Clinical Review

Best practices for call—to make for a sustainable career

Author and Disclosure Information

Extended duty can be onerous. Recommendations from 2 OBs who surveyed their peers can vastly improve the experience.


 

References

The authors report no financial relationships relevant to this article.

Call is a fact of life for most obstetricians; there’s no alternative to having obstetric care available 24 hours a day, 7 days a week. Although we recognize call as part of the job we’ve accepted, many of us have a love–hate relationship with the call schedule.

One of the most fulfilling experiences in our career is following a patient through her pregnancy and then safely placing a baby in her arms. And call is the time during which many of us earn a significant part of our income. But it is also a time when we can never fully relax—particularly as we become more aware of the potential safety issues and medicolegal concerns inherent in traditional call practices.

We studied the matter with the goal of making call more palatable

In 2004 and 2005, we surveyed 66 obstetricians, attempting to talk to one person from every large or medium-sized group practice in the state of Wisconsin.

Our aim? To identify patterns in call practice that might be beneficial to our groups and other obstetricians.

Some of our findings were published in the American Journal of Obstetrics and Gynecology.1 We have since formulated suggestions for groups to consider when they design or modify their call practices.

Those suggestions form the bulk of this article. Please read on—you may find that they apply to your work.

A shortage of physicians?

Residencies in obstetrics and gynecology are increasingly hard to fill. The medical malpractice climate is often cited as a major reason, but studies demonstrate that “lifestyle” is as much or more of a concern for medical students who are deciding on a specialty.2-4

At the other end of the career trajectory, obstetricians are retiring from the specialty earlier than in the past, and research shows that obstetric call is one of the most important variables driving retirement.5 The combined effect of these two realities will likely challenge our ability to maintain sufficient numbers of obstetricians.

Although the restriction of resident work hours has drawn attention of late, the work-life demands of practicing obstetricians have been largely ignored. (For an exception, see “The unbearable unhappiness of the ObGyn: A crisis looms,” by Louis Weinstein, MD, in the December 2008 issue of OBG Management at www.obgmanagement.com.)

We found significant differences between residents’ call and the typical private-practice call (TABLE).

TABLE

Residency versus private practice: Which call pattern is more onerous?

ResidencyPrivate practice
More intenseLess intense
Focused (often on only one area)Multiple responsibilities and sometimes multiple hospitals
More likely to go without sleepLess likely to go without sleep
Shorter durationLonger duration

Dangers of call

Although 56% of respondents to our survey indicated that they go without sleep for 24 hours most or some of the time, only 13% reported being concerned that fatigue limits their ability to safely deliver care.1 This finding runs contrary to many studies that demonstrate that prolonged periods of wakefulness are associated with a high risk of error and potential compromise of patient safety.

The need to be in several places at once


“A bigger concern than fatigue is the risk inherent in handling multiple simultaneous responsibilities”Perhaps a bigger concern than fatigue—and largely unexplored in scientific study—is the risk inherent in handling multiple simultaneous responsibilities. It is not uncommon for a doctor to be seeing one patient in the clinic while another patient is being prepped in the operating room and a third patient is in labor.

“I can be two places at the same time on a good day with a tailwind, but never three,” one OB joked.

Even when the OB’s activity is limited to the labor and delivery unit, it is not unusual for two patients to be delivering at once, sometimes in different hospitals.

In our study, 26% of obstetricians delivered in more than one hospital, with the maximum being five hospitals.1 One OB proudly described having five patients in five different hospitals and being fortunate enough to deliver them all.

Is it possible, or wise, to attempt to please every patient?

It can sometimes be difficult to balance patient satisfaction and patient safety. Most women in labor prefer to have their own doctor provide their care. At one time, they seemed to have accepted the fact that the physician might be late for an office visit because of a simultaneous delivery.6 Now, however, they seem less accepting of even this inconvenience.

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