One of us, Jeffrey M., is on weekend call for our office-based internal medicine practice. It is midafternoon, and a patient leaves a message with our answering service — she is concerned about her mother’s respiratory symptoms.
So, Jeffrey interrupts his late lunch and rings her back. As she explains that her 96-year-old mother has a harsh cough and nasal congestion, he hears both the facts and the worry in her voice. After a moment or two of symptom description, she says that her deepest concern is preventing a visit to the hospital that she knows will be disruptive, frightening, and risky.
Together, they create a treatment plan and Jeffrey reminds her that he is available for the rest of the weekend, in case her mother’s condition changes and she is uncertain what to do. She thanks him sincerely with a calm tone that reveals that she is reassured. The call ends with a rewarding feeling that Jeffrey has done something meaningful for a person who is feeling distressed and vulnerable at an off hour when access to familiar clinicians and office staff is limited. And in a labyrinthine health care system that is increasingly difficult to navigate, this distress can be profound.
For every successful on-call experience, though, there have been many when neither of us was at our best. During training and throughout our primary care careers thus far, being on call has just come with the territory of doctoring. It is often exhausting and can be unnerving when the patient’s sense of urgency does not match the doctor’s-eye view of the clinical situation.
In recent years, the tide has turned; relieving primary care clinicians of after-hours duty has become a priority and part of a long-overlooked focus on clinician well-being. Many other specialties have already figured out ways to make work more predictable with appropriate downtime: Emergency medicine clinicians work shifts; obstetrics has switched to a laborist model; hospitalists have split into daytime hospitalists and nocturnists. We would not dream of asking an emergency medicine clinician to take calls from home after a shift is over, yet the assumption has been that primary care clinicians who are already overburdened should provide fragmented, interruptive after-hours care.
For clinicians, the task load in contemporary electronic health record-equipped, value-based primary care has expanded and increasingly infringes on personal time, while the pandemic has inspired many clinicians to rethink their work-life balance. Primary care practices are charged with doing too much with limited resources and comparatively inadequate reimbursement. Patients are best served when there is some form of after-hours care that provides continuity, yet with a dwindling supply of primary care clinician candidates, health systems that want to hire competitively can’t demand the same kind of on-call duties they once did. This is the world we are in.
But there are solutions.
One approach is to build more sustainable rotations that include recovery time for the on-call clinician. The drawback here is loss of productivity, since after-hours call volume is unpredictable and usually far less than daytime hours when visits can be scheduled. Traditional phone-based after-hours care also offers no reimbursement option, no matter how complex the interaction.
A better approach may involve leveraging telemedicine technology. Rather than sending these calls to a clinician in the practice working overtime after a full day, calls can go directly to virtual care clinicians on shift — primary care-trained doctors or nurse practitioners who have chosen a non-continuity career path with more regular hours. Primary care clinicians would no longer need to be “on-call” for their practices and can be kept informed of any issues managed by the virtual group. Patients would still have access to after-hours care as they always have, with the added opportunity for video visits. The health system we work for now is piloting such an approach.
Patients may perceive any new after-hours care process as a loss of something comfortable and familiar. Yet they will likely receive improved care when clinicians providing the care are not stretching themselves beyond a full work schedule. After-hours care should not be an afterthought, but rather a seamless extension of the same high-quality health care they receive during regular office hours.
After-hours encounters may become reimbursed virtual appointments scheduled in a short time frame and offering more thorough assessment with clinicians than typical on-call phone conversations. Patients can retain team-based, integrated health system continuity at any time of the day or night without leaving their homes. Alternative options must be available for patients who have insurance constraints or barriers to using the required technology for virtual care.
It will be illuminating to survey clinician and patient experience once an updated process begins. Will having a dedicated after-hours care team reduce unnecessary use of urgent care or emergency room services? Will the addition of video interaction add value from the patient’s perspective? Will this process improve patient outcomes and/or reduce the cost of care? Will primary care clinicians report an improvement in their quality of work and overall well-being?
As primary care continues to evolve and improve, it helps to take stock of what was edifying in the previous world. The vivid experience of hearing patients’ and caregivers’ anxious voices on call and helping bring them to a place of comfort has been onerous, yet at times uniquely gratifying. But tradition in this case must give way to innovation and improvement. Patients deserve an on-call team that is ready to address their concerns whenever they arise, and clinicians deserve the opportunity to rest and recharge.
Jeffrey Millstein, M.D., is a primary care physician and regional medical director for Penn Primary Care. Jeffrey Tokazewski, M.D., is a primary care physician; medical director, Penn Medicine On Demand; and associate medical director for clinical informatics — Penn Primary Care and Penn Specialty Practices.