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"Clinic call???" Is this normal?


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New grad NP here in a family practice clinic.  I rotated through this clinic as a student, feel like I know the providers well and love them all (as well as the staff).  Pretty close to a dream job in a private practice group and my compensation is very fair.  However, a bomb of sorts was dropped today.  The office manager started to approach me to tell me what my call schedule (?!?) was, but just as she started to, one of the doc's (a clinic partner), shook his head at her as if to cut her off.  She backed off and said something like, "Oh, you haven't talked to him about that yet?"  Best I can gather, this outpatient/FP clinic takes call from patients after hours and apparently, they plan on adding me to the call rotation along with three other providers.  This is not hospital call, but "clinic call."  What?!?  

 

Is taking after hours call for clinic patients normal in primary care?  Regardless, this was not disclosed to me during negotiations.  In fact, they said "no call" but in retrospect, I (now) know they were talking about hospital call.  Is it common for FP clinics to take calls from frantic mothers in the middle of the night who have kids with a runny nose and a fever?  Not only was this not disclosed (or perhaps it was decided upon after I agreed to come on board), but it sounds like an INCREDIBLY STUPID idea.  Is this normal?

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yup. pretty much every clinic has at least an answering service that screens calls and forwards the reasonable ones to clinicians at any hour. it's a liability thing. someone needs to be able to tell a pt on a new drug 24/7 that they should call 911 or go to the ER for anaphylaxis, etc.

That being said, they should have told you about it before now...

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It is common for small practices. At my current, about to be previous, job I took call every 6 days and every 6th Weekend. The Docs I covered were my SP and 4 other docs from other practices that are close to retiring so all their pts were old an SNF residents. My SP and I trained our pts that the call service was not suck call or advice line. It is for Oroviders/facilities to reach us about a pt after hours. I took my last weekend last week and unfortunately I was on call Thurs as well so I had 4 glorious nights of BS calls from older pts. It ranged from "I cut my leg, should I put on a bandage?" to "blood is coming out of my rectum, should I go to the ER?" Basically it's just triaging "ER or No ER" and giving orders for SNF pts. I My new job I take no call. Thank the Lawd!

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Very common to take call after hours, especially in a private practice.

While I dont think one could call it patient abandonment if a practice does not take call, it is common to have some mechanism in place for patients of a practice to turn to after hours. 

It is not realistic to expect that patients only have concerns during clinic hours. One may say if so, go to the urgent care clinic or the ED but that costs money and many times is not needed.

I would say it can be viewed as stupid when you are dealing with patients lack of common sense and overwhelming anxiety. But we do that quite a bit as healthcare providers. It is also a service to the patients of the practice but something that many practices are reconsidering or at least placing a call service in the way with triage instructions.

As for being responsible, this should be clearly outlined in negotiations. It appears it was not for the OP.

The first thing I would do is get this right out in the open with the owners of the practice since it sounds like you are liking this job.

Survey the lay of the land. Is everyone taking call? If everyone is taking call, are they owners of the practice or employees? If they are employees, is there separate call compensation? If everyone else is an owner and you are the odd man out, this needs to be pointed out in a tactful manner. Is there schedule adjustment based on call ie the morning off after taking call? 

There is a fine line you have to tread here but also avoid getting railroaded into something you cannot give back. The days of being on call all night and then showing up at the office bright eyed and bushy tailed is over. All that does is make people unhappy. This could turn out to be a huge quality of life issue for you.

I would also say sharing call amongst 4 providers sucks as a ratio. Being on every 4th night blows and it is likely that they also do one weekend a month to split it up amongst everyone.

Good luck with this.

G Brothers PA-C

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Itis not as bad as it sounds if it is managed correctly. Your voicemail/pager mail/answering service should make it VERY clear that this is NOT for routine questions, appt requests, or non emergency medication refills. And then should state there will be a potential delay in returning messages so if there is any medical emergency or complaint they should call 911 and go to ER. Half my phone calls never left a message. My last 3 years in private practice I developed a policy where I called in no antibiotics or acute care treatments. I would refer everyone to urgent care. My rationale is if you can treat over the phone on SAT why is it not ok to treat them MON- FRI ?

 

A three provider practice (I was part of a 4 provider group) should not receive more than 10 phone calls a week. They should provide at a minimum phone reimbursement. I would not be pushed over on this at will set precedent. Make sure they know you are surprised and require some added compensation. Unless of course they are already paying you 100k with good benefits. 

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My current soon to be former job in FP has no call.  But then half of our patients don't have working phones.  Thank the Lawd!!!

 

My soon to be new job in Primary Care/Internal Medicine has call once every 13 weeks or so, shared by all the MD/DO/PA/NPs in the group.  It is only for weekend after hours call and was clearly outlined for me in my contract.  It will consist mostly of SNF calls and some triage which they say is mostly answering the pt. of whether or not they should go to ER or wait til Monday to be seen. 

 

I will get paid $40/month for the extra use of my own cell phone, plus compensation for this type of work is figured in with extra Rvu's at the end of the quarter.. I can't figure out how much I will actually get paid.....not much I think, but at least call is shared with 12 others. 

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just about every PCP has call

I have been on call for 2.5 years straight....  but my patients know not to call in the off hours - and it is just my patients so i know them all

 

HOWEVER - if you are working for a paycheck in a practice and are a new grad - NOPE NADA should not happen.

 

 

HOLD firm on not taking call, it was not negotiated, not mentioned and you should not cave in to make them happy, this is called taking advantage of you.

 

I see it time and time again where younger PAs think it is no big deal and just take some call, well it is a big deal and if you ask around to people that have done it for a while you realize it is a huge quality of life issue. Hence why the doc's that are nearing retirement age are looking for any way out of it (including putting a brand new grad PA on first call)

 

I would politely and firmly decline for the length of your first contract, and you may say that it can come up for renegotiation at your contract renewal.

 

In general I have heard that call coverage on a weeknight for just telephone call runs about $100 - $200 per night (I also like the 25% of a full days pay).  if you have to go in, or see patients you NEED to be paid a % of collections.   

For weekends - I would say bare min of $750 as you effectively kill the entire weekend.  I clearly remember getting called > 10 times in the 1.5 hour funeral service for my uncle.... I was a very unhappy PA for that weekend - and will never forget the disdain I gained for call in a large practice.

 

 

 

A few "rules for call" that need to be practice wide for you even to consider taking call

 

1) Absolutely no narcotic or pain med refills - if they ask just saw we don't do it - and everyone in the practice needs to say the same thing

1b) NO benzo refills - see #1, same goes for sleep aides, motrin 800, muscle relaxants, and other script meds.

2) no routine med refills - they can call office next business day to refill - there is always exceptions to this - ie cardiac meds so you have to think about it

3) No Abx scripts on call - if they are sick enough to need ABX they are sick enough to require an evaluation by a provider.

4) if you are covering nursing homes - well that is a whole different story - need to find this out before saying yes to call - they likely are getting paid a hefty amount by the NH to be a medical director and cover call, usually 10-30k/year - and if they are going to ask you cover you should be paid.  you WILL get calls at all hours of the day and night and sometimes they of zero value added besides waking you up and destroying your night sleep

5) you will need a doc on call behind you every time you are on call - you are  dependent practitioner - and the doc always has to be reachable - especially as a new grad you will have questions on management - and they need to mentor you.  Also it is a legal issue......

 

 

Good luck, just don't do it for free or out of guilt.... 

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Agree with the others, this needs to be negotiated and compensated. I doubt they will have you taking call straight out of the gates though.

 

BUT---for your first job especially, this is a fine line you're walking here. Stand up for yourself as a professional but also don't come off as obstinate. Many docs could take you for lazy or entitled, and you being the new fish it may not bode well for your employment.

 

I remember in my first gig we had to take a ton of call, like q3 or q4. And it was all trauma call. I never outright complained, but a couple of times I made some jokes about being there so late and one of the docs did not like that at all. He pretty much hated me during my short tenure there and I never quite knew why, until I reflected on it after I left. Among other reasons, by making jokes as a newbie I had made myself the lame duck.

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The reason primary care docs do "clinic call" has nothing to do with liability and everything to do with them being suckers who mistakenly bought into the mantra put out by "experts" that PCPs have to be available 24/7.

 

Now that patients have gotten used to that idea for a few years, they expect it out of every primary care clinic.

 

That's whats really going on here -- it is perfectly legal and perfectly acceptable from a liability standpoint to put a message on your answering machine after 5 PM that says "go to the ER" for every person who calls.  No liability there whatsoever.

 

This is yet another example of doctors (and PAs) voluntarily screwing themselves over based on some "expectation" placed on them by people who don't work in healthcare.  

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SNF's are required by law to report patient findings or events to a physician on the weekends.  They would be the exception to what Gordon, PA-C states. 

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The reason primary care docs do "clinic call" has nothing to do with liability and everything to do with them being suckers who mistakenly bought into the mantra put out by "experts" that PCPs have to be available 24/7.

 

Now that patients have gotten used to that idea for a few years, they expect it out of every primary care clinic.

 

That's whats really going on here -- it is perfectly legal and perfectly acceptable from a liability standpoint to put a message on your answering machine after 5 PM that says "go to the ER" for every person who calls.  No liability there whatsoever.

 

This is yet another example of doctors (and PAs) voluntarily screwing themselves over based on some "expectation" placed on them by people who don't work in healthcare.  

 

 

Ah NO

 

Most insurance companies mandate that you have off hour call and you sign a legal contract saying that you have so

Medicare is requiring 24 hour call coverage to bill CCM codes, most insurance companies follow suit from Medicare.

Hospitals require call coverage for admitting coverage (a least mine)

State board looks down on PCP that do not have call coverage

 

and 

 

It is just plain wrong to not care for your patients - 

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Ah NO

 

Most insurance companies mandate that you have off hour call and you sign a legal contract saying that you have so

Medicare is requiring 24 hour call coverage to bill CCM codes, most insurance companies follow suit from Medicare.

Hospitals require call coverage for admitting coverage (a least mine)

State board looks down on PCP that do not have call coverage

 

and 

 

It is just plain wrong to not care for your patients - 

 

I stand by what I said.  Insurance companies do NOT require the doctor answer every phone call personally 24 hours per day, 7 days per week  If you doubt this, I would encourage you to call random PCP offices at 3 AM tonight and see how many of them actually connect you to a doctor at the clinic.  Some clinics choose to offer this service, but it is NOT required by anybody.  All you have to do is put a message on your machine telling everyone to call 911 and that is completely sufficient.

 

Hospital call is a choice by the PCP -- again not required.  I know many PCPs who gave up hospital work a long time ago and they have no responsibility to take call in the ER or admit patients to the hospital.  So it is 100% completely optional.

 

"State board looks down on PCPs not doing call coverage"  -- please cite an example of a state board who disciplined a doctor because he/she didnt answer their phones 24 hours a day or pay someone else to do it.

 

"It is just plain wrong not to care for your patients."  -- That's an expectation put on docs/PAs by outsiders who are looking to control you.  But if you want, I can play that game too.  If that is really what you believe, then I'm going to declare you a bad PA for taking vacation once a year because you are clearly abandoning your patients when you do so.  They are YOUR patients, so you must NEVER go out of town because they might need you in an emergency.  

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I think there needs to be a clear distinction between outpatient primary care and urgent/ER care.

 

I have no idea about the legalities involved, but IMHO I think primary care providers---PAs, NPs, and MDs--should in no way be obligated to provide after-hours consultation or care. They are OUTPATIENT providers, who by definition see patients (usually) on a scheduled basis only during specified office hours. Anything that falls outside of that? If it's not life or limb-threatening the patient can wait till tomorrow, if it is that's what ERs and urgent care clinics are for.

 

Call gives patients the impression they can call us for anything and get a response. If PCPs do take call then I think it should be phone call only---basically ER vs. Come In Tomorrow, which can actually be solved with a simple message telling them to call 911 if they are experiencing a medical emergency.

 

The moral of the story is, primary care call needs to be explicitly specified in our contracts---e.g. hours, rotation, compensation---and factored into our salary OR paid on an hourly or periodic basis. This is extra work, extra liability, and affects quality of life. Do you pay a plumber extra money to come fix your overflowing toilet at 2 am?? Absolutely. 

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I think there needs to be a clear distinction between outpatient primary care and urgent/ER care.

 

I have no idea about the legalities involved, but IMHO I think primary care providers---PAs, NPs, and MDs--should in no way be obligated to provide after-hours consultation or care. They are OUTPATIENT providers, who by definition see patients (usually) on a scheduled basis only during specified office hours. Anything that falls outside of that? If it's not life or limb-threatening the patient can wait till tomorrow, if it is that's what ERs and urgent care clinics are for.

 

Call gives patients the impression they can call us for anything and get a response. If PCPs do take call then I think it should be phone call only---basically ER vs. Come In Tomorrow, which can actually be solved with a simple message telling them to call 911 if they are experiencing a medical emergency.

 

The moral of the story is, primary care call needs to be explicitly specified in our contracts---e.g. hours, rotation, compensation---and factored into our salary OR paid on an hourly or periodic basis. This is extra work, extra liability, and affects quality of life. Do you pay a plumber extra money to come fix your overflowing toilet at 2 am?? Absolutely. 

 

This the way I see it too.  More to the point -- using your plumber example -- no plumber in the world would take call 24/7 to answer plumbing questions FOR FREE.  I brought the call schedule up with my "SP," who was not aware that I had found out there was call (the other physician partner did not tell him about the incident I mentioned in my original post).  He claims that the medicaid program in a neighboring state, which we take in my clinic, requires it to the best of his knowledge, but was kind of vague.  No timetable has been proposed for me to start taking call, and apparently they did not even want it discussed with me at this point.  He did say, however, that he has received on average 3-4 calls per week on the weeks he was on call since the clinic started taking call.

 

I politely noted that I didn't really care for the idea.   I wouldn't mind 3-4 calls a week every 4 weeks too much, but I'm not doing it for free and I'm not doing it until I have a lot more experience under my belt. 

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yes, it's normal. 

 

I, for one, as an occasional patient, am grateful that I can call my PCP's office after hours and either get reassurance or direction, based on what I am calling about (including concerns re my kid). after all, don't we all as health care providers want to see the practice of overloading the EDs with primary care patients ended?

 

if it's the fact that call was not part of your original negotiation that irks you, then when you are approached about it, you might want to consider (and think about it ahead of time, so you have a plan) asking them what their expectations are, what additional compensation you can expect from taking call, or, even, profit sharing. if you are going to share the full load of responsibility to your patients for this practice, it would not be unreasonable to ask them for a piece of their profits.

 

if they stare at you like you have 3 heads, and/or you don't like their reply, I would thank them, put a smile on my face, continue doing an excellent job...and get your resume out there.

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yes, it's normal. 

 

I, for one, as an occasional patient, am grateful that I can call my PCP's office after hours and either get reassurance or direction, based on what I am calling about (including concerns re my kid). after all, don't we all as health care providers want to see the practice of overloading the EDs with primary care patients ended?

 

if it's the fact that call was not part of your original negotiation that irks you, then when you are approached about it, you might want to consider (and think about it ahead of time, so you have a plan) asking them what their expectations are, what additional compensation you can expect from taking call, or, even, profit sharing. if you are going to share the full load of responsibility to your patients for this practice, it would not be unreasonable to ask them for a piece of their profits.

 

if they stare at you like you have 3 heads, and/or you don't like their reply, I would thank them, put a smile on my face, continue doing an excellent job...and get your resume out there.

 

I appreciate what you are saying, but, I don't see it as my duty to offer myself up for free to help the ER over-utilization problem, which, by the way, I think is a bit overblown.  Not to mention the fact that while providers may get irked over sniffles in a 2 year old at 3 AM in the ER, hospital admin loves it (whether profit or non-profit) so long as they have insurance. The thing is though, I am not an after hours ER triage volunteer.

 

In my vast 3 weeks of experience as an FNP in a clinic, I've not eRX'd a couple of scripts (I blame it on NextGen - an AWFUL EMR! - but that's another post), and had an AOM in an adult with pain that spread to his temple, jaw and mastoid that I got calls from after the clinic had closed but before I had left.  I am 100% OK with those calls and, in fact, want them. I treated them and am responsible within reason.  And...In my vast 3 weeks of experience as an FNP in a clinic...I go out of my way with pt. ed regarding their treatment plans so that they don't have something they feel like they need to go to the ER for (or call the clinic about) after hours unless it is really necessary.

 

Clinic call would mean every 4th week I would take call from patient panels of every provider in the clinic (2 MD's, 1 NP + my own).  The load seems reasonable now, but I wonder what it will be like once the word gets out to the patient panels given the fact that my clinic has only started "clinic call" in the last few months.  And yes, one concern is that I did not agree to this during contract negotiations.

 

Good advice though.  Being a newb, I'm not comfortable taking call, and with a contract that didn't include this, I think I have some leverage regarding my role and call.  I love the clinic, the doc that hired me, the staff, and the patient population, so I think I'll just let this ride and see where it goes.

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I work for an FQHC and was told up front I'd be taking after hours clinic call. At first it was every other week alternating with my SP, but I didnt mind because before that he was on call for a year by himself. The problem was my area didn't have cell phone/pager service the first year so I couldn't leave my apartment off hours as I had to stick around the land line. We have a firm policy of no rx refills after hours. Most of the time I'll get a call around midnight from the lab that someone had a critical glucose if 402 when the blood was drawn at 10, or any patient who mentions coumadin gets pushed through.

 

This has been my only job since I graduated 2.5 years ago. My SP is wonderful in that if I ever got a call I wasn't sure how to deal with, I could call him at ANY time. We don't get compensated for call and it's now up to 1:4.

 

Being rural though, people will either show up on my doorstep or call me directly at home, so the call thing is kind of a joke

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I stand by what I said.  Insurance companies do NOT require the doctor answer every phone call personally 24 hours per day, 7 days per week  If you doubt this, I would encourage you to call random PCP offices at 3 AM tonight and see how many of them actually connect you to a doctor at the clinic.  Some clinics choose to offer this service, but it is NOT required by anybody.  All you have to do is put a message on your machine telling everyone to call 911 and that is completely sufficient.

 

This totally incorrect, I just looked at a Blue Cross Shield primary care credentialing contract today, required 24 x 7 x 365 Call coverage.  It does not have to be each and every individual physicians covering each night, but there does need to be a provider available 24/7/365

 

 

Hospital call is a choice by the PCP -- again not required.  I know many PCPs who gave up hospital work a long time ago and they have no responsibility to take call in the ER or admit patients to the hospital.  So it is 100% completely optional.

 

I don't think you understand what I'm talking about, I am not referencing hospital call coverage, but instead credentialing through the hospital requires, at least my hospital, that you are providing off-hours call coverage for your patients. Insurance companies won't eventually you unless you are Credentialed with a local hospital.

 

"State board looks down on PCPs not doing call coverage"  -- please cite an example of a state board who disciplined a doctor because he/she didnt answer their phones 24 hours a day or pay someone else to do it.

www.mass.gov/massmedboard says otherwise

 

"It is just plain wrong not to care for your patients."  -- That's an expectation put on docs/PAs by outsiders who are looking to control you.  But if you want, I can play that game too.  If that is really what you believe, then I'm going to declare you a bad PA for taking vacation once a year because you are clearly abandoning your patients when you do so.  They are YOUR patients, so you must NEVER go out of town because they might need you in an emergency.  

 

 

I don't mean to be blunt, but it appears that you are not up to speed on the practice environment at least in my state, Massachusetts. May well be different in different states.

 

 

I cannot disagree with the sentiment that you are bringing up, I give away far too much knowledge at far too late in the night, but please do not confuse the sentiment with a what is the medicolegal environment that I practice in in Massachusetts. 

 

I would have never known there was such issues until I started my own practice. Now I start to see the light at how over regulated and under compensated And underappreciated primary care is.

 

 

 

 A simple question, do you practice in primary care?( see below) How long have you been up PA? Have you reviewed credentialing contracts? have you reviewed practice credentialing contracts with the local hospital?  It appears as though you work in a specialty--> pediatric Surgery, I therefore take your answers with a grain of salt. I would not ask the pediatric surgeon how to manage dementia, nor would I ask the pediatric surgery PA about primary care call issues.  However I would ask you quickly how to manage a surgical pediatric issue. We all have to understand we are experts in their own area, but that does not make us experts in every area.

 
 

I actually train pediatric surgeons at my job all the way up to the fellows and junior attendings, so I know very well what MD residents/fellows are capable of and how they grow.

 

Surgery fields are the only one in which MDs can do things that PAs simply can not do and will never be able to do unless PA training is changed.  Not because PAs are not capable, but simply because PAs dont get the experience they need running cases solo in the OR.  Every other field PAs and MDs are virtually interchangeable, maybe not at day 1 of graduation of a brand new PA, but after years of experience there is no difference.

 

I don't understand your point about PAs not being equal in the eyes of the law.  Are you OK with that status quo?  Because I am not.  I understand the way things are, but that's NOT the way they should be.  I think you know deep down that PAs can do anything doctors can do except for very rare exceptions in surgical fields, and we should be judged according to our clinical outcomes, not our training.

 

Show me the data that physicians provide superior care to PAs, or they do more work to justify a higher income.  If they see more patients or treat patients that PAs cant treat, then by all means pay them more.  Otherwise we should get paid the same.  Equal pay for equal work.

 
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I appreciate what you are saying, but, I don't see it as my duty to offer myself up for free to help the ER over-utilization problem, which, by the way, I think is a bit overblown.  Not to mention the fact that while providers may get irked over sniffles in a 2 year old at 3 AM in the ER, hospital admin loves it (whether profit or non-profit) so long as they have insurance. The thing is though, I am not an after hours ER triage volunteer.

 

In my vast 3 weeks of experience as an FNP in a clinic, I've not eRX'd a couple of scripts (I blame it on NextGen - an AWFUL EMR! - but that's another post), and had an AOM in an adult with pain that spread to his temple, jaw and mastoid that I got calls from after the clinic had closed but before I had left.  I am 100% OK with those calls and, in fact, want them. I treated them and am responsible within reason.  And...In my vast 3 weeks of experience as an FNP in a clinic...I go out of my way with pt. ed regarding their treatment plans so that they don't have something they feel like they need to go to the ER for (or call the clinic about) after hours unless it is really necessary.

 

Clinic call would mean every 4th week I would take call from patient panels of every provider in the clinic (2 MD's, 1 NP + my own).  The load seems reasonable now, but I wonder what it will be like once the word gets out to the patient panels given the fact that my clinic has only started "clinic call" in the last few months.  And yes, one concern is that I did not agree to this during contract negotiations.

 

Good advice though.  Being a newb, I'm not comfortable taking call, and with a contract that didn't include this, I think I have some leverage regarding my role and call.  I love the clinic, the doc that hired me, the staff, and the patient population, so I think I'll just let this ride and see where it goes.

 

I didn't say anything about doing anything for free. 

 

did you actually read my post? I suggested several options for addressing additional compensation for taking call.

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I didn't say anything about doing anything for free. 

 

did you actually read my post? I suggested several options for addressing additional compensation for taking call.

 

If I'm a clinic/clinician independent of an ER triaging patients on their behalf, then I (and my clinic) am doing it for free unless the ER pays me, my clinic, or both for doing it.  Furthermore, I don't want my clinic/group paying me (and thus incurring additional costs) to be the local ER triage volunteer.  That is something the ER should be paying for, not my clinic/group.  Unless the ER pays for it, then we ARE doing it for free.

 

I've discussed this once again with my SP and he is not budging.  The latest reason is that it is a requirement for signing up for being a PCMH (whatever the heck that really is - how is it different from a normal primary care clinic, exactly?).  Uggghh.  And people want to treat patients on government insurance????  And groups and clinics want to take patients on government insurance with all the strings that are attached?   And, worse still, there are clinicians that think government health insurance is the solution to all problems.  Yeah, we all should be willing to take call at 0300 for a 4 year old that woke up and vomited x 1 -- that's patient centered care!  Government health insurance is the genesis of most problems, not the solution.  If the PCMH really is at the root of this (or Medicare/Medicaid - whatever), then mark my words.  You think access for government insured patients is a problem now?  Just wait.

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wow

 

what about the reality that medicine is a 24x7 profession?

 

If you want a 9-5 job then I would recommend corporate USA

 

As for taking call - yes it is a part of almost every aspect of medicine......

 

We are not the extenders of the ER - they are our extenders for patients that can not wait

 

 

I do agree that there needs to be limits and what would be really nice is to be paid for off hours calls, but to think that a patient does not have the ability to call their PCP for something they deem worthy (that sometimes need education as well) is simply wrong in my book.

 

We (at least I) am in medicine to help my patients, and patients get sick at different times and need our help and deserve to have it.

 

however - it needs to be stated clearly in compensation packages PRIOR to hire, as it is the company that employs you responsibility to provide this service to all there patients, and hence FAIR call schedules are required.

 

 

Seriously, do you really think Ortho or any other specialist gets to say "we are not on call ever"  

people get sick and need care in off hours - that is medicine....  

 

We do not need to become a high maintenance profession of providers that do not want to pull their own weight, however, we should not allow ourselves to be taken advantage of either

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