It is challenging to accept the degree of uncertainty that dominates the near horizon of my future. For the first time, I find myself as a doctor without a checklist of next steps. As a stopgap, locums work is intriguing because it represents an opportunity to expand my clinical acumen, but the cost is continued instability.
In an attempt to find a more definite path forward, I recently spoke to an anesthesia group in a town that might suit my family. The primary suburban practice is negotiating to take over a rural hospital that has struggled with anesthesia staffing in a model that is doomed to fail under the compensation structure of the parent group. Because anesthesia billing is based on time increments, survival of an anesthesia group mandates efficiency system-wide. Rural health systems are rife with time inefficiency not because they are mismanaged but because there is mismatch between availability of resources and utilization. The most cost-effective models are ASCs, where all paid staff are working to generate revenue and then the facility closes, or like tertiary care centers with enough revenue-generating work to keep staff around the clock without incurring a significant loss, especially given the premiums required to incentivize after hours labor. Enter the concept of being "on call." The question is how to compensate for availability in such a way that it's not too arduous for the system or the staff; an error in calculation creates an existential threat either because underutilized staff incur unsustainable financial losses or because inadequate compensation for excess availability causes an exodus of willing bodies.
The time frame of availability also matters. Emergent availability is required for work that alleviates threats to life or limb, like police or firemen … and doctors. In the former careers, availability is considered fully part of the work itself. This means that my husband, a firefighter, works for 48 hours straight and is paid for all of those, regardless of how many are spent on actual calls. His schedule – two on, four off – means that he works roughly 60 hours a week. But it feels like an easy schedule for us as a family relative to my work, when my 60-hour weeks have counted only actual patient care and my availability hasn't counted at all.
Historically, physicians' all-hours availability was compensated by elevated social status. The locus of non-financial value was in the doctor-patient relationship(s) and separate from the fee paid for the work of doctoring when it was required and performed. As our interventions have become more successful at preserving life and limb, we have been pushed farther away from the individuals whose lives and limbs we are preserving, eroding the social value of the work and leaving only the fee. Those fees are high in part to compensate for the time required to become what society deems an appropriately proficient physician. Furthermore, the safety and competency of medical care has increased demand in non-emergent and elective circumstances. Meanwhile, our health insurance industry operates on the opposite framework: higher reimbursement for elective procedures and less for emergent ones, including no compensation at all for access to those services at all hours. Our availability, like our safety and proficiency, are taken for granted by everyone in the conversation.
Americans tend to be true believers in the ability of market competition to right myriad wrongs, but in this scenario, competition exacerbates the problem and compounds inefficiency with respect to staffing overhead as availability across the system as a whole has dramatically increased. Physicians' acceptance of call as "part of the job" has failed to check the excesses of the health system in its demands for our time. Availability of care is one of the drivers of market competitiveness and yet the pressure on physicians created by that availability remains wholly uncompensated by the biggest winners in the game: hospitals and insurers. After all, why pay for something that has so long been given away for free?
I said as much in a recent meeting. For the eight days prior I had provided 75 hours of patient care and an extra 46 hours of immediate availability for patient care. For each of those extra hours I was within 30 minutes of being at the hospital ready to save someone's life. Which also means I was within 30 minutes of being pulled away from my life – from my child with a bloody lip or a fight with a sibling, from sex with my husband, from tea with a girlfriend going through a divorce. But who am I kidding? After a decade I just don't bother to schedule things at all, and I pay surrogate caregivers even when I am home in "just in case."
Many physicians can relate, since call is a burden almost all of us share. Over a lifetime, with no interruptions, total lack of control becomes death by a thousand paper cuts to a marriage, or a friendship, or a lifetime of disappointment for a child whose parent can never guarantee that they come first. And as the system's expectation of availability increases, control decreases in a directly inverse proportion.
Thus, I circle back to the one option that offers a solution to the availability problem: locums work. As I learn my way through my first locums contracts, I would never dream of taking call for free. Nor would the systems expect me to, and yet that was expected in every other job I've ever held. What I don't have to argue anymore is that my availability is in and of itself valuable. Now, though both parties still assume there is a difference between working and being immediately available, the relative ratio of value is overtly negotiable. And I suspect my experience may be axiomatic of a valuable lesson the whole system needs to learn.
What do you think "availabilty" should be worth? Share in the comments.
Shannon Meron is a private practice anesthesiologist in Vail, CO.
Image by Comstock / Getty
