SCOTTSDALE, ARIZ. — A telephone survey of 66 physicians, each representing an obstetric group in Wisconsin, found that most groups did not have formal rules regarding call responsibilities or provisions for physicians to recover after being on call.
Yet 16 groups delivered babies at more than one hospital, leaving open the possibility that there would be simultaneous call at different locations, according to a poster presentation at the annual meeting of the Central Association of Obstetricians and Gynecologists.
“Most of [the respondents] said, 'We just call one of our colleagues if we need extra help, and they will come on in. We help each other,'” one of the investigators, Dr. Charles W. Schauberger, said in an interview. “There is a real brotherhood and sisterhood of obstetricians who will cover for one another.”
Avoiding call at multiple locations was the first of three “call best practices” recommended by Dr. Schauberger, medical director for quality and performance improvement at Gundersen Lutheran Medical Center in La Crosse, Wisc., and his coauthors.
The second and third best practices were, respectively, having a formal backup system and restricting work after being on call “to avoid difficult or complicated surgery or medical care,” he said.
The survey found a wide variety of ways of handling call, but no perfect call system. Dr. Schauberger and coauthor Dr. Robert K. Gribble, of Marshfield Clinic in Marshfield, Wisc., conducted the physician-to-physician survey by telephone. Working with third coauthor Brenda Rooney, Ph.D., of Gundersen Lutheran, they identified 70 “call pools” and obstetric groups in the state. After accounting for two physicians who declined to participate and those who did not return calls, there was a total of 66 participants.
The size of call pools ranged from 1 to 11 physicians, with 5 physicians being the median staffing, according to the investigators. Physicians were usually on call for 24 hours, but many groups had longer call duties on weekends.
Everyone provided obstetric care and emergency department consults on call. A large majority also did regular office work (82%) and provided backup for family physicians (68%). Others (24%) provided backup for midwives, but none performed home deliveries. Separately, more than 30% taught residents and about 25% taught students while on call.
Only 23% of the groups had formal rules governing call responsibilities. Just 26% had provisions for recovery after call, and 21% had decreased call with age. Some physicians said they did not do surgery on the day after being on call.
Asked how often they questioned their ability to provide safe care due to too many call responsibilities, 8% of respondents said occasionally. When asked the same question due to sleep deprivation, 1% said frequently and 11% said occasionally.
Although most physicians delivered at only one hospital, the survey found 10 physicians delivering at two hospitals, 4 physicians at three hospitals, and 2 physicians at four hospitals. Initially, Dr. Schauberger was surprised to find physicians providing multiple coverage.
“After I got to talking to the doctors, the rationale for it became apparent,” he said. “When you have patients that have insurance and can deliver in any hospital they want, they may choose to deliver in [a particular] hospital because they had a friend who had a good experience there. And if you want to keep that patient, you will have privileges in that hospital also.”
Nonetheless, Dr. Schauberger expressed concern about the risk that a physician might not be available in an emergency. “The problem is if you are trying to deliver a baby in one hospital and have a patient in another hospital, you can't provide emergency care for that patient,” he said. “If you are in the same physical proximity, you can manage more than one patient at a time.”
Another concern related to the contrast between call as experienced by residents and the real-world experience of obstetric groups. The investigators described resident call as being more intense and highly focused, occurring in-house, and carrying a higher likelihood of no sleep. They said private practitioners spend longer hours on call (sometimes over 2 or 3 days), have multiple responsibilities, and may cover in multiple hospitals.
“I'm not sure residents who are being trained these days have a very good understanding … that what their call is in residency will be significantly different from what it will be in private practice,” Dr. Schauberger said.