User login
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?
| Residency | Private practice |
|---|---|
| More intense | Less intense |
| Focused (often on only one area) | Multiple responsibilities and sometimes multiple hospitals |
| More likely to go without sleep | Less likely to go without sleep |
| Shorter duration | Longer 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.
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”
Here are more ways to improve call
Depending on the size of your call pool and volume of deliveries, you might consider the following options to improve your call system.
A few simple measures can boost mental and physical alertness during extended duty.
Physical activity—This is the best strategy to counter fatigue. Stretch often, and walk around. Bright lights help.
Talk—Active participation in a conversation helps keep you focused; passive listening does not.
Drink caffeinated beverages—This calls for moderation, of course. Caffeine isn’t, and shouldn’t be, a cure-all.
Eat well and keep hydrated—A healthy diet and lots of uncaffeinated fluids keep your body running smoothly.
Take short naps—Even 20 minutes can help.
Support your colleagues—Cover another physician long enough for him or her to take a nap, and then take your turn.
Call for help—Call in backup if you are faced with a difficult situation and sense symptoms of serious fatigue in yourself. Also, watch for those symptoms in your colleagues.
Take a shower—A change of clothes helps, too.
Source: Adapted from “Fatigue countermeasures: alertness management in flight operations.” Available at http://humanfactors.arc.nasa.gov/zteam. Accessed March 12, 2009.
If you increase the number of obstetricians in your call pool, the number of calls you take may diminish. However, the volume of activity will probably increase as a result, so that you have a greater chance of being busy while on call. Hiring a nurse-midwife may decrease the number of uncomplicated vaginal deliveries you perform, but you still need to be prepared to provide backup.
Shorten the call duration
The most common duration of call in our study was 24 hours. However, some call pools take call for a weekend or week at a time.1 This gives the physician a longer interval between calls, but the unpredictability of the patient load may make this a horrendously long period of time.
Another potential disadvantage of a shortened call, especially when it is abbreviated to less than 24 hours, is that it increases the number of handoffs in patient care and, therefore, enhances the risk that the circumstances of any given patient will be incompletely understood at this time.
In a busy OB practice, handoffs usually involve a meeting of obstetricians in labor and delivery to “run the board.” When participants attempt to make these handoffs as complete as possible, patient safety is significantly improved.
One way to ensure completeness of patient handoffs is to borrow training and skills from the world of airline pilots. There, crew resource management has introduced the concept of SBAR [Situation-Background-Assessment-Recommendation] as a specific tool to decrease risk inherent in handoffs.
Another helpful idea is attending nurses’ report sessions. These reports can provide you with useful information that you may not have recognized otherwise. By giving them your attention, you may also strengthen relationships with the nurses, your first line of defense.
Develop in-house call
Dildy and colleagues estimated that a call volume of approximately 2,400 deliveries a year would justify a hospital developing 24-hour in-house obstetric coverage.10 In our study, almost all of the hospitals that required in-house call did so because they had residencies, and in-house staff call was required.
Although Clark and colleagues found 24-hour in-house call to be safer than regular call in their review of closed perinatal claims at one large hospital chain, there has been a paucity of studies that confirm or extend our knowledge in this area.11
Hire laborists
Weinstein introduced the word “laborist” into our lexicon in a 2003 paper.12 Barbieri suggested the addition of “nocturnalist” or “weekendist” as possible terms to describe specialists assigned to work certain shifts that prove particularly onerous to practicing obstetricians.13 A number of hospitals and groups are examining and developing this call model.14 However, little research has been conducted on its effects on patient safety and obstetric practice.
For more information, visit www.oblaborist.org and http://obgynhospitalist.com.
Balance—that is the goal
For some of us, perfect balance between safety and patient satisfaction, and between work and home life, may be impossible. Nevertheless, we all need to explore ways to make call a safe and sustainable practice. For many of us, the growing recognition that we have more beautiful, sunny Sunday afternoons behind us than in front of us may be the signal to shift our focus to less demanding, and time-depleting, call schedules.
1. Schauberger CW, Gribble RK, Rooney BL. On call: a survey of Wisconsin obstetric groups. Am J Obstet Gynecol. 2007;196:39.e1-39.e4.
2. Dorsey ER, Jarjoura D, Rutecki GW. Influence of controllable lifestyle on recent trends in specialty choice by US medical students. JAMA. 2003;290:1173-1178.
3. Gariti DL, Zollinger TW, Look KY. Factors detracting students from applying for an obstetrics and gynecology residency. Am J Obstet Gynecol. 2005;193:289-293.
4. Deutsch A, McCarthy J, Murray K, Sayer R. Why are fewer medical students in Florida choosing obstetrics and gynecology? South Med J. 2007;100:1095-1098.
5. Bettes BA, Chalas E, Coleman VH, Schulkin J. Heavier workload, less personal control: impact of delivery on obstetrician/gynecologists’ career satisfaction. Am J Obstet Gynecol. 2004;190:851-857.
6. Pradhan A, Raman A, Lim C, Yoon E, Ananth C. The patient perspective. Is the hospitalist model a viable option for obstetric care [abstract]. Obstet Gynecol. 2008;111:40S-41S.
7. American Academy of Pediatrics and the American College of Obstetricians and Gynecologists. Guidelines for Perinatal Care. 6th ed. Elk Grove, Ill: American Academy of Pediatrics; 2007:157.
8. Clark SL, Belfort MA, Byrum SL, Meyers JA, Perlin JB. Improved outcomes, fewer cesarean deliveries, and reduced litigation: results of a new paradigm in patient safety. Am J Obstet Gynecol. 2008;199:105.e1-105.e7.
9. Bland ES, Oppenheimer LW, Holmes P, Wen SW. The effect of income pooling within a call group on rates of obstetric intervention. CMAJ. 2001;164:337-339.
10. Dildy GA, Clark SL, Belfort MA, Herbst MA, Thompson J. Twenty-four hour, in-house obstetric coverage in a community-based tertiary care hospital [abstract]. Obstet Gynecol. 2007;109:43S.-
11. Clark SL, Belfort MA, Dildy GA. Reducing obstetric litigation through alterations in practice patterns—experience with 189 closed claims. Am J Obstet Gynecol. 2006;195:S118.-
12. Weinstein L. The laborist: a new focus of practice for the obstetrician. Am J Obstet Gynecol. 2003;188:310-312.
13. Barbieri RL. Will the “ists” preserve the rewards of OB practice? OBG Management. 2007;199(9):8-12.
14. Yates J. The laborists are here, but can they thrive in US hospitals? OBG Management. 2008;20(8):26-34.
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?
| Residency | Private practice |
|---|---|
| More intense | Less intense |
| Focused (often on only one area) | Multiple responsibilities and sometimes multiple hospitals |
| More likely to go without sleep | Less likely to go without sleep |
| Shorter duration | Longer 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.
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”
Here are more ways to improve call
Depending on the size of your call pool and volume of deliveries, you might consider the following options to improve your call system.
A few simple measures can boost mental and physical alertness during extended duty.
Physical activity—This is the best strategy to counter fatigue. Stretch often, and walk around. Bright lights help.
Talk—Active participation in a conversation helps keep you focused; passive listening does not.
Drink caffeinated beverages—This calls for moderation, of course. Caffeine isn’t, and shouldn’t be, a cure-all.
Eat well and keep hydrated—A healthy diet and lots of uncaffeinated fluids keep your body running smoothly.
Take short naps—Even 20 minutes can help.
Support your colleagues—Cover another physician long enough for him or her to take a nap, and then take your turn.
Call for help—Call in backup if you are faced with a difficult situation and sense symptoms of serious fatigue in yourself. Also, watch for those symptoms in your colleagues.
Take a shower—A change of clothes helps, too.
Source: Adapted from “Fatigue countermeasures: alertness management in flight operations.” Available at http://humanfactors.arc.nasa.gov/zteam. Accessed March 12, 2009.
If you increase the number of obstetricians in your call pool, the number of calls you take may diminish. However, the volume of activity will probably increase as a result, so that you have a greater chance of being busy while on call. Hiring a nurse-midwife may decrease the number of uncomplicated vaginal deliveries you perform, but you still need to be prepared to provide backup.
Shorten the call duration
The most common duration of call in our study was 24 hours. However, some call pools take call for a weekend or week at a time.1 This gives the physician a longer interval between calls, but the unpredictability of the patient load may make this a horrendously long period of time.
Another potential disadvantage of a shortened call, especially when it is abbreviated to less than 24 hours, is that it increases the number of handoffs in patient care and, therefore, enhances the risk that the circumstances of any given patient will be incompletely understood at this time.
In a busy OB practice, handoffs usually involve a meeting of obstetricians in labor and delivery to “run the board.” When participants attempt to make these handoffs as complete as possible, patient safety is significantly improved.
One way to ensure completeness of patient handoffs is to borrow training and skills from the world of airline pilots. There, crew resource management has introduced the concept of SBAR [Situation-Background-Assessment-Recommendation] as a specific tool to decrease risk inherent in handoffs.
Another helpful idea is attending nurses’ report sessions. These reports can provide you with useful information that you may not have recognized otherwise. By giving them your attention, you may also strengthen relationships with the nurses, your first line of defense.
Develop in-house call
Dildy and colleagues estimated that a call volume of approximately 2,400 deliveries a year would justify a hospital developing 24-hour in-house obstetric coverage.10 In our study, almost all of the hospitals that required in-house call did so because they had residencies, and in-house staff call was required.
Although Clark and colleagues found 24-hour in-house call to be safer than regular call in their review of closed perinatal claims at one large hospital chain, there has been a paucity of studies that confirm or extend our knowledge in this area.11
Hire laborists
Weinstein introduced the word “laborist” into our lexicon in a 2003 paper.12 Barbieri suggested the addition of “nocturnalist” or “weekendist” as possible terms to describe specialists assigned to work certain shifts that prove particularly onerous to practicing obstetricians.13 A number of hospitals and groups are examining and developing this call model.14 However, little research has been conducted on its effects on patient safety and obstetric practice.
For more information, visit www.oblaborist.org and http://obgynhospitalist.com.
Balance—that is the goal
For some of us, perfect balance between safety and patient satisfaction, and between work and home life, may be impossible. Nevertheless, we all need to explore ways to make call a safe and sustainable practice. For many of us, the growing recognition that we have more beautiful, sunny Sunday afternoons behind us than in front of us may be the signal to shift our focus to less demanding, and time-depleting, call schedules.
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?
| Residency | Private practice |
|---|---|
| More intense | Less intense |
| Focused (often on only one area) | Multiple responsibilities and sometimes multiple hospitals |
| More likely to go without sleep | Less likely to go without sleep |
| Shorter duration | Longer 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.
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”
Here are more ways to improve call
Depending on the size of your call pool and volume of deliveries, you might consider the following options to improve your call system.
A few simple measures can boost mental and physical alertness during extended duty.
Physical activity—This is the best strategy to counter fatigue. Stretch often, and walk around. Bright lights help.
Talk—Active participation in a conversation helps keep you focused; passive listening does not.
Drink caffeinated beverages—This calls for moderation, of course. Caffeine isn’t, and shouldn’t be, a cure-all.
Eat well and keep hydrated—A healthy diet and lots of uncaffeinated fluids keep your body running smoothly.
Take short naps—Even 20 minutes can help.
Support your colleagues—Cover another physician long enough for him or her to take a nap, and then take your turn.
Call for help—Call in backup if you are faced with a difficult situation and sense symptoms of serious fatigue in yourself. Also, watch for those symptoms in your colleagues.
Take a shower—A change of clothes helps, too.
Source: Adapted from “Fatigue countermeasures: alertness management in flight operations.” Available at http://humanfactors.arc.nasa.gov/zteam. Accessed March 12, 2009.
If you increase the number of obstetricians in your call pool, the number of calls you take may diminish. However, the volume of activity will probably increase as a result, so that you have a greater chance of being busy while on call. Hiring a nurse-midwife may decrease the number of uncomplicated vaginal deliveries you perform, but you still need to be prepared to provide backup.
Shorten the call duration
The most common duration of call in our study was 24 hours. However, some call pools take call for a weekend or week at a time.1 This gives the physician a longer interval between calls, but the unpredictability of the patient load may make this a horrendously long period of time.
Another potential disadvantage of a shortened call, especially when it is abbreviated to less than 24 hours, is that it increases the number of handoffs in patient care and, therefore, enhances the risk that the circumstances of any given patient will be incompletely understood at this time.
In a busy OB practice, handoffs usually involve a meeting of obstetricians in labor and delivery to “run the board.” When participants attempt to make these handoffs as complete as possible, patient safety is significantly improved.
One way to ensure completeness of patient handoffs is to borrow training and skills from the world of airline pilots. There, crew resource management has introduced the concept of SBAR [Situation-Background-Assessment-Recommendation] as a specific tool to decrease risk inherent in handoffs.
Another helpful idea is attending nurses’ report sessions. These reports can provide you with useful information that you may not have recognized otherwise. By giving them your attention, you may also strengthen relationships with the nurses, your first line of defense.
Develop in-house call
Dildy and colleagues estimated that a call volume of approximately 2,400 deliveries a year would justify a hospital developing 24-hour in-house obstetric coverage.10 In our study, almost all of the hospitals that required in-house call did so because they had residencies, and in-house staff call was required.
Although Clark and colleagues found 24-hour in-house call to be safer than regular call in their review of closed perinatal claims at one large hospital chain, there has been a paucity of studies that confirm or extend our knowledge in this area.11
Hire laborists
Weinstein introduced the word “laborist” into our lexicon in a 2003 paper.12 Barbieri suggested the addition of “nocturnalist” or “weekendist” as possible terms to describe specialists assigned to work certain shifts that prove particularly onerous to practicing obstetricians.13 A number of hospitals and groups are examining and developing this call model.14 However, little research has been conducted on its effects on patient safety and obstetric practice.
For more information, visit www.oblaborist.org and http://obgynhospitalist.com.
Balance—that is the goal
For some of us, perfect balance between safety and patient satisfaction, and between work and home life, may be impossible. Nevertheless, we all need to explore ways to make call a safe and sustainable practice. For many of us, the growing recognition that we have more beautiful, sunny Sunday afternoons behind us than in front of us may be the signal to shift our focus to less demanding, and time-depleting, call schedules.
1. Schauberger CW, Gribble RK, Rooney BL. On call: a survey of Wisconsin obstetric groups. Am J Obstet Gynecol. 2007;196:39.e1-39.e4.
2. Dorsey ER, Jarjoura D, Rutecki GW. Influence of controllable lifestyle on recent trends in specialty choice by US medical students. JAMA. 2003;290:1173-1178.
3. Gariti DL, Zollinger TW, Look KY. Factors detracting students from applying for an obstetrics and gynecology residency. Am J Obstet Gynecol. 2005;193:289-293.
4. Deutsch A, McCarthy J, Murray K, Sayer R. Why are fewer medical students in Florida choosing obstetrics and gynecology? South Med J. 2007;100:1095-1098.
5. Bettes BA, Chalas E, Coleman VH, Schulkin J. Heavier workload, less personal control: impact of delivery on obstetrician/gynecologists’ career satisfaction. Am J Obstet Gynecol. 2004;190:851-857.
6. Pradhan A, Raman A, Lim C, Yoon E, Ananth C. The patient perspective. Is the hospitalist model a viable option for obstetric care [abstract]. Obstet Gynecol. 2008;111:40S-41S.
7. American Academy of Pediatrics and the American College of Obstetricians and Gynecologists. Guidelines for Perinatal Care. 6th ed. Elk Grove, Ill: American Academy of Pediatrics; 2007:157.
8. Clark SL, Belfort MA, Byrum SL, Meyers JA, Perlin JB. Improved outcomes, fewer cesarean deliveries, and reduced litigation: results of a new paradigm in patient safety. Am J Obstet Gynecol. 2008;199:105.e1-105.e7.
9. Bland ES, Oppenheimer LW, Holmes P, Wen SW. The effect of income pooling within a call group on rates of obstetric intervention. CMAJ. 2001;164:337-339.
10. Dildy GA, Clark SL, Belfort MA, Herbst MA, Thompson J. Twenty-four hour, in-house obstetric coverage in a community-based tertiary care hospital [abstract]. Obstet Gynecol. 2007;109:43S.-
11. Clark SL, Belfort MA, Dildy GA. Reducing obstetric litigation through alterations in practice patterns—experience with 189 closed claims. Am J Obstet Gynecol. 2006;195:S118.-
12. Weinstein L. The laborist: a new focus of practice for the obstetrician. Am J Obstet Gynecol. 2003;188:310-312.
13. Barbieri RL. Will the “ists” preserve the rewards of OB practice? OBG Management. 2007;199(9):8-12.
14. Yates J. The laborists are here, but can they thrive in US hospitals? OBG Management. 2008;20(8):26-34.
1. Schauberger CW, Gribble RK, Rooney BL. On call: a survey of Wisconsin obstetric groups. Am J Obstet Gynecol. 2007;196:39.e1-39.e4.
2. Dorsey ER, Jarjoura D, Rutecki GW. Influence of controllable lifestyle on recent trends in specialty choice by US medical students. JAMA. 2003;290:1173-1178.
3. Gariti DL, Zollinger TW, Look KY. Factors detracting students from applying for an obstetrics and gynecology residency. Am J Obstet Gynecol. 2005;193:289-293.
4. Deutsch A, McCarthy J, Murray K, Sayer R. Why are fewer medical students in Florida choosing obstetrics and gynecology? South Med J. 2007;100:1095-1098.
5. Bettes BA, Chalas E, Coleman VH, Schulkin J. Heavier workload, less personal control: impact of delivery on obstetrician/gynecologists’ career satisfaction. Am J Obstet Gynecol. 2004;190:851-857.
6. Pradhan A, Raman A, Lim C, Yoon E, Ananth C. The patient perspective. Is the hospitalist model a viable option for obstetric care [abstract]. Obstet Gynecol. 2008;111:40S-41S.
7. American Academy of Pediatrics and the American College of Obstetricians and Gynecologists. Guidelines for Perinatal Care. 6th ed. Elk Grove, Ill: American Academy of Pediatrics; 2007:157.
8. Clark SL, Belfort MA, Byrum SL, Meyers JA, Perlin JB. Improved outcomes, fewer cesarean deliveries, and reduced litigation: results of a new paradigm in patient safety. Am J Obstet Gynecol. 2008;199:105.e1-105.e7.
9. Bland ES, Oppenheimer LW, Holmes P, Wen SW. The effect of income pooling within a call group on rates of obstetric intervention. CMAJ. 2001;164:337-339.
10. Dildy GA, Clark SL, Belfort MA, Herbst MA, Thompson J. Twenty-four hour, in-house obstetric coverage in a community-based tertiary care hospital [abstract]. Obstet Gynecol. 2007;109:43S.-
11. Clark SL, Belfort MA, Dildy GA. Reducing obstetric litigation through alterations in practice patterns—experience with 189 closed claims. Am J Obstet Gynecol. 2006;195:S118.-
12. Weinstein L. The laborist: a new focus of practice for the obstetrician. Am J Obstet Gynecol. 2003;188:310-312.
13. Barbieri RL. Will the “ists” preserve the rewards of OB practice? OBG Management. 2007;199(9):8-12.
14. Yates J. The laborists are here, but can they thrive in US hospitals? OBG Management. 2008;20(8):26-34.