The calls started during dinner.
“I forgot to get my med refilled, and now I’m out. Can you call it in?”
“I’m reading these colonoscopy prep instructions, and I see I was supposed to stop eating seeds a week ago. Should I still take the prep?”
“I haven’t had a bowel movement in three days. What should I do?”
The calls continued during the night. As usual, there were a lot of bowel prep calls (terrible taste is a common reason for calling the doctor). One was post-procedure pain, wanting to know if they should go to the ED. Most callers seemed surprised that I wasn’t looking at their charts. Because I was, you know, in bed.
I’d worked a long day Monday, took calls all night, and on into Tuesday morning (along with a few from the ED). The calls were still coming at 7:15 as I headed into work to start a complex ERCP. After I got an irate message from one of the callers mid-morning that I hadn’t yet documented our conversation from the night before, causing them to have to “explain it all again” to the day nurses, the thought occurred to me: Why are we still allowing patients access to us at night?
I posted this question on one of my doctor Facebook groups. We are a diverse group of women from all specialties, and the tie that binds us is a shared interest apart from medicine. The responses were many, varied and insightful. Many described multiple calls from patients wanting medical advice or treatment so they could avoid going to urgent care or coming to clinic during the day. Some described being yelled at because the caller expected more. One felt that our society had changed too much to allow access like this any longer. We live in an age of need for immediate answers. “Waking up the doctor” is no longer something people think twice about. A few advised me that some insurers require after-hours coverage. It’s in your contracts. This was news to me. At least two physicians expressed dismay that such a thought as not taking these calls would occur to me. One felt that us shirking this duty would completely overwhelm the doctors who cover hospitals at night.
Must patients have after-hours access to medical advice? It seems clear that they do, perhaps especially for those of us who do procedures. Even though we provide very clear instructions about when to seek care, most patients seem to require a discussion about whether or not to go in. To not answer those phone calls at all risks further burdening our already-overwhelmed EDs and urgent care centers. To be clear, I am not talking here about avoiding the calls of other physicians. I understand the need for subspecialty and surgical consultation from the ED, although it is my opinion that this should be compensated, and the compensation should be enough such that time off the next day is covered. Who, though, can take the calls of all the patients? The easiest answer seems to be nurses. They are trained and willing, as long as you pay them. Other options might be paying physician assistants (recognizing that they, too, must not be required to work the next day), or doctors who have left conventional practice and are looking for other options.
It will be costly to pay them. I contacted a nurse group that performs this duty. They kindly explained to me the guidelines they follow. They charge by the minute. As they should; they are billing for their expertise. They bill your practice directly. We’re good for it, of course. There is no chance of denial of payment for services rendered, like the game that every insurer plays with doctors.
Why, though, must it be us that bear the cost of paying for overnight coverage? Because the insurer says so? Why, if I saw someone in clinic three months ago for IBS, do I now own them after hours, indefinitely, any time they feel like calling? Because they are magically “established” with me? The clearest solution to me seems to be requiring insurers to bear this cost. If they require coverage for their patients’ nighttime needs, then they need to pay for it. They can do the negotiating with local or national nurses’ groups, and leave us out of it entirely.
I am not saying we should be paid for patient calls, and I do understand that it has become possible to charge for phone calls in some cases. I am saying that we should no longer provide this service. It should not be expected of anyone, in medicine or otherwise, to work all day, all night, and all the next day. We must stop treating sleep and downtime like dispensable commodities. Paid or not, we all need hours off. Our rising suicide rates, high rates of burnout, and physicians leaving the profession in droves should tell us that we must have it. No other profession allows what we have simply always done without complaint. Those in high-risk professions (and I would consider doctors as exactly that), such as pilots and truck drivers, have mandatory hours off. I can’t call a lawyer at midnight, nor would I expect any contact to be free.
There may be those of us who feel it is our societal duty. But I ask you, what other service is given away by a single segment of the population to the rest of the population, out of the goodness of their hearts? This is a Free Lunch, and you, my colleagues, are providing it. Except it’s not free, at least not for you. It costs you every single time you answer a call, both in terms of professional time, loss of leisure time, liability, and wear-and-tear. You docs in your twenties and thirties: You feel it, but it’s not so bad. Trust me when I tell you that your body will tolerate it poorly in 15 to 20 years. You docs in your fifties and sixties, especially those who retired early or are considering retiring early: Would you still leave, if your job allowed you to sleep at night, like everyone else?
Physician burnout is rampant. We are told to engage in self-care. We are admonished to meditate and unplug. Why does no one state the obvious? Working people 48 hours in a row seems like a bad idea. I know, it’s a “home call,” so those hours don’t count. They should, if you’re working, no matter where you’re working from. And I’m one of the lucky ones: I don’t usually have much trouble going back to sleep. But so many do. So many get a call at 1 a.m. and never go back to sleep.
Why are we still taking patient calls at night? Because we always have. It is time to realize that this is an antiquated practice that needs to go the way of the house call.
Sarah “Betsy” Rodriguez is a gastroenterologist.
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