Standing in your office are two quite upset surgeons, one anxious and the other quite angry. There is a dispute about the now overdue call schedule for their specialty over the approaching summer. The senior member of the four-person group has announced he is going off call for nights and weekends but the other three do not agree. It seems some of the larger specialties allow such change at fixed ages and an assumption has been made this must also apply in this small surgical division. All four have different views and there is no call schedule.

A certainty as anyone ages is a gradual decline in stamina, slower recovery from lack of sleep and a desire to simplify one’s life. This need varies dramatically from one person to another and its impact on practice will vary by specialty. Since age is not a clear measure of competence, many hospitals have introduced programs to monitor physician performance and policies to deal with any emerging concerns. The following discussion is directed towards the reverse situation where a physician is determined to change their involvement in their usual workplace in the hospital.

Currently, most physicians work in a team-based environment while at the hospital. The practice of most physicians evolves over time with a refinement of their scope of practice. This is accelerated later in life, often with changes in complexity and volume. This can be a problem if there are agreed upon volumes of specific services to be delivered such as cancer care or hip replacements. Along with a more managed approach to care delivery may come specific local or regional call obligations. There will be tension between the physician wanting to change personal obligations and colleagues or hospitals who must maintain current obligations.There will be resistance to change if it leads to instability.

The status quo in most hospitals is governed by by-laws plus related rules and regulations. When things devolve down to the front line team the local rules governing change are often unwritten and are based on precedence or seniority. Change comes about through negotiation, often at great personal cost. If there is a problem it will usually land on the chief’s desk, who will then be guided by current policy. If there is no policy, then there may be difficult negotiations which may damage workplace cohesion or result in the subject physician leaving for practice elsewhere.

The solution is to mitigate the risk of a destructive exchange by having in place, before the problems arise, very clear guidelines based on by-laws and existing rules that are specific to and developed by each team that reflects their workstyle and culture. Guidelines for a surgical group are unlikely to be a good fit for a psychiatric group. The process will be similar but the outcomes will vary. Guidelines can draw on precedent for each group but should be developed absent of conflict and consistent with hospital and medical staff policy. Some elements that might be included would be on-call obligations, resource allocation such as clinic time, volume of work, access to funding and others specific to the group.

The goal of quality care and reasonable access can be balanced with a physician’s desire to retire gracefully. If it turns out that the routine monitoring process noted at the beginning of this discussion identifies an individual of concern the agreed upon options for slowing down may lead to a planned and less conflicted career end.

Comments

Be the first to comment on this!