, he says. "Attendings do not want to come in unless it is absolutely necessary," McConnell says. "At one academic facility, they had residents read imaging, but that did not cut the mustard — they missed too many things."
Another model being suggested, says McConnell, is having an acute care surgeon — or "surgicalist" — on staff. This person would be based in the facility, just like a hospitalist.
The growing cost of these options has hospitals making difficult decisions. For example, notes McConnell, in 2005 seven trauma hospitals in Oregon had their trauma designation downgraded from II to III or threatened to be downgraded because of on-call issues. They had to juggle with the choice of paying out perhaps half a million dollars a year or facing the downgrade, he explains.
It puts a great strain on a lot of hospitals to provide on-call specialists, says Benanti, "But the alternative is much worse if you can't provide the services patients need and expect in a timely fashion," he says.
The primary challenge, says McConnell, "is to determine what the right blend is to make sure specialists are available, and that everyone is reasonably happy, and making sure nobody's leaving the hospital [without being treated] — which is happening all over the country."
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