August 1999 Bulletin

Weary of on-call, an orthopaedist retires

Excitement gives way to longing for free time, escape from demands of managed care

John W. Wickenden, MD

My heroes, during my youth, were orthopaedic surgeons. Through college and medical school I worked as an orderly and as an OR tech. When I was off duty I haunted the emergency room so that I could follow the orthopods as they dealt with on-call demands. I can honestly say that I went into orthopaedic surgery because I loved the various aspects of on-call orthopaedics.

Early in my career it was exciting, challenging and fun to be on-call. My adrenaline flowed and I spent a lot of time running to the library to double check my intentions, but I loved the on-call experience.

Gradually, over four decades, I have come to hate being on-call. This year, at age 59, I am retiring. My primary motivation is to escape being on-call. Three out of 10 nights and weekends are not my own. After all these years, I still can't sleep well when I'm on-call. Interruptions are sufficiently frequent that I don't participate in any social activities on those days.

Too often, sleep disruption leaves me tired on the day after being on-call. My biorhythms have long ago accommodated to 12-hour work days. But they no longer accept 16 or more hours of intense work, followed by a short night of fitful sleep, followed by a full day of "normal" work on the day after being on-call.

I have gradually become primarily a spine and shoulder surgeon, but the emergency pathology does not respect my realms of particular talent. Too often I must temporize until my differently focused colleague can better deal with the problem the next day-or I choose to transfer the patient to another hospital where a colleague with different expertise is better able to meet the needs of the patient. I have become accomplished and skillful in the realms of orthopaedics for which I choose to schedule patients in the office, but I am too often inadequate to meet the responsibilities that intrude upon my on-call watch.

Today, the economic and political realities of practicing medicine intrude upon on-call orthopaedics in a particularly obnoxious way. Neither Medicare nor the carrier of a managed care patient will readily accept my judgment that there was no alternative to admitting an older person with a vertebral compression fracture or any number of other problems which are familiar to any orthopod who reads these words. I must craft my admission notes not for the enlightenment of those who will share with me the care of the patient, but to justify the admission to a clerk who will plug my findings into a protocol which pays no heed to the social, familial, geographical or even weather realities which prevail.

If I transfer a patient I must spend more time with the federally mandated transfer papers than with the pertinent orthopedic needs of the patient. If I fail in an element of documentation, I or my hospital may be fined thousands of dollars. Among the uncollected and uncollectable accounts in my office there is a disproportionate percentage for services that were provided when I was on-call. Virtually no patient comes to my office drunk or disorderly. Many come that way to the emergency room. Inappropriate drug-seeking behavior is common among the patients I encounter on-call.

I live and practice in a lovely community on the coast of Maine. I presume that many orthopods have much more difficult realities than those which are inherent in my on-call life. On the other hand, many of my colleagues practice in hospitals where a house staff will deal with the grit and annoyance of the out-of-office patient encounters. In my hospital, we have emergency room physicians. These doctors have tremendously improved the quality of my practice, and of my life. Without them I would have burned out a decade ago. However, the ER doctor does not, and never will, absolve the orthopod of his required availability for on-call services.

Is there a way to relieve me of my responsibility to be on-call as an integral part of my practice? I believe that there is not. Obviously, many orthopaedic needs occur when our offices are not open. Obviously, the skills of an orthopaedic surgeon are frequently required to meet unscheduled needs. Neither emergency room doctors nor house staff physicians can sufficiently often meet these needs to make it possible for most orthopaedic surgeons to escape the responsibility of being on-call.

Being on-call comes with the territory when one chooses a career in orthopaedic surgery. A maxim which has been postulated by our Academy is that we are all generalists first, whatever specialty niche we should additionally choose. As generalists, we are capable of being in the first line of service to meet any orthopaedic need. If we are not capable of fully meeting an orthopaedic need when we are on-call, we can temporize better than a non orthopaedic physician. Unless a particular hospital is sufficiently large that it can muster a separate call schedule for a subspecialist group of its physicians, such as the hand or spine surgeons, then all of those subspecialists must participate in the general call schedule.

Is it appropriate, or acceptable, for an orthopod to be relieved of his/her responsibility to be on-call at a particular age? Perhaps. This is an issue which is appropriately left to the individual hospital to decide in the context of its realities. However, the reality which will prevail in many hospitals is that the on-call load will unacceptably increase for the younger orthopods when the older orthopod is relieved of on-call responsibility. In my community we have five orthopods. One of them no longer takes call because of his age (and he pays a substantial financial penalty for that privilege). If I were to be relieved of on-call responsibility my colleagues would have to live with an unacceptable frequency of on-call work. If I were one of them I would not let me escape call while continuing to receive the other benefits of a full-time orthopaedic practice.

Perhaps it is primarily my age and the late stage of my career, which influences my impressions. However, I believe that the call issue will become one of increasing contention among orthopods. The practice of medicine is becoming more humane to the physician and to his family. Younger doctors seem to better "have a life" than have many of my generation. The social, legal, political and financial stresses associated with call responsibilities are increasing. Our abilities to truly perform adequately as generalists are decreasing in this age of greater subspecialty expertise.

I predict that there will be changes in the way orthopaedic surgeons deal with the traditional on-call aspects of our work. Among the changes which will enhance the provision of optimal care to our patients and enhance the quality of life for the orthopaedists who provide that care, will be some of the following.

Emergency room physicians, specialty trained physician assistants, and others will be better trained to provide full management of most orthopaedic problems through overnight intervals.

Patients who require urgent orthopaedic specialty care will be more liberally transported to larger centers where there is available an orthopaedic surgeon who is not on call, but is working his periodic night or weekend shift.

Hospitals within reasonable proximity will allow their orthopedic surgeons to spread the call schedule among a significantly larger group of physicians, and patients will be transported more readily to the "competing" hospital which that night or weekend has the on-call orthopod available.

I want to take back a big chunk of my life. I want it badly enough that I'm going to retire. I suspect that many of the young people who we would want to follow in our footsteps into orthopaedic surgery and other on-call intensive medical careers are not willing to give up a big chunk of their lives in the first place. Let's make it more possible for those young people to follow us and to better "have a life." In my present scheme of values it is just not acceptable to work 50 to 60 hours a week, and then to spend 40 more hours on-call. And I will bet that being on-call will not seem as acceptable-let alone as exciting, challenging and fun-to those who will follow us as it seemed to most of us at the front-end of our careers.

John W. Wickenden, MD, is in private practice in Rockport, Me.

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