A Day at the Office: Call and the Private Practice Orthopaedic Surgeon

“Call.” Just saying the word elicits a visceral response from most of my colleagues. I say “most of my colleagues” just to be diplomatic, but the truth is, I don’t know anyone who enjoys taking call. Why would they? I’ve seen “disagreements” (again, being diplomatic) about call result in practice breakups, ruptured friendships, and strained professional relationships.

From the physician’s perspective, the burden of call can be overwhelming. The constant disruption to one’s sleep, personal life, and even marriage can damage relationships and the overall mental and physical wellbeing of physicians. The stress of call (serving patients’ needs while also being the one the staff looks to for answers) can be severe, and is a major source of burnout [3].

As an orthopaedic trauma surgeon, I also recognize that surgeons in my subspecialty have a distinct advantage when talking call. It is conceivable that my sports medicine or total joint partners could be forced to care for a patient with an urgent condition that they haven’t seen since residency. If I negligently place the tunnels for an ACL reconstruction (an operation I haven’t done in 20 years), I only have myself to blame. My sports medicine partner, however, may be forced to deal with a patient with a pulseless, complex, open, comminuted tibial fracture with compartment syndrome just because she has hospital privileges and is required to cover call. This can be a recipe for disaster. Orthopaedic surgeons often freely admit that they are unable to provide the appropriate level of care, and as a result, they feel highly exposed to the possibility of harming another person, which could lead to medical liability claims.

From the hospital’s perspective, orthopaedic surgeons have an obligation to cover call. Based on my conversations and experiences working with hospital leadership, it’s clear that the societal investment in our training and the intangible benefits of being on hospital staff supersedes any inconvenience that call may inflict on our personal lives. Like it or not, the ability to take call and be available to care for a patient who does not already have an established relationship with an orthopaedic surgeon (known as an unassigned patient) is part of the overall value of the physician to the community. Hospital leadership believes that we get a “fair share” of well-insured patients by being on call, and that we underestimate the financial benefit of covering the emergency room for unassigned patients. They believe that their system bends over backwards to support physicians, and we should be more thankful for the opportunity to serve in this capacity. Many hospital systems compensate surgeons for taking call [4], and they feel that this has adequately compensated the physicians for the inconvenience.

Like most things in healthcare these days, the argument comes down to value. The value of an orthopaedic surgeon can be measured in many ways. Surgeons’ skills, their reputations, their ability to generate revenue, and their availability all are part of that equation. As much as orthopaedic surgeons may detest the inconveniences of call, our actual willingness to take call raises our perceived value to the system and community where we serve. I have seen neurosurgeons effectively block expansion of scope of practice for orthopaedic spine surgeons by using the threat that the neurosurgeons would abandon “head-injury call.” The fear of losing head-injury coverage is usually sufficient to motivate hospital administration enough to limit spine call to the neurosurgeons and exclude the orthopaedic surgeons. Our willingness to cover the needs of the unassigned patients who present with musculoskeletal complaints raises our value. Whether that value is material or not is very dependent on the individual community.

So, what is the orthopaedic surgeon’s inherent responsibility to the community? Do orthopaedic surgeons have an obligation to cover call and take care of unassigned or uninsured patients that present to the hospital? From the hospital and the community side, a tremendous amount of societal investment has been made in the training and development of an individual physician. The cost to train a physician in the United States exceeds USD 1.1 million [1]. It is important for us to remember that, to some degree, the public is paying for our education, and we bear some degree of public responsibility.

The argument changes in postgraduate training. Residency training incurs both direct (resident salaries) and indirect (the expense of having the residents at the hospital) costs. In 2014, the Alliance for Academic Internal Medicine calculated that the direct and indirect costs to train a resident was USD 183,416 per year [2]. Considering that most of us also complete fellowship training, the 6 years of orthopaedic postgraduate training costs USD 1.1 million (not including the expense to get through college and medical school). The federal government funds a substantial portion of postgraduate medical education. There are those who believe that the cost to produce an orthopaedic surgeon is largely underwritten by the general public, and as a result, we owe that same public the availability of our services.

The hospital has an even bigger responsibility to the community that it serves. It cannot cherry-pick the patients who present to their door; it must provide appropriate care to everyone within the limits of the Emergency Medical Treatment and Labor Act. Hospitals need to find a way to cover the demands of under- or uninsured patients given a limited supply of orthopaedic services. The recipe to ensure appropriate care for patients while simultaneously satisfying the attending physicians can lead to an unsustainable financial model for the hospital’s service line.

Scope of practice issues naturally flow from this dilemma. I recall conversations with colleagues about orthopaedic surgery potentially not taking call while simultaneously refusing to condone an expansion of the scope of practice of the general surgeons. This led to additional conversations about whether we would allow the general surgeons to do orthopaedic “first-aid” care. In the end, our colleagues covered call, recognizing that expanding the scope of practice of general surgeons was not the best decision

In the private practice model, the burden usually exceeds the benefits of call. Private practice orthopaedic surgeons begrudgingly cover call for several reasons. Generally, we have to be on the call panel so that we can perform hospital-based surgery and maintain admitting privileges. Another reason is to reduce the pressure of the hospital to employ their own orthopaedic surgeons. We realize that if we don’t cover the call schedule, we are forcing the hospital to expand their employed physician pool with orthopaedic surgeons who will cover call. Even though these may be orthopaedic trauma surgeons or orthopaedic surgicalists, we recognize that the hospital may then recruit elective specialists who will compete with our private groups. As a result, many private groups cover call just to keep the hospital at bay.

To address the call burden, many private groups seek out orthopaedic trauma surgeons like me. This model can be successful for all involved or it can be an absolute disaster. In some situations, the trauma surgeons can feel like they are the dumping ground for the uninsured patients that the other doctors don’t want to treat. The nontrauma partners may feel that they have to cover call and “tee-up” patients so the trauma surgeons can have an easier practice. There can also be inequities with practice ancillaries since trauma surgeons tend to be among the most hospital-based partners in the group. The outcome is often based on the philosophy and culture of the group and the hospital, and it is incumbent that all parties involved feel valued and not abused. The ideal culture would equally recognize the independence of the elective surgeon who practices exclusively in the office and surgery center and the emergency-based surgeon who practices nearly exclusively in the hospital setting. The combined value of the hospital relationship and the autonomy of the group should be paramount. To offset the expense of uninsured, unassigned patients as well as the psychosocial burden of call, many have negotiated call stipends from the hospital. The value of this stipend can be tough to pin down because if the private group demands too much, the hospital will do the math and decide that its less expensive to simply hire its own orthopaedic surgeons, which would leave the private group out in the cold.

I believe that we as a profession should be available to cover the community where we serve. A fair and equitable system should be constructed including the hospital and the practices of those who do take call. I’ve practiced in groups with both extremes. One group split ambulatory surgery center (ASC) revenue equally whether the surgeon operated in the ASC exclusively or barely at all (hospital-based trauma surgeons). My other practice excluded hospital-based physicians from any ASC revenue claiming that the hospital-based physicians didn’t do anything to make the ASC successful. A carefully allocated blend between these extremes could be a fair compromise. The call surgeons should be protected from abuse (like dumping uninsured patients, infections, and inconvenient cases), and an open, ongoing dialogue must be maintained between the hospital and the practices. Systems for enabling efficient care of orthopaedic patients must be maintained by the hospital system in order to sustain this coverage. Lastly, the tremendous burden of call must be recognized by the hospital and the group, and the surgeons on call must be treated fairly for everyone’s sake.