Can we help residents feel happier about taking call for free?

“I stayed up all night, and for what, $10 a consult?” A clearly exhausted and exasperated colleague and friend said to me one morning after his very busy call shift.

As a chief resident, one of my roles is to manage the call duty schedule. As such, I frequently hear about how residents feel about call. Interestingly, many comments have to do with the economics of call: “It’s just not worth it.” Lots of advocacy has gone into increasing resident call stipend and reducing call duty hours, and over the years, both have occurred. For example, in Ontario, the weekday rate was increased from $116.00 to $127.60 in 2018, and a new weekend premium of $140.36 was implemented last year. However, at least anecdotally, along with my own experience, residents’ perception of the “deal” we get on-call hasn’t changed dramatically.

I suggest we can apply insights from behavioral economics to help residents feel a little happier about our “deal” on call. Specifically, I believe we can leverage mental accounting to make call duty feel more rewarding, without costing the residency programs a single dime.

Mental accounting is behavioral economics-speak for how people actually keep track of money. As it turns out, not every dollar is created equal. For example, spending $50 of lottery winning feels much easier than spending the hard-earned $50 you have stashed away for a rainy day. How we perceive gains and losses are influenced by context. And because we see money in relative value rather than absolute value, we are able to design specific contexts to help residents perceive the same call remuneration as a better “deal.” Here are two examples of how we can leverage mental accounting: hedonic editing and decoupling.

First, we are hedonic editors. Hedonic editing refers to our tendency to either integrate or segregate monetary outcomes to make ourselves as happy as possible. We prefer multiple gains over a single gain, and a single loss over multiple losses. This means that rather than lumping the call stipend in with our regular salary in a single electronic deposit, as it is the practice now, individual call stipends could be separately deposited on payday. Getting a paycheck with or without that few hundred dollars added doesn’t feel all that different, but to see multiple $127.60 deposits in my bank account would feel like I’ve gained something extra. We may go further and take advantage of salience to enhance hedonic editing. Suppose you are handed $127.60 in cash every time you show up to a call shift, you might feel differently about how you are remunerated that day, even though the stipend is unchanged.

Hedonic editing might help us perceive the value of call stipend differently, but it does not address the other economic problem of call: diminishing returns. With each additional consult, the “rate-per-consult” decreases exponentially. By the time my friend saw his twelfth consult that night, he was down to $10 for every patient he saw. Obviously, the flat-rate stipend was never meant to be converted to fee-for-service. No one is ever happy in a world where they think the more they work, the less their services are monetarily valued. So how might we help residents feel less financially exploited? One strategy is to decouple the stipend and the number of consults seen, and in doing so, to reduce the perceived diminishing returns. For example, a resident could be paid an upfront lump sum stipend for all the call shifts the resident is expected to complete in the coming year. A lump sum makes it much harder to calculate remuneration per consult during a given call shift, so residents are less tempted to disappoint ourselves by converting the flat-rate to a rate-per-consult or rate-per-hour equivalent.

Call duty is arduous but meaningful work; ultimately, no resident does it for the money. However, being happier about the economic prospects of call certainly doesn’t hurt, especially if we can make that happen for free.

Chien-Shun Chen is a psychiatry chief resident.

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