Conversations in Cardiology: Should Interventional Cardiologists Get Paid for Being On Call?

Morton Kern, MD, of VA Long Beach Healthcare System and University of California, Irvine, often engages his colleagues via email in brief, informal dialogue on clinically relevant topics in interventional cardiology. With permission from the participants, TCTMD presents their conversations for the benefit of the cardiology community. Your feedback is welcome—feel free to comment at the bottom of the page.

James Blankenship, MD (Geisinger Medical Center, Danville, PA), asks:

Mort, here is a topic that might be worth a discussion:

Geisinger has four different hospitals where interventional cardiologists take call. Historically, each hospital has taken a different approach to giving interventionalists recovery time after taking call. We are trying to develop one policy throughout the system. The question arose of how other hospitals handle this. Could you query the listserv members to see who gets time off in return for taking call (eg, Monday off after a weekend of call) or financial compensation specifically for taking call (and how much?), and what happens if an interventionalist has spent most of the night doing procedures but has a full clinic or cath schedule the next day?

Thanks very much.

Kern replies:

Who gets time off in return for taking call?

Nobody in my system or anyone I've ever heard tell about it. While it makes sense, most institutions don't pay the docs for extra work unless built into a contract. Certainly not the VA or university here. Private hospitals who employee on-call docs should pay them when they work.

Just my thoughts.

Christopher J. White, MD (Ochsner Medical Center, New Orleans, LA), replies:

No one in our system gets time off for taking call.

Bonnie Weiner, MD (Saint Vincent Hospital, Worcester, MA), replies:

Seriously?? Can’t imagine that ever happening anyplace I have worked.

Robert J. Applegate, MD (Wake Forest School of Medicine, Winston-Salem, NC), replies:

Only our fellows get to go home early after a call night.

Samuel Butman, MD (Heart & Vascular Center of Northern Arizona, Cottonwood), replies:

LOL. No, seriously, seriously LOL. Also, I want to work at whoever says they work somewhere where they do that . . . LOL still . . .

Lloyd Klein, MD (UCSF Medical Center, San Francisco, CA), replies:

No, me either. I do know some community hospitals that used to pay a fee for on call and still do to vascular surgeons and orthopedic surgeons, but no longer for interventional cardiology. Some private practices and hospitals give those cardiologists who take extra call opportunities to take extra noninvasive rotations.

Keith Oldroyd, MBChB (Golden Jubilee National Hospital, Glasgow, Scotland), replies:

Hi Sam,

You’re welcome to come to Glasgow. I was on call yesterday (three STEMIs and one IABP) and spent most of today out on my bike! You may not be so keen on the salary scale though!

Duane Pinto, MD, MPH (Beth Israel Deaconess Medical Center, Boston, MA), replies:

It is all how you want to classify the imperative, the financial source to accomplish it, and the compensation trade-offs. If one decides that the operator should not be working the day after call (Kaiser does this from what I understand), then the group has decided that one of two things happens since someone needs to do the work or less work gets done overall:

1) salary goes down since revenue goes down

2) salary stays the same and the revenue source negotiated to accomplish this is either called “call pay” or “being paid to not work the day after call.” A revenue dollar and an expense dollar are the same regardless of how it is classified.

The revenue for #2 either comes from the hospital or the other MD’s salary (good luck finding that).

It may not be called “getting time off after call,” but it is simply a decision of whether to schedule things this way—which you can only do if you have enough personnel to get it done and 1) people decide to take a pay cut to do it or 2) the system decides to commit additional financial resources/MD time/FTE to make it happen without reducing salary.

I actually have had enough people at times to do this Sunday-Thursday and have tried it intermittently. People don’t feel strongly either way, since in our practice it’s rare to be up all night and have a full clinical day the next, and most end up doing some non-cath work regardless.

BTW our systems and responses to this query highlight that we only pay lip service to currently PC topics like work-life balance/burnout/effectiveness postcall when speaking to millennials because that’s how we are.

Jeffrey J. Popma, MD (Beth Israel Deaconess Medical Center), replies:

Seriously.  

Arnold Seto, MD (Long Beach VA Medical Center, CA), replies:

In the VA system all physicians are specifically excluded from pay or comp time for on-call duties. The VA claims that physician salary adequately/appropriately compensates us for on-call time, though if one is routinely rounding in the hospital for a full 8-hour day on weekends this is doubtful.

In terms of the private sector, our local community hospital used to pay their private physicians a $750 daily stipend for STEMI coverage, until they built a cadre of internal foundation physicians to take call. At the university hospital, I can earn an extra $500 for any 24 hours of STEMI coverage that is outside of my usual call days. These are roughly in line with MGMA estimates of on-call pay for interventionalists, which averages $650, though holiday rates are higher: “Invasive-interventionalists reported a bump in compensation for both holiday and weekend rates. The median holiday rate for invasive-interventional cardiologists was $2,000 compared with $500 for invasive cardiologists, while median on-call weekend rates were $2,500 and $500, respectively.”

Fortunately for us, though the impact on our families and clinic patients may occasionally be acute at times, there is no evidence our sleep impairment worsens outcomes in elective PCI.

Otherwise, I second Duane's comments and would highlight Bob's comment about fellows/residents: how well are we preparing trainees for the real world?

Carl Tommaso, MD (NorthShore University HealthSystem, Skokie, IL), replies:

It's interesting that all the chatter has been about money and recuperative time. I think there is one element that no one has mentioned. By and large interventional cardiologists have a significant "machismo" about our profession. Most ICs even if given opportunity for time off after call would still be in the lab the next day.

Ajay J. Kirtane, MD (NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY), replies:

NOT ME. . . . I value my beauty sleep. Times they are a changing.

Michael Lim, MD (Saint Louis University, MO), replies:

It is very possible that the interventional cardiologists are way behind in the thinking behind this. As I am told about anesthesiologists getting paid “overtime” and seeing more and more young medical students chose careers for “lifestyle” rather than take up a lifelong commitment to caring for patients in the cath lab with 24-7 responsibilities—I can’t help but think that the ship has sailed and we missed it. I am, as Carl put it, part of the same group that doesn’t “understand” having an “off day” after call. However, I believe that the specialty needs to evolve to make sure that the brightest and most dedicated of the current generations will be attracted to taking our place in the years to come. Unfortunately, this has proven to be one of our very weakest points—we have talked for years of changing the training (whether it be a “fast-track” from internal medicine to cardiology or the “1 year” interventional fellowship) without success. I don’t think we have missed the last boat leaving the harbor though . . .

White replies:

Ok, well, I’ll get back on my soapbox about our need to reassess how many interventional cardiologists we train.  

The future will be a value-based environment, with “population health” holding the “cap” with negative incentives for overutilization (hopefully balanced by similar negative incentives for underutilization). The fact is, despite the expanding number of baby boomers, the diabetes epidemic, etc, we will likely be doing fewer PCIs and needing fewer ICs to do them. Most structural/valve specialists have significant bandwidth to do more of those procedures, which is why there are few high-volume jobs for structural fellows leaving training.  

I see the contraction of cath labs in community hospitals in favor of a hub-and-spoke centralized service. I see a future when ICs, at the hub, are actually doing higher volumes of necessary PCIs than today, but the total volume of PCIs contracting nationally. Once we get off the RVU wheel, which fuels unneeded or unnecessary PCIs, if we don’t control the number of fellows we are training, we will be at the mercy of those who control the cap. It will be a race to the bottom to lower IC compensation. 

Why do we not have any leverage for getting paid to take call, or to take the day after call off? Because there is someone waiting in line to replace us. ICs are not lazy. They enjoy their time in the lab. Given the choice of doing cases or seeing clinic/consults, we always choose to be busy in the lab.

Other specialties have done a much better job of controlling their growth, anesthesia for example, heavily relying on advanced practitioners, rather than residents and fellows, as work extenders. We need to do the same. Convert most of your fellow slots to APPs and invest in your future.

Weiner replies:

Carl is right that most of us like what we do and would rather be in the lab the next day than almost any place else. I think the other thing that this conversation is missing is the patient. I think most of us were trained and had our primary career experiences at a time when we took care of the patient until everything was done. That means staying there while things are unstable/fluid and making sure we follow-up the next day. Handoffs were really not an issue because they didn’t occur. I think if you ask patients, they would still prefer this approach (as would their families) and the same concept applies to outpatient care. Patients want to know who their doctor is and have a familiar face taking care of them.

Yes times have changed, but I am not sure it has been for the better.

Kirtane replies:

I probably should clarify what I meant given some of the responses I got (worst one was from Jeff Popma, who asked if my beauty sleep was actually working—ouch 😉).

I have definitely cancelled cases after a heinous call. On these occasions I have personally called elective patients who didn’t understand and explained to them the situation; not once has a patient insisted on getting done (especially when I say, “Honestly I don’t feel comfortable doing the procedure, because I want to be fully alert and focused on you”). For more urgent/emergent cases, we often will get another attending to do the case(s) . . . one of the benefits of working in a non-RVU system. Some of our attendings won’t do complex cases the day after long international flights for the same reason.

While I think that the systemic issues relating to payment/coverage are real, at the end of the day we are only exposing our patients to suboptimal care (and ourselves to legal risk) but trying to think we are superhuman. Hospitals and systems that turn a blind eye to it likely do so because it’s ultimately not their responsibility. But for me, I just stopped doing these post-brutal call cases when I realized that I myself wouldn’t want my family member treated by a sleep-deprived MD.

Mitchell W. Krucoff, MD (Duke University Medical Center, Durham, NC), replies:

Same here—fellows on call get the next day off, attendings not so . . .

Kenneth Rosenfield, MD (Massachusetts General Hospital, Boston), replies:

Ajay, your response resonates with me and I’m sure with many others. Although, to be sure, in certain circumstances or practices, this is not feasible. That said, it’s probably the best approach and makes the most sense.

Carl, yes, we tend to be very machismo and “proud,” which I have to admit may have gotten in the way of best care in some instances in my past. We always seem to push through it, but it may still not be the best thing for our patients, so I appreciate Ajay’s comments. One other aspect of this has to do with the occupational hazard of sleep loss. This is why I recruited Ariana Huffington as keynote to speak about this topic at the Society of Cardiovascular Angiography and Interventions meeting a few years ago. We all discuss the orthopedic and radiation hazards, but we don’t often address the sleep loss that is associated with being an interventional cardiologist. Something to think about.

Be well, everybody. Get some sleep!! Even if I can’t get any!!!

Klein replies:

Our negative focus on RVUs is understandable in that none of us like to be “scored” and compared to others. But the point is that you can’t be compensated more than the revenue that is produced. Ultimately, the economics isn’t that complicated, you get paid more or less what you earn. Naturally, there is more revenue if there are more cases. We harbor negative feelings about administrators who hold this over us to “motivate” us to work even harder, but the reality is that if not them, someone else would have to do this (although perhaps with more sensitivity?).

Which leads to the fact that few among us will willingly choose to earn less than what we can push ourselves to earn. And, as has been well articulated, we chose this field because we love the work and the satisfaction it brings, so few of us will voluntarily accept less work than what we can push ourselves to do. Ajay, your situation differs as described because you will do that case tomorrow. Suppose your choice was to do it today or your partners would do it? And as Chris well describes, we can expect that income will be going down perhaps significantly in the foreseeable future, which further adds to the pressure to just keep plugging away.

So undoubtedly left to oneself, almost all of us choose to do as much as we can possibly do. The problem, as Ken and Ajay state, is whether that is the best thing for us and our patients. And as previously said, it really is not. So as a profession, we will need to recognize these factors and ultimately generate policies and guidelines that outline what optimal practice is in this regard. The time we work is an occupational/professional condition that we need to join together to control and supervise, not to leave the decision to individuals motivated to work like crazy. 

To say that this is all about sleep makes it appear like we are slacking, and that is not the strongest argument. The way to position this is truly about work-life balance. All of our employees, including physicians and ourselves, will be happier and better workers if they are emotionally supported at home and at the job to take appropriate time away. 

When we say things like “you eat what you kill,” then we are basically saying that you have to work as hard as you can at all times. Instead we should be saying that your mental health is very important to your employer, and if it means we all make a little less, that is okay: what we want are happy balanced workers. We are indeed a far, far way away from that philosophy in medicine.

Andrew Doorey, MD, of Christiana Care Cardiology Consultants (Newark, DE), replies:

“But for me, I just stopped doing these post-brutal call cases when I realized that I myself wouldn’t want my family member treated by a sleep-deprived MD.”

Just to snip a quote from one of the responses. 

I have recently (only) as I've gotten older and more senior declined to do cases if I've been sleep deprived, especially if it involved a draining off-hours case. But that is not always the case as the comments have noted. We have been doing some cath lab safety work comparing us to “high reliability” institutions (nuclear power, aviation), and it may be instructive to compare us to them. In the US at least, a flight crew member may not be involved in an active flight after so many hours on duty (the times vary, I just googled and found this: “The maximum flight time during the day is now 9 hours, and 8 hours at night. Flight Duty Period limits under the new rules range from 9 to 14 hours, depending on how many segments are flown and the start time of the pilot's duty day.)”

That is duty time, from when you first show up for work. I'm sure most of you have been disappointed when the airline announces ‘the flight is cancelled as the crew has timed out.’ This is why. And here we're talking about a two-person crew, sitting in a comfortable seat, where the autopilot can (and often does) fly virtually the entire flight. Yet based on actual accidents, simulator data, etc, this is what the FAA and NTSB think is safest for the flying public, the economics be damned. Yet most of us will continue to work a much longer duty day, and are often the only “pilot in command” of our team. Hard to believe we are as adept at doing our jobs while fatigued as we think we are.

White replies:

Lloyd,

Don’t get trapped in a “revenue” argument, when there is so much opportunity on the “savings” side. Remember that hospitals are really interested in “margin.” It costs a lot of money to earn revenue, while savings come with little expense. Some have estimated that one saved dollar is worth seven earned dollars.

The trick is to get “savings” flowing into the compensation bucket, so you can realize the benefit of “vendor consolidation,” limiting labor costs (paying nurses and techs overtime for marginal cases, that earn doctors RVUs).

We do have leverage here, because ICs “control” what the spend is. For inpatients, we are capitated (DRGs); not only CMS but many other insurers use “day rates.” So the ICs choice of disposables has a major impact on cost per case. 

When ICs are solely motivated to earn RVUs in capitated inpatients, not margin, the hospital is feeling the pain. I guarantee you they want to have this conversation.

Population health is here my friend . . . the sooner we prepare for it the better . . . if you are not at the table, you are the meal. 

Peter N. Ver Lee, MD (Northern Light Cardiology, Bangor, ME), replies:

I’m late to this conversation. Our group is a little bit different than most. We are a hospital-employed cardiology group: 22 cardiologists, 15 NP/PAs, and the only cardiology group in the area. We structured our contract when we joined the hospital such that some of the pay was for call, split between weekdays and weekends. We have no fellows. On weekday nights, there is one non-IC and one IC on. On weekends, there are three docs on: one IC and two non-IC. We split the work, everyone pitches in, and if the IC gets slammed with a long tough shock case, the non-ICs round on his patients. We also have two PAs working weekends and they do a huge amount of the work, rounds, consults, etc. The three weekend guys work until Sunday night and then they are off. Two new docs start Sunday night and work ‘til Monday AM. We don’t get time off after a hard night of call but the schedule is lighter, you see a few patients, you read some echos. The pay for each cardiologist evens out since we all take the same amount of call. The advantage of attaching value to each call rotation is that if someone is sick or injured, there is no problem finding volunteers for call. However, we don’t get a day off after call.

This is a long-winded response and diverges quite a bit from the original question. But it’s how our group has worked it out. And it seems to be a fair, workable way for the entire group to divide the work and get paid.

Klein replies:

Chris,

This is a very sophisticated response and only a system chair would have this kind of insight. I take it as a lesson above my scale, although I wonder if even my administrators would understand it.

Neal Kleiman, MD (Houston Methodist Hospital, TX), replies:

When I’ve told a patient I was too tired to work on him, no one has ever responded: “Come on, doc, I know you can do it.”