Taking call is one of the more challenging ― and annoying ― aspects of the job for many physicians. Calls may wake them up in the middle of the night and can interfere with their at-home activities. In Medscape's Employed Physicians Report, 37% of respondents said they have from 1 to 5 hours of call per month; 19% said they have 6 to 10 hours; and 12% have 11 hours or more.
"Even if you don't have to come in to the ED, you can get calls in the middle of the night, and you may get paid very little, if anything," said Robert Bitterman MD-JD, an emergency physician and attorney in Harbor Springs, Michigan.
And responding to the calls is not optional. Bitterman said if on-call physicians don't perform their duties, they could lose their hospital privileges, be fined by the federal government, or be sued for malpractice.
On-call activities are regulated by the federal Emergency Medical Treatment and Active Labor Act (EMTALA). Bitterman said it's rare for the federal government to prosecute on-call physicians for violating EMTALA. Instead, it's more likely that the hospital will be fined for EMTALA violations committed by on-call physicians.
However, the hospital passes the on-call obligation on to individual physicians through medical staff bylaws. Physicians who violate the bylaws may have their privileges restricted or removed, Bitterman said. Physicians could also be sued for malpractice, even if they never treated the patient, he added.
After-Hours Call Duty in Physicians' Practices
A very different type of call duty is having to respond to calls from one's own patients after regular hours. Unlike doctors on ED call, who usually deal with patients they have never met, these physicians deal with their established patients or those of a colleague in their practice.
Courts have established that physicians have to provide an answering service or other means for their patients to contact them after hours, and the doctor must respond to these calls in a timely manner.
In a 2015 Louisiana ruling, a cardiologist was found liable for malpractice because he didn't respond to an after-hours call from his patient. The patient tried several times to contact the cardiologist but got no reply.
Physicians may also be responsible if their answering service does not send critical messages to them immediately, if it fails to make appropriate documentation, or if it sends inaccurate data to the doctor.
Cases When On-Call Doctors Didn't Respond
The Office of the Inspector General (OIG) of the US Health and Human Services Administration oversees federal EMTALA violations and regularly reports them.
In 2018, the OIG fined a hospital in Waterloo, Iowa, $90,000 when an on-call cardiologist failed to implant a pacemaker for an ED patient. According to the OIG's report, the patient arrived at the hospital with heart problems. Reached by phone, the cardiologist directed the ED physician to begin transcutaneous pacing but asked that the patient be transferred to another hospital for placement of the pacemaker. The patient died after transfer.
The OIG found that the original cardiologist could have placed the pacemaker, but, as often happens, it only fined the hospital, not the on-call physician for the EMTALA violation.
EMTALA requires that hospitals provide on-call specialists to assist emergency physicians with care of patients who arrive in the ED. In specialties for which there are few doctors to choose from, the on-call specialist may be on duty every third night and every third weekend. This can be daunting, especially for specialists who've had a grueling day of work.
Occasionally, on-call physicians, fearful they could make a medical error, request that the patient be transferred to another hospital for treatment. This is what a neurosurgeon who was on call at a Topeka, Kansas, hospital did in 2001. Transferred to another hospital, the patient underwente an operation but lost sensation in his lower extremities. The patient sued the on-call neurosurgeon for negligence.
During the trial, the on-call neurosurgeon testified that he was "feeling run-down because he had been an on-call physician every third night for more than 10 years." He also said this was the first time he had refused to see a patient because of fatigue, and he had decided that the patient "would be better off at a trauma center that had a trauma team and a fresher surgeon."
The neurosurgeon successfully defended the malpractice suit, but Bitterman said he might have lost had there not been some unusual circumstances in the case. The court ruled that the hospital had not clearly defined the duties of on-call physicians, and the lawsuit didn't cite the neurosurgeon's EMTALA duty.
On-Call Duties Defined by EMTALA
EMTALA sets the overall rules for on-call duties, which each hospital is expected to fine-tune on the basis of its own particular circumstances. Here are some of those rules, issued by the Centers for Medicare & Medicaid Services (CMS) and the OIG.
Only an individual physician can be on call. The hospital's on-call schedule cannot name a physician practice.
Call applies to all ED patients. Physicians cannot limit theiron-call responsibilities to their own patients, to patients in their insurance network, or to paying patients.
There may be some gaps in the call schedule. The OIG is not specific as to how many gaps are allowed, said Nick Healey, an attorney in Cheyenne, Wyoming, who has written about on-call duties. Among other things, adequate coverage depends on the number of available physicians and the demand for their services. Healey added that states may require more extensive availability of on-call physicians at high-level trauma centers.
Hospitals must have made arrangements for transfer. Whenever there is a gap in the schedule, hospitals need to have a designated hospital in which to send the patient to. Hospitals that unnecessarily transfer patients will be penalized.
The ED physician calls the shots. The emergency physician handling the case decides if the on-call doctor has to come in and treat the patient firsthand.
The on-call physician may delegate the work to others. On-call physicians may designate a nurse practitioner or physician assistant, but the on-call physician is ultimately responsible. The ED doctor may require the physician to come in anyway, according to Todd B. Taylor, MD, an emergency physician in Phoenix, Arizona, who has written about on-call duties. Bitterman noted that the physician may designate a colleague to take their call, but the substitute has to have privileges at the hospital.
Physicians may do their own work while on call. Physicians can perform elective surgery while on call, provided they have made arrangements if they then become unavailable for duty, Taylor said. He added that physicians can also have simultaneous call at other hospitals, provided they make arrangements.
The Hospital Fine-Tunes Call Obligations
The hospital is expected to further define the federal rules. For instance, CMS says physicians should respond to calls within a "reasonable period of time" and requires hospitals to specify response times, which may be 15–30 minutes for responding to phone calls and traveling to the ED, Bitterman said.
CMS says older physicians can be exempted from call. The hospital determines the age at which physicians can be exempted. "Hospitals typically exempt physicians over age 65 or 70, or when they have certain medical conditions," said Lowell Brown, a Los Angeles attorney who deals with on-call duties.
The hospital also sets the call schedule, which may result in uncovered periods in specialties in which there are few physicians to draw from, according to Healey. He said many hospitals still use a simple rule of thumb, even though it has been dismissed by CMS. Under this so-called "rule of three," hospitals that have three doctors or fewer in a specialty do not have to provide constant call coverage.
On-call rules are part of the medical staff bylaws, and they have to be approved by the medical staff. This may require delicate negotiations between the staff's leadership and administrators, Bitterman said.
It is often up to the emergency physician on duty to enforce the hospital's on-call rules, Taylor said. "If the ED physician is having trouble, he or she may contact the on-call physician's department chairman or, if necessary, the chief of the medical staff and ask that person to deal with the physician," Taylor said.
The ED physician has to determine whether the patient needs to be transferred to another hospital. Taylor said the ED physician must fill out a transfer form and obtain consent from the receiving hospital.
If a patient has to be transferred because an on-call physician failed to appear, the originating hospital has to report this to CMS, and the physician and the hospital can be cited for an inappropriate transfer and fined, Brown said. "The possibility of being identified in this way should be a powerful incentive to accept call duty," he added.
Malpractice Exposure of On-Call Physicians
When on-call doctors provide medical advice regarding an ED patient, that advice may be subject to malpractice litigation, Taylor said. "Even if you only give the ED doctor advice over the phone, that may establish a patient-physician relationship and a duty that patient can cite in a malpractice case," he noted.
Refusing to take call may also be grounds for a malpractice lawsuit, Bitterman said. Refusing to see a patient would not be considered medical negligence, he continued, because no medical decision is made. Rather, it involves general negligence, which occurs when physicians fail to carry out duties expected of them.
Bitterman cited a 2006 malpractice judgment in which an on-call neurosurgeon in Missouri was found to be generally negligent. The neurosurgeon had arranged for a colleague in his practice to take his call, but the colleague did not have privileges at the hospital.
A patient with a brain bleed came in and the substitute was on duty. The patient had to be transferred to another hospital, where the patient died. The court ordered that the on-call doctor and the originating hospital had to split a fine of $400,800.
On-Call Physicians Can Be Charged With Abandonment
Bitterman said that if on-call physicians do not provide expected follow-up treatment for an ED patient, they could be charged with abandonment, which is a matter of state law and involves filing a malpractice lawsuit.
Abandonment involves unilaterally terminating the patient relationship without providing notice. There must be an established relationship, which, in the case of call, is formed when the doctor comes to the ED to examine or admit the patient, Bitterman said. He added that the on-call doctor's obligation only applies to the medical condition the patient came in for.
Even when an on-call doctor does not see a patient, a relationship can be established if the hospital requires its on-call doctors to make follow-up visits for ED patients, Taylor said. At some hospitals, he said, on-call doctors have blanket agreements to provide follow-up care in return for not having to arrive in the middle of the night during the ED visit.
Taylor gave an example of the on-call doctor's obligation: "The ED doctor puts a splint on the patient's ankle fracture, and the orthopedic surgeon on call agrees to follow up with the patient within the next few days. If the orthopedic surgeon refuses to follow up without making a reasonable accommodation, it may become an issue of patient abandonment."
Now Everyone Has a Good Grasp of the Rules
Fifteen years ago, many doctors were in open revolt against on-call duties, but they are more accepting now and understand the rules better, Healey said.
"Many hospitals have begun paying some specialists for call and designating hospitalists and surgicalists to do at least some of the work that used to be expected of on-call doctors," he said.
According to Taylor, today's on-call doctors often have less to do than in the past. "For example," he said, "the hospitalist may admit an orthopedic patient at night, and then the orthopedic surgeon does the operation the next day. We've had EMTALA for 36 years now, and hospitals and doctors know how call works."
Leigh Page is a freelance writer living in Raleigh, North Carolina.
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Cite this: Legal and Malpractice Risks When Taking Call - Medscape - Oct 28, 2022.