Narrative Inquiry in Bioethics

Almost all physicians take call as part of their job. Call responsibilities can be broadly divided into two categories: responsibility for a physician’s own patients after hours and providing coverage for hospitals and emergency rooms (ERs). It is the second of these which is by far the most contentious. Call arrangements between physicians and hospitals vary greatly based on physician specialty, employment status (hospital employed vs. private practice), and local health care market conditions. In general, physicians would prefer to take no ER call, as patients who come to the ER for health care tend to have no insurance or Medicaid and tend to come at inconvenient times, while hospitals would like [End Page 72] private practice physicians who operate or admit patients to the hospital to provide call services for free. Hospitals are required by law to provide care to patients who come to their ER and would like to provide specialist care as cheaply as possible. Some specialists will end up being paid to take call, while some will be forced to take call for free in order to have privileges at a hospital, depending on local supply and demand conditions. As a specialist in Otolaryngology, otherwise known as Ear, Nose and Throat, who is employed by a university, I am required to take uncompensated call on a rotating basis (one week at a time) for the university hospital and its ER. It is important to note that the hospital is not owned by the university, but rather by a for–profit hospital chain. This case illustrates the complex economic and legal forces that shape the magnitude of call responsibility.

Two years ago, a simplified referral center for outside physicians was instituted by my hospital, with the stated aim of increasing patient referrals from other hospitals. A single number was provided for referring physicians, including outside ER physicians, to utilize, if they wanted to transfer patients. I learned later that of particular interest to the hospital were stroke patients, who tend to be insured (mostly Medicare) to facilitate growth of a Stroke Center, which offers thrombolysis (clot busting) and other well–reimbursed services. I was informed by my Chairman of ENT, who, like myself, is employed by the University Medical Group that exclusively staffs the for–profit hospital owned by a publicly traded company where we work, that our department’s attending physicians would now be taking direct calls from emergency rooms in the region to provide advice and facilitate transfer when necessary. Previously, we were only responsible for cases that physically showed up in our ER or were transferred to us by other ENT physicians (a rarity). I was told that I would have discretion over which patients to accept in transfer and which to reject; no further guidance was given.

My first week on call under the new system was unbelievable. I was receiving several calls per night from emergency room physicians who did not have ENT coverage at their hospitals, asking for advice or for me to accept their patient in transfer. I was extremely leery of providing advice at hospitals I did not have privileges at and, as was frequently the case in a neighboring state where I did not have a medical license. Illinois, from which the majority of these calls originated, is an area known to have the worst medical–legal climate in the U.S., particularly the adjacent Madison and St. Clare counties. My response was to refuse to take direct calls from outside ER physicians, which constituted 95% of the calls, on the basis that I did not have privileges at the hospitals in question and thus could not be responsible for taking ER call at these outlying hospitals. This was met by a harangue from my Chairman and then another harangue at 3 A. M. from the Hospital CEO for refusing to accept in transfer every ER consult. It became obvious that I was not allowed to use my medical or ethical judgment but was instead being forced to accept all ER consults and transfers in the name of growing patient volume. This struck me as odd...