Best practices for call—to make for a sustainable career

There is no “standard” call pattern

Overall, we found no standard pattern of call. Each system seems to have evolved, or been designed, to meet the needs required to provide care.

Our perception is that call arrangements must balance two main concerns: safety and sustainability. Someone must be available and able to function, but the call pattern cannot be so onerous that the doctors sharing it find it unlivable. Each group of obstetricians who provide care needs to identify rules that ensure safety—but also care that can be delivered over years of a career.

Best practices

We have several suggestions for best practices, though we recognize that some of them may not be practical for every practice. However, we believe that these generalizations may be useful to a broad range of obstetric call groups.

Deliver in one hospital only

The obstetricians we surveyed who were delivering at multiple hospitals indicated that the decision to do so was patient-driven; many physicians were dissatisfied with this practice.

Groups that had restricted themselves to one hospital felt that this decision had made their call easier and more sustainable.

Develop a formal backup policy

Many survey respondents indicated that, even without a formal policy, they can call a partner or other obstetrician in the community when the volume of work becomes too much to handle. We found that there is a true brotherhood and sisterhood of obstetricians who will drop everything to help when called upon.

Certainly, the volume of deliveries and other responsibilities will determine how frequently you need to call your backup. Unless a formal backup system is in place, however, there is no certainty that you will be able to reach another obstetrician and that he or she will be able to help. When you need assistance, it’s a terrible distraction to spend 30 minutes going down the list of your partners, trying to figure out who is in town and who isn’t. What if you call one of your partners late Saturday night and find him or her to be in no condition to perform?

If your call is busy enough, make sure a designated backup is carrying a beeper and understands his or her call responsibilities.

Restrict your responsibilities while on call

In a large practice, where it is not unusual for at least one or two patients to be in labor at any given time, consider assigning the call person solely to labor and delivery to ensure adequate availability for emergencies.

The American College of Obstetricians and Gynecologists recommends that a provider be “immediately available” when a patient is attempting vaginal birth after cesarean or when oxytocin is being utilized.⁷ Although the definition of “immediately available” is not codified, it probably means that the obstetrician should not be doing a major surgical procedure or seeing a full schedule of patients in an office 10 miles from the hospital.

Leaders in one large hospital chain have defined being immediately available as being available within 5 minutes. ⁸

Restrict responsibilities after being on call

This recommendation, too, is volume-driven. If it is likely that you will get little or no sleep during call, the next day’s activities should not include a difficult hysterectomy for severe endometriosis or endometrial cancer. If you must schedule these cases, do so with the patient’s understanding that last-minute rescheduling may be needed.

Even seeing a full slate of clinic patients may be challenging and could have a negative impact on patient satisfaction if you do not sleep the night before. Keep your next day short, and concentrate on activities that require limited mental and physical attention.

Align reimbursement systems

It became apparent, during our discussions with obstetricians in our survey, that financial incentives were aligned in ways that could potentially cause the physicians to overextend themselves. Although none of our respondents expressed concern about this fact from a safety standpoint, it was clear that people may sometimes work when they shouldn’t because of their desire to capture the charges for the care given.

A Canadian study reported a significant drop in elective inductions, as well as increased mean duration of labor, after implementing an income-pooling remuneration system. ⁹

Take call intelligently

Don’t begin call with a sleep deficit. Make sure you get a good night’s rest the night before. If possible, learn how to take “combat naps.” Even 20-minute naps can be helpful.

In our survey, all respondents indicated that their hospital had dedicated call quarters. Some institutions even provided meals and exercise facilities. See “How to combat fatigue (and win) during call”