Should doctors be paid overtime for taking call?

Should doctors be paid overtime for taking call?

Taking call is the worst thing about being a doctor. There, I said it. But wait! What about medical malpractice lawsuits? What about dealing with patients’ suffering or dying either from their illness, or far worse, relating to decisions you made or procedures your performed? Certainly these are far worse events than being on call.

Granted. However, these awful events are part of the battle that we signed up for when we made the decision to become doctors. The soldier goes into battle with the attitude that he or she will do everything possible to avoid getting shot or killed, while at the same time realizing these are distinct possibilities. So too doctors leap into the fray with a positive attitude, while similarly realizing that, inevitably, there will one day occur a bad outcome with its attendant soul-crushing consequences. These bad outcome events, similar to earthquakes, occur randomly (“stochastically” is the term the geologists use). If you live in California you usually don’t spend every waking minute of your day worrying about “the big one.” So doctors don’t spend all their time worrying about bad outcomes.

I did however spend an inordinate amount of my time worrying about being on call when I was a practicing cardiologist working for a hospital-owned health care system. My life was divided into two phases. Phase one occurred between call nights and was spent worrying about the next call night that was coming up. Phase two occurred when actually on call, and was worse than phase one. The only saving grace of being in phase two was that phase one was coming up soon, which was a relief. In fact, the day after call (especially after a weekend on call) I always had a sense of relative euphoria because call was over, at least until the next time.

What made call miserable? There were many elements. There were the routine calls to reconcile medication orders for newly admitted patients. Mind-numbing but easy. There were calls for clarification of orders that were already perfectly clear. There were the dreaded calls to the emergency room, almost always implying a new admission. There were pages for new consults, sometimes with the words “see today” appended, even though it was the middle of the night, and after talking with the nurse I still hadn’t a clue why the consult was deemed urgent. There were the routine admissions for chest pain in the middle of the night for which I would give garbled, sleepy orders, which a helpful nurse would translate into reality, at least until it was required that we enter these orders into our EHR system directly, removing that last human barrier between sleep-deprived confusion and the patient.

Finally there always seemed to be at least one “problem” patient, who was doing worse and worse despite multiple phone orders, resulting in an inevitable visit to the hospital at 3 in the morning.

My practice provided coverage to all the hospitals in Louisville, split between 2 and then 3 doctors on call (the coverage scheme kept evolving as our health care group absorbed more and more practices into its fold). Also covering were the cardiac interventionalists, whose on-call night had fewer phone calls, but unfortunately each call proved significant in that it usually led to a rapid trip to the hospital to perform a coronary intervention on a deathly ill patient suffering an acute myocardial infarction. My call nights in contrast were characterized by many phone calls (anywhere from 20 to 40 per night) punctuated by occasional trips into the hospital. Although I tried to sleep when I could, I was only intermittently successful, and the sleep achieved was a mixture of sleep phases never intended by nature.

As time went on call got worse. With more practices absorbed, more doctors were added to the call pool, but the number of patients covered also increased. The net result was that the call frequency (about one weeknight a week, and one weekend every 3 or 4 weeks) never really decreased, though the amount of calls that needed to be handled did. So with time the dread of being on call only worsened.

Perhaps it is not widely known that doctors are not paid to be on call. This stems from the masochistic, self-flagellant nature of medicine that is our tradition. In fact if one looks across the generations of physicians, the older generation always looks down on the younger generation of doctors, feeling they have it too easy, saying things like, “If you think you have it bad, when I was training I was on call every other night …” and so forth.

In fact just looking at my generation, I recall that at Methodist Hospital in Houston, where I was a cardiology fellow in the early 1980s, the surgical resident in the post-cardiac surgical ICD (this was during the heyday of Michael DeBakey) was on call for 2 months straight! He never left the unit for 2 months. They sent a barber in to cut his hair. I remember seeing him shuffling around the unit from time to time at all hours, looking like a zombie. But I’m sure his elders thought he had it easy. (“In my day, we were on call for 6 months straight.”) Nowadays house staff associations have brought about reforms, so that actually on call for today’s house staff is easier — uh oh, there I go, proving my point.

Anyway, doctors don’t get paid overtime, or any additional time for being on call. Sure, doctors make good salaries, and it’s always said that somehow being on call is factored into their salaries. Right. Try that with nurses, lab technicians, even your local plumber and see how far it gets you. But doctors do tend to just suck it up and take call, because they have a duty to their patients and there does not seem to be any other system to cover a medical practice 24/7.

But I did hate being on call more than anything, and I am happy to be free of that responsibility. My only advice to my still-working colleagues is that, when the hospital systems that own you start cutting your pay, point out to them all the back hours of overtime they still owe you.

David Mann is a retired cardiac electrophysiologist and blogs at EP Studios.

Image credit: Shutterstock.com

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  • Dr. Drake Ramoray

    Generally speaking I disapprove of any post by a physician (or not) that complains about compensation, but this article is unique in that it is actually complaining about things that are actually related to your job (EMR order enrty point aside). For the most part physicians are paid very well, and if we are to complain about something not getting paid for, prior authorizations, beureacratic red tape, and all the paperwork and preparation for an insurance company audit would be far higher on this list.

    Add to this that as an electrophysiologist you are probably in one of the highest paid specialties, this article will either A. Fall on deaf ears or B. See some seriously irate posters or more likely both. And while the RUC does not take into account lifestyle, for the most part pay seems to be somewhat linked to lifestyles. While I don’t support how the RUC sets pay scales you shouldn’t be surprised if a life saving procedure can only be performed by you that you will get called in the middle of the night to perform that procedure. Other than derm and radiology most “lifestyle” specialties have a lower pay than “non-lifestyle” specialties. Endo (if you stay out of the hospital) is generally a lifestyle specialty and our pay reflects that relative to our colleagues.

    From a pure financial perspective the money to pay you more for call or a night time procedure has to come from somewhere. Shall the hospital start billing higher costs of weekend and night procedures. Perhaps I should be certain that my future MI occurs between the hours of 9 AM and 5 PM.

  • PrimaryCareDoc

    When I still did inpatient medicine, it was torture to be on call. I was every 4th night and every 4th weekend. After being up all night on call, I had to be at the hospital rounding at 6AM (if I ever left in the first place), in the office by 8, seeing patients until 6PM and then back to the hospital to do more rounds and admissions.

    I did this up until 7 years ago, when we finally got a hospitalist system in place, my life has improve immeasurably. Oh, and I did not get paid for being on call. Because I was employed on a salary, it’s not even like I got the extra billings for the hospital work. A princely sum of $120,000 a year, for what was about 70 hour work weeks.

    Once in a while, I’ll hear a beep that is the same tone and frequency of my old pager. I get an immediate, nauseating adrenaline rush that leaves me shaking for several minutes.

  • http://barefootmeds.wordpress.com/ Barefootmeds

    So you don’t get paid overtime in the US? Wow. In South Africa, we actually do – but only up to eighty hours overtime per month, so any additional overtime goes unpaid. But then again, South African doctors’ baseline salary (at least in state institutions) is much lower than in the US.

    • ninguem

      What would be typical for a State employee physician in South Africa? If you don’t mind saying…….I figure it must be information accessible to the public, so not secret.

      I’ve noticed more and more American doctors working outside America, finding the deal the docs get in other countries is comparable to the USA.

      Either we’re deteriorating, or the other countries are getting better, or some combination of the two.

  • Patient Kit

    Plenty of Americans, who work on salary (in many different fields), do not get paid extra for “overtime” hours worked or for additional tasks, assignments, etc.

    Using myself as an example, when I worked as a research analyst for a nonprofit organization, my salary was $52,000 a year regardless of how many hours beyond 40 I worked or what new projects I took on. Depending on deadlines to be met, campaign phases and assorted other demands, it was not unusual for me (and my colleagues) to be in the office working from 9am until 10pm. We also didn’t get paid extra when we traveled or when we worked on weekends. I know very few people in “9-to-5″ jobs who actually work 9 to 5.

    I guess my question to the OP is this: Are you unaware of how many hours many salaried Americans work and how we get paid? Or do you just believe that doctors should be different?

    • Eric Strong

      I think being on call should just get lumped into standard physician compensation and being on-call is a reasonable expectation of our choice of profession. However, to be fair, the extra time most Americans put into their jobs cannot be compared to being on-call for a physician. Most other workers don’t expect to be awoken at 3am with an emergent problem that requires them to rush to their place of employment half asleep, with the potential to stay not just the rest of the night, but then need to stay for a full workday following. Plus, the decisions you need to make at 3am are often life-or-death issues (otherwise, it would have just waited until the morning).
      Another example: Your spouse gets tickets to a concert or sporting event for a night you’re on call? Guess what – you ain’t going.
      The majority of work done outside of normal business hours by many white collar workers in the US may be uncompensated, be painful, and total the same number of hours as physicians on call, but it is generally more flexible and less stressful. There are obviously exceptions to this, but they are not common.

      • Patient Kit

        I’m not comparing the importance of doctors relative to other professions. Doctors are special. In general, I love and admire docs.

        But non-docs do miss their kids birthdays, recitals and Little League games a lot. And mandatory conferences and emergency meetings are suddenly scheduled for the week you already had a vacation trip planned. Goodbye vacation trip, all or part of it. We may not get called to the hospital at 3am, but do docs routinely have to leave home in NYC early enough to be at a 9am meeting in Washington DC?

        Our bosses issue us iPhones and then use them to call, text and email us 24/7. I’ve rarely had a boss who wasn’t reachable and working — daily — while on his/her vacation. I realize that on-call for docs is a special thing like nothing else. But I think you’re out of touch with life outside of medicine if you don’t realize how many people’s personal lives are impacted by the demands of their jobs. Some of those people are your patients. And many of us get paid far less than docs (as it should be). In 20 years, I haven’t had a job where I can walk out at the so-called end of the work day and leave everything at the office.

        Docs do have one of the most important jobs in the world. You have a lot of responsibility, often involving matters of life and death. I recognize that. But some non-docs have heavy responsibilities too such as nurses, airline pilots, firefighters, police officers and teachers. All different but just as important as docs.

        I think achieving a good life/work balance is difficult for plenty of people these days, not just doctors. And it shouldn’t be a competition about who has it worse. It should be something that we can relate to in each other.

        • Lisa

          Saying that doctors have one of the most important jobs in the world is going too far. And I sort of hope you are being sarcastic when you say doctors are special. Doctors have important jobs, with heavy responsibilities, but many people have important jobs, also with heavy responsibilities. In an ideal world all jobs would be recognized as necessary and contributing to our joint good. And everyone should be fairly compensated for their work, including doctors.

        • azmd

          All of us worker bees, doctors included, are getting squeezed by our employers these days. Things will probably continue on this way until we all wise up and started joining unions.
          However, I think the one thing people miss about doctor’s on-call responsibilities is this: it involves sleep deprivation, sometimes to a very serious degree. I can honestly think of very few other jobs that require someone to be available to be awakened in the middle of the night, after a full days work, and before going in to anothr full day’s work. It is completely miserable, very few other people ever have to do it, and it is mostly what doctors are complaining about when they complain about being on call.

          • Patient Kit

            I take sleep deprivation very seriously and definitely see your point about how much sleep deprivation is involved in doctors being on call and their having to do serious stuff while sleep deprived. I just don’t think docs are completely alone in that.

            The Walmart truck driver who plowed into Tracy Morgan’s vehicle causing both death and serious injury was allegedly awake for 24 straight hours and driving his truck for 13.5 hours prior to the fatal accident. I have no reason to doubt that plenty of truck drivers drive while seriously sleep deprived.

            Also, let’s not forget the serious sleep deprivation of new moms and some dads. And the people who are working 3 jobs because each one pays so little. Maybe not as serious a responsibility as doctors but, if they cause a serious accident in the restaurant kitchen or commercial laundry because they are working while so sleep deprived, people do get hurt.

            I’m by no means minimizing the seriousness of sleep-deprived docs, to themselves or to their patients. I just think there are more sleep-deprived folks out there than you think.

        • Suzi Q 38

          Another example of this would be a city manager who gets a regular late night or early morning call from the mayor, fire department or police department.
          People do not realize that no one pays them overtime for doing city business during personal time at home.

  • Shirie Leng, MD

    I’m afraid I agree with exit 7. It is part of what we signed up for. Sorry.

    • ninguem

      Whatever “deal” we “signed up for”, so to speak, has been unilaterally changed a thousand times from Sunday, yet we are still expected to keep our end of the “bargain”.

    • buzzkillerjsmith

      Even martyrs have their limits.

    • azmd

      We also signed up for work in which we could function as independent professionals, make treatment decisions based on what would be most beneficial to our patients, and enjoy the human interactions that are part of working in a caring profession.
      Oh, wait…
      I think the problem here is that as a profession, some specialties are being expected to quietly cooperate with the advantages of our profession disappearing while the disadvantages are just “part of what we signed up for.”

  • PrimaryCareDoc

    Realizing it and actually experiencing it are two very, very different things.

  • David Mann

    As the author of the post, thanks for the comments. My original intent in writing it was to vent on how awful being on call can be, and to point out what seems to be an anomaly compared to other jobs: the fact that there is no specific compensation for being on call for physicians. Other health care workers such as cath lab nurses and techs also take call but are specifically paid money both for taking call and for the times when they are actually called in, in addition to their baseline salary. I understand the need for taking call, and the historical reasons doctors, when they managed their own practices, did not compensate themselves for taking call, but now that most doctors in the US are simply employees of hospital health care corporations, is it wrong to reconsider this lack of compensation? Or to take other steps that might ease the burden of call, such as training nurses to prioritize and then either defer non-urgent calls to the AM or queue them up to be batch-handled? Or for hospitals to take some of their CEO salary money and hire night staff (PAs or NPs?) that could handle 90% of the calls? Having sleepy, grumpy post-call doctors making life-or-death decisions is not optimal heath care. But as long as physicians as a group just continue to roll over and take it, nothing will ever change.

    • Dr. Drake Ramoray

      While you clarification to this issue being considered while under employment of the hospital certainly differentiates your take on the compensation factort, as my initial rebuttal addressed the issue from a standard indpendent fee for service type arrangement and merely hospital privileges, I believe that you are living under the false assumption that physician salaries are going to increase under th ACO/PCMH, corporate hospital business model that American medicine is becoming.

      The entire infrastructure and model of healthcare is moving towards algorithms and care provided by those other than doctors. The CEO is more than happy to oblige in this manner.

      I still maintain the issues of third party payers hoops, bureacratic red tape, prior authorizations, are for more onerous to the practice of medicine.

      That being said we do agree on one thing however, “as long as physicians as a group just continue to roll over and take it, nothing will ever change.”
      I think it will take unionization to fix it, although I’m not convinced it will happen in my lifetime, and it opens up a whole nother can of worms.

      • Patient Kit

        I use the term “human piñata” often. Apple autocorrect doesn’t need to correct me.;-) I type the word “primary” on my phone often when commenting here at KMD and it never autocorrects primary to piñata. Mysterious Apple. I do love the word “piñata”.

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      The day when physicians are paid overtime for being on call, is the day when their baseline salary will be the same as “[o]ther health care workers such as cath lab nurses and techs”, i.e. not enough to pay your mortgage with. And that day is coming, precisely because “physicians as a group just continue to roll over and take it”. Nothing will ever change is in the realm of wishful thinking at this point.

      • ninguem

        Sort of an N=1 series, but I knew a doc who worked for a hospital on salary, but with no contract.

        Salary was very low for his specialty, and he was expected to take a lot of call, and they also got hospitalist duties out of him, over and above what was expected of him as a specialist. They didn’t have hospitalists in those days.

        In any event, there was a brief time where he started punching in and out of work, no different from the janitor.

        Seems that absent a contract, the doc was legally considered no different from any other employee, and the state labor laws defaulted to a 40-hour week.

        An hourly wage was calculated from his annual salary, based on a 40-hour week.

        On-call time is now “time and a half”, based on that hourly wage.

        The hospital closed that loophole fast.

    • Lisa

      As a group, doctors who are employed by hospitals could wield a great deal of power. Form a union and negotiate, like other workers. And be prepared to defend youn union (and other unions) from those who would pass laws to undermine them.

    • Patient Kit

      Beware of saying that NPs and PAs could handle 90% of the calls they bother you with at night. It begs the question of whether NPs and PAs could handle 90% of what doctors handle during more convenient daytime hours. I’m no lawyer or CEO, but that statement stood out to me, coming from a doctor. Definitely in the “be careful what you wish for” zone.

      • ninguem

        That speaks directly to the “deal” that we supposedly “signed up for” in medical school.

        The “be careful what you wish for”, thing, may apply to the docs, and to the “10%” left over from that “90%” factoid.

        When that 10% finds that neither the physicians, nor the NP’s or PA’s, want them.

      • David Mann

        Actually 90% of the calls are trivial, though sleep-interrupting, and they are handled by NPs and PAs during the daylight hours. Don’t confuse answering phone calls with 100% of a doctor’s work. I spent my days doing electrophysiology procedures and seeing consults and office patients that only I (and my electrophysiology colleagues) could take care of. I was happy to delegate other matters such as calling in admitting orders and reconciling med lists to mid-level providers. It was the best use of my time. Of course I am just speaking from my own experience, and others undoubtedly have different experiences with being on call. Also doctors have pretty strong opinions when NPs and PAs are mentioned. It is a good way to generate comments.

  • ninguem

    That would be fine and dandy, if what we “signed up for”, was what we actually got at the other end.

    That “contract” so to speak, is constantly being torn up, re-written, and shoved down our throats.

    The only thing that remains constant is the responsibility expected of us.

  • ninguem

    Agree with Mengles 1000%

  • T H

    There is a saying in the Navy: “Choose your rate and choose your fate.”

    If you’re a Radioman, you’re going to be in the radio room alot. If you’re an engineman or HT, prepare to be on ship for a long time. If you’re a cardiologist… guess what? People have heart attacks in the middle of the night. If you’re an OBGYN… babies come before 0800 and after 1700. ED? Prepare for drug seekers and non-specific abdominal pain.

    Modern docs, hopefully more savvy than us old guys, have a chance to get plenty of things fixed through proper contracts. Some of us even learn from our past mistakes and get things added when contract time comes back around.

    Stop whining about call and do something about it:
    > on call money: $50-100/night
    > daytime hospitalists band together and get admin to hire a nocturnist.
    > document properly and you can get paid for seeing the patient in the middle of the night (and Dr. Mann, when you get that midnight cath, take home a pretty penny for a procedure where someone else did all of the workup).

    • David Mann

      Well I don’t do caths. I do electrophysiology procedures that are always electively scheduled during the daytime. But I agree with your ideas to fix this.

      • T H

        Sorry – somehow I missed the EP thing.

  • azmd

    I don’t know of too many pre-med college students (or anyone else, judging from some of these responses) who have a clear idea of what it would be like to go without sleep every few days for years and years and years.

  • azmd

    I may be mistaken, but the author of this piece is not referring to being on call for a hospital. He is on call for his practice. It’s an entirely different set of responsibilities than that managed by interns and residents taking call in a hospital.

  • azmd

    These days, most physicians in private practice (I am actually a hospitalist at a county hospital) do not follow their patients once they are admitted for inpatient care. The author of this piece is describing being on call for consults and for problems with outpatients in his practice, not for

    But…I just love how everyone is an expert on healthcare practice and policy these days, even people who apparently don’t know the first thing about it.

  • guest

    There’s only one problem with this theory, which is that the millennials are a savvy lot. They have no intention of being activists and negotiating with employers for better working conditions.

    Instead, they are all scrambling to position themselves for cushy non-clinical 9-5 jobs after they complete residency. Either that or a ROAD specialty.

  • Suzi Q 38

    I have had great service given to me by the on-call physician.
    I asked for a prescription for my then 80 year old mother, told him where to call it in, and he did so within 30 minutes.

    I have had really bad service given as well.
    The on-call doctor for my mother while she was in the hospital was such a jerk.
    I should have had a clue when his voice came on the line and the nurse who was standing next to me would not speak. She just handed me the phone.
    My mother was having hallucination while on her steriods and he had ordered them to be abruptly DC’d rather than slowly titrated down.
    His prior order made her hallucinations even more intense, and she was combative.
    I asked him if he would please put her back on the steriods and titrate them slowly. His answer to my request was: “What medical school did you graduate from???” I asked him if he would repeat what he just said and I could quote him? He then backed off with his attitude a bit, especially when I told him he was now on speaker phone. I told him that these steriods are so strong that it gets worse when they are abruptly discontinued. I then said that if he doesn’t believe me, just consider the FACT that what you have already ordered is not doing very well.

    He then said that he was in the middle of watching his son come by in a parade. The parent in me sympathized, and I asked him to call me back when the parade was finished.

    I realized that it is tough being an on-call physician, but I theorized that there are worse professions in life.