Juggling last minute scheduling changes even in the midst of a pandemic.
Dear Director,
It doesn’t happen often, but we do have docs who get sick and call out at the last minute. I’m concerned about finding coverage, particularly if a doc needs to quarantine. What are some options for emergency backup coverage?
Most of us went into emergency medicine because we had a mentality that when we’re off, we’re off and we didn’t want to be on-call. My first full-time job out of residency didn’t have an on-call doc. The chair or volunteers covered callouts.
Those were the days when it was routine to get a couple liters of IV fluids and some Zofran before a shift if you were sick, and work with a heplock in your arm in case you needed more fluids. With as tough as our job is, it’s a good thing that tanking up on fluids and self-medicating to get through a shift isn’t the norm anymore.
A colleague who is an academic chair used to say that his job was to go to work no matter how bad he felt, and it was the doctor getting off shift who decides if it’s safe to give sign out or not.
While I love that attitude and I think most of us work sick, the reality is that emergencies happen— whether it’s waking up from your night shift vomiting, you can’t leave the bathroom, a car accident driving to work (or in our Executive Editor Dr. Mark Plaster’s case, a tree falling down and blocking his exit from his peninsula when he was on his way to relieve me a decade ago) or you have appendicitis. You’re on your way to the OR, which seems to happen not infrequently to people in my group.
COVID adds a new layer of complexity as you can be prevented from working minutes before your shift is beginning, by having a fever during routine temperature screening on your way into the hospital or you can be taken off the schedule for a prolonged period of time after an exposure.
One of my beliefs as a chair is that you have to build the right system that works regardless of the situation. This is just as true for ensuring staffing as it is for not missing a STEMI.
Most chairs have a paragraph in their contract that holds them accountable for staffing the emergency department. Fortunately, there’s a variety of possibilities we can employ to make sure the ED is appropriately staffed.
Chair as Point Person
The model at most community sites and certainly the model used when I first became a chair was that the department chair serves as the immediate backup. Although we have hospital and administrative responsibilities, we generally have the most open space in our clinical calendars and can more easily fill in for a shift at the last minute.
I remember dropping everything when one of my docs called me that she was in pre-term labor doing solo coverage and I think I was there to relieve her within 15 minutes. My commute now is not as friendly.
On the other hand, there are times where the chair either can’t do the shift (working clinically that same day or has another reasonable conflict) or timing is a little less sensitive and allows for some phone calls to be made. I can remember calling a doc and asking him if he’d started happy hour yet.
When he said “no,” then I explained that he was drafted and needed to work that evening/night. Some groups may have a group text that goes out saying they need coverage. That could work great. I used to look at the list of available docs and start calling people. It’s easy to ignore a text. It’s harder to ignore a direct plea for help.
Volunteers
I’ve talked to docs at other sites who tell me they have no trouble getting shifts filled with volunteers for the rare callout. So much of this comes down to the culture of the group and I think this is fantastic — if it always works. If you can always find coverage for a Saturday overnight shift during the peak of the summer vacation season, that’s an amazing group.
One of the concerns I have with this model is that much like my marriage where I think I’m doing 50% of the family household duties, I’m probably only doing 40%, and my wife thinks I’m doing 30% and that breeds discontent. Depending on the size of your group and your group dynamics, it’s probably very hard for a couple of people to be very flexible and easier for others to pick up shifts at the last minute whether they want to or not.
If you’re counting on a volunteer to drop everything and fill in, then hopefully it’s not always the same person. I spoke to two chairs who recently switched from a volunteer approach to using an on-call doc. Although call-outs were uncommon at their sites, inevitably there were no volunteers for weekends or holidays, and it became an unfair burden for the chairs to keep picking up these shifts.
On-Call Doc
When I started at my current site about 10 years ago, they had an existing policy in place having docs serve as on-call for 24-hour intervals for the site (630a-630a). This was a relatively foreign concept to me but as I’ve talked to colleagues in other groups, it doesn’t seem as uncommon now as it was a decade ago.
None of us went into emergency medicine to be tethered to work, but having an on-call doc allows for the needed last minute, drop everything flexibility that sometimes is required to fill a shift. We build our on-call shifts into the schedule, have it count towards weekend commitments, and track it for equal distribution. Although we only have docs take call, some smaller sites I know use APPs as well (though that doesn’t cover you for a sole overnight).
Another place I used to work divided call into 12 hours blocks, but depending on the number of docs on the schedule, that could add up to a lot of extra chunks of time on call. We also use call for high volume surges, but that’s another story. At the end of the day, I know who calls out the most, how frequently call is used a month, and their reasons.
I’ve been called at 3:30 a.m. for the 6:30 a.m. shift when the doc got admitted for diverticulitis and I’ve been called at 7:15 p.m. for the 8:30 p.m. night shift when the doc had a family emergency. As the chair, it would have been impossible for me to fill these shifts with volunteers at the last minute and I would have worked them a little ticked off.
As the on-call doc, it just is what it is, and I had kept my day free to be able to cover if needed. Like anything, there are some people who seem to have bad luck and end up being called in a few times over a few months, but in the long run, it generally balances out. And it always ensures that there is a doc available for the shift, which is reassuring to the hospital, and should be reassuring to the individual doc if they ever need to call out for a shift.
I don’t think anyone ever takes calling out lightly and I know most docs will try to power through, particularly if they don’t think there’s a good option to fill the shift. But that’s not always the best move for the doc or the patients. Before activating the on-call doc, if time allows when a shift opens up unexpectedly, I still put out a group email (though a text might be even better) to see if someone voluntarily wants to work the shift. This is a “win” for the doctor volunteering to work the shift (they want/need the money) and saves your on-call doctor if there are any other issues that require them.
Schedule Changes — Extending Shifts
Our schedule has eight docs on a Monday schedule, seven for the mid-week schedule and six for the weekend schedule. The total scheduled hours decrease by about 10%, but if needed, I could switch staffing patterns, use less docs and/or extend shift length to bulk up coverage if we had a callout.
Another site I worked in went from four docs working 10 hours each to five docs working eight hours each. With a little notice, it would be easy to adjust some shift start and end times and maintain coverage while using one less body. A callout doesn’t always mean a fresh body, but it may require some creativity and flexibility to provide the necessary coverage.
Plan Ahead
There are some emergency callouts you can anticipate. The best example is maternity or paternity leave. Whether it’s a female or male doc, there’s a good chance the baby will arrive on their own timeframe and not when the doc is scheduled for FMLA.
Depending on the situation, we typically develop a volunteer call list that is different from our on-call doc, for scheduled shifts from about three weeks before the due date, or earlier if the mother-to-be has a history of delivering early. This way, everyone can plan and we’re not scrambling for potentially a lot of coverage at the last minute.
Of course, avoiding callouts is also good. While not every surgery can be delayed, it’s certainly helpful to the group when a doc is scheduling “elective” surgery and it’s safe to wait far enough down the road that it can be planned for in the scheduling period. I was so appreciative when one of my docs asked me about the timing for his elective surgery.
At the time, our schedule was made a couple of months in advance. It wasn’t a stat procedure and we could build his FMLA request into the schedule. It’s also then important to make sure the recovery time is factored in as the return to work schedule may need to be on the light side to allow for fatigue or unanticipated restrictions.
Pay or No Pay
I helped design an incentive program early in my career, and one of the biggest lessons I learned is that you can literally incentivize anything. We all have a payroll budget and we can pull a fixed amount of money from that budget to incentivize people to take call by paying them.
In a perfect world, our budget would grow to allow extra money to be paid to the on-call doc. But we live in the healthcare reality where the money isn’t easy to find. Pulling that money out of the payroll pot then impacts the hourly rate or the RVU reimbursement, etc…
You also have to decide how much you will pay someone to take call. I doubt most docs would do it for $100 and I bet most would do it for $500. Keep in mind, that 90-95% of the time, there’s no callout necessitating the on-call doc to work, so it’s important to balance the inconvenience of call with the likelihood of being inconvenienced as well as the impact on the hourly rate of the docs who are actually working.
Maybe people would be less resentful about being on call if they’re paid but at the end of the day, if everyone is doing the same amount of calls, it probably doesn’t matter and it’s easier to invest that money in the hourly rate.
Conclusion
The ultimate goal for the chair is to have seamless coverage so that we can provide high-quality care. Inevitably, callouts happen. And it’s usually last minute and for a weekend night shift. Layer on the unpredictable nature of COVID where someone can easily be pulled off the schedule for two weeks, it’s more important than ever to have an easily implementable plan. I realize many docs are against the idea of having an on-call physician, though more and more groups are switching to it so there’s a safe, automatic fill in the gap doc ready to go.
