Taking call is hardly a new burden for cardiologists, but emerging trends as well as evolving attitudes are taking some of the sting out of the obligation.
Tackling call to reduce burnout
In a 2017 white paper, the National Academy of Medicine (NAM) reported that on-call commitment was a prevalent factor contributing to physician burnout and that night or weekend call increased the odds of burning out by 3 to 9 percent for each additional on-call shift. Clinician burnout—which according to a 2015 survey by the American College of Cardiology Foundation affects a quarter of cardiologists—in turn exacts a toll in the form of medical errors and malpractice lawsuits.
While the requirement of taking call isn’t likely to go away anytime soon, experts hope emerging healthcare trends will reduce the burden on clinicians. In a four-part Healthcare 2020 report, the Healthcare Financial Management Association pointed to big shifts—the transition from volume- to value-based reimbursement, consumerism, consolidation of hospitals and physician practices, and the innovation transformation—that are underway in healthcare. These and other drivers are encouraging practices to rethink how they approach on-call duty.
Cardiology groups are experimenting with practice consolidation; wider employment of cardiologists at academic medical centers and on-call pay by other large health systems; and training hospitalists and advanced practice providers (APPs) to serve as first-responders. These new models are giving cardiologists opportunities to take control of their on-call fate, but such innovations are not proving to be a magic bullet that automatically alleviates physician burnout, according to Cathie Biga, RN, MSN, president and chief executive officer of Cardiovascular Management of Illinois in Woodridge. “The burden of call is much more indicative of physician well-being and happiness than is the frequency,” she explains. “If you’re on call every other night or every other third night but you rarely go [into the hospital] or you have fellows or hospital staff who take care of [call], it’s not nearly as bad as trying to round on 80 patients in a weekend.”
New on-call models emerging
In some cases, practices are throwing out old models in favor of new approaches, says Edward Fry, MD, chair of the cardiology division at St. Vincent Medical Group and physician chair of the cardiovascular service line at St. Vincent and Ascension Health in Indiana.
“You have to identify on-call as a specific work obligation,” says Fry, who works with approximately 100 cardiologists across the statewide practice. The traditional model, where cardiologists worked over two days with call in between “before going home the second night and collapsing, has pretty much gone away,” he explains. Instead, new models are treating call duty as a component of scheduled shift work, with some hospitals paying for the coverage. According to David Gans, senior fellow of industry affairs at the Medical Group Management Association, on-call payments range from about $500 a day for noninvasive cardiologists and electrophysiologists to about $800 for invasive/interventional cardiologists.
Health system mergers also are allowing for a hub-and-spoke concept to develop, where a tertiary care center receives patients transferred from outlying hospitals that, by design, do not have first-line, in-house responders. Other practices are assigning call responsibilities to a hospitalist or “first-call” advance practice provider whose only job is to cover call. Such first-responders conduct patient assessments and order lab tests with the goal of minimizing the intrusion on the physician’s time and maximizing his or her efficiency. Some hospitalists and cardiologists are now positioning themselves as “nocturnists,” meaning they only work in the hospital on evenings and weekends to cover call.
Regardless of the specialty or the model, first-responders have access to the on-call cardiologists as needed, such as to perform emergency cath lab procedures or imaging.
Even with new models, call coverage looms large in cardiologists’ lives. While on-call compensation paid by hospitals might be only 10 to 15 percent of a cardiologist’s compensation, there’s a steep price if, for example, he or she wants to step out of the call schedule. In Fry's practice, quitting call in a physician's mid-50s could trigger as much as a 55 percent cut in compensation due to the cost of filling the coverage with a locum tenens or new physician.
New models in action
The 70 cardiologists at the Sanger Heart and Vascular Institute at Carolinas Health System are not paid extra for on-call duties. It’s considered a job obligation, but still, they are working to reduce the stress associated with taking call, according to Geoffrey Rose, MD, chief of adult cardiology. “We strive for fairness,” he says, which includes structuring call duty by sub-specialty. Sanger maintains a separate call rotation for interventional cardiology, where door-to-balloon time expectations, for example, require different processes. “Our interventional cardiologists do not take general cardiologist call,” he says. “We have to make sure we have enough interventional cardiologists in the rotation so nobody is burning out.”
As far as general cardiology, a driver for change at Sanger has been the option of 24/7 first-responder call coverage by hospitalists, with the general cardiologists providing phone consults as needed. Together the emergency department clinicians and hospitalists handle the initial treatments for what Rose calls “the big three cardiology diagnoses that come through the emergency department”: unstable angina, heart failure and atrial arrhythmias with rapid ventricular response. “It doesn’t necessitate cardiologists coming in at 3 a.m., whereas 10 years ago, that was the norm,” he says.
It also helps that most general cardiology call obligations now can be handled remotely with the on-call cardiologist reading images from a home computer. Sanger’s general cardiologists work four and a half days a week to allow a day of relief after being on call, which occurs about every two weeks. At some of the smaller spoke sites, on-call may be more frequent but tends to be less complex due to patient transfers.
Not far away, Wake Forest Baptist Medical Center also has evolved its approach to call coverage, according to Megan S. Berlinger, MHA, business administrator for the heart and vascular center. They have separate call loops for general cardiology, electrophysiology and interventional cardiology, with APPs serving as “the first-line response system” for some cardiology services.
Cardiologists’ quarterly compensation includes “a component for taking call,” Berlinger says. The section chief uses an incentive payment formula that takes on-call efforts into account. Recognizing that interventional cardiologists’ call is more burdensome, they are eligible for more compensation credits.
Taking call coverage is an unavoidable aspect of cardiology that needs to be driven by what’s best for patients, Berlinger says. “There is a sweet spot for having enough people in the call loop to make it sustainable [while preventing it] from being burdensome,” she says. “We want the right number of providers across our network—from on-call to procedures to clinic—in the best care model possible.”