On call for obstetrics--time for a change.

Thearticle in this issue entitled “Oncall: a surveyofWisconsin ObstetricalGroups”bySchaubergerandcoauthors is important, timely, and demonstrates a glaring problem that our professionmust address. It is remarkable that there isminimal information in the obstetric literature on how obstetrician-gynecologists structure their call responsibilities. The critical importance of the latter is that it profoundly affects patient safety, job satisfaction, lifestyle issues, professional liability exposure, and generation X and Y expectations for a career in obstetrics-gynecology. Theirfindings illustratedby this surveyofobstetrician-gynecologist physician groups speak to a number of issues that we as a specialty need to specifically address. The medical profession in general has recognized sleepdeprivationof residents in training as an important patient safety issue, and regulations have been created to deal with this. However, it is remarkable that this has not yet emerged as an issue for practicing physicians who provide the bulk of patient care. This survey found that Wisconsin obstetrician-gynecologists cover for an average of 5 physicians while on call, andcalldurationaverages24hours.Only26%hadprovisions for reduced work hours after being on call, and only 18% restricted themselves from major surgery the following day. The dangers inherent in these long work hours are well documented. Evidence supports that working 18 hours is equivalent to driving with a blood alcohol level of 0.08, the national standard for impairment.Militarygunnerswhoaredeprivedof sleep formore than 24 hours can hit their targets but often shoot at the wrong targets. Another important patient safety issue identifiedwas the inability tohavea rapidresponse teamavailable for themajorityof laboring patients. Eighty-eight percent of respondents were not required to remain in the hospital when on call, and of the 12% that remained inthehospital, themajorityof theseweresecondary to ACGME requirements for residency supervision. Despite ACOGguidelines for “immediate availability” for laboringVBAC patients, 20%of respondentswere not in house for these patients. A substantial proportion of call groups required obstetric coverage at more than 1 hospital, clearly not a practice that supports patient safety. Also, the authors discovered that having a formal back up call identified is an uncommon practice. WhileWisconsin isnotastatedominatedby largeurbancenters and thusmay differ in the way call coverage is provided, our own experience would suggest that the information reported in this paper is not substantially different from many other practices in other areas of the country. As a specialty we need to carefully look at our current methods of practice as related to prevention of medical errors before we ask legislators and insurers to provide relief from outside pressures such as professional liability issues and reimbursement. Theauthorspointout, andwestronglyagree, thatmoredataare needed to provide us with information on how our night call and otherworkpractices affect patient safety, lifestyle, andother issues important to our professional lives. We need to realize that professional liability issues, burdensome paperwork, and inadequate reimbursement are not the only factors negatively impacting the well being of our profession. A recent gathering of themost influential organizations in our specialty concluded that lifestyle was the singlemost important issue that drivesmedical students away from obstetrics and gynecology. This is the common theme among generation X and Y professionals. In obstetrics and gynecology and in medicine, in general, very little impacts lifestyle more than longwork hours. It is critical that we address this issue for the future of our specialty. Once we recognize that these common call practices are a detriment to our patients, our own lifestyles, and the future of our specialty, we will then collectively need to come up with alternatives that address these problems. In our opinion, such alternatives includeamovetoamore formalizedandwidespreadpractice of havinghospitalists or laborists, as has occurred inother specialties, or call alternatives that create reasonable shifts ideally located in house. This would allow individuals to work fewer hours in a controlledmanner.Allowing job sharing for physicianswhowant to placemore emphasis onhome and familywould also provide a welcome alternative for many. We need to turn to our liability insurance providers to provide relief in order to allow us to proceed in these new directions. One option is to have an individual physician slot that can befilled by several practitionerswho, combined,make 1 full-timephysician. Such solutions have the potential for a real “win-win” result with improved patient safety, decrease in preventable medical errors, better lifestyles, and improvement in the long-term health of obstetrics and gynecology as a specialty. Making these changes will go far in asking for public support for an improved tort system. “Salus populi suprema lex—the people’s (our patients’) safety is the highest law” and should be our highest priority. f