Taking call as a solo doctor, and getting help for challenging cases as a solo doc

We were recently in Chicago for the Illinois state society meeting and led a roundtable discussion about solo practice as well as what life is like for an attending for the residents in attendance. Not surprisingly, they were sharp and asked some good questions about solo practice.

What is taking call like as an attending? If you are in solo practice who takes call for you?

Taking call in a private practice (or even academics) is very different from taking call as a resident. It depends on if you’re only on call for the patients in your practice, or on call for a hospital also. If you’re on call for a hospital, it depends on if the hospital is a level one or two trauma center and if call includes inpatient consults.

For the patients in your practice, often what happens is that local physicians, either solo or in small groups, get together to split weekend call duty. In my group job, the four of us plus about four other doctors that operated at the ambulatory surgery center chose to cover weekends for each other. Some of the doctors at my ASC simply chose to cover their own patients.

So I was on call for about five weekends per year plus two holidays. During the weekdays, we cover our own patients. Both on weekdays and weekends, it’s very unusual to get calls, usually they are quick questions. We only have to go in a few times every year.

In my solo practice, I take my own call. If I am out of town, my receptionist is there during the daytime to screen calls and contacts me should the need arise. If it’s after hours, the message box forwards to my cell phone so I can handle it accordingly. Again, there are relatively few calls.

If the patient needs to be urgently seen, I have friends in town that are comprehensive ophthalmologists that can cover for me. Most emergencies are retina related, and the retina doctors that I refer to are more than happy to help out. If you’re retina or oculoplastics, find someone else in town that is willing to help out. This is true even if you join a group and are the only retina or oculoplastics doctor in the group- a glaucoma specialist may not be the expert at looking at your vitrectomy or ptosis repair postops!

Most docs are happy to help out not only because they want someone to return the favor when they go on vacation, but also because it’s different from residency in that they get compensated for when they seen the patient.

It is a different story if you are on hospital call. When I was a resident, I remember being in the hospital all day on January 1 doing consults after all the New Years Eve traumas. Same for many weekends at the county hospital, I often had to work nonstop.

My first job with the government (Indian Health Service) we took call for the hospital ER as well as inpatient consults. Unlike the county hospital for my residency where the ER docs were pretty good at handling and triaging eye problems, the immediate reflex of the IHS ER was to phone us without any attempt to figure out what was going on. Still, it wasn’t anywhere near as busy as residency because it wasn’t a trauma center. I was on call about every fifth night and weekend, but only had to go in maybe every other weekend when I was on call.

Some solo docs, especially when they open their own practice and aren’t busy, take a lot of hospital trauma call to generate income to keep their practice afloat. In some parts of the country, taking hospital call is a requirement to be on hospital staff. If you are taking call, you should definitely be paid for it, as a solo doc directly from the hospital. Even if it’s a requirement to be in staff, you should still get paid for doing it. How much per night depends on if the hospital is a level one or two trauma center.

The hospitals get a lot for becoming a level one trauma center, and their administrators and staff sure don’t work for free. Neither should we, especially if we are the ones doing the after hours heavy lifting.

If you are on call to do inpatient consults this should be paid separately from ER call. As every ophthalmology resident knows, it’s labor and time consuming to take your equipment to the hospital and the exam there isn’t as thorough as what can be done in the office.

If you are employed, make certain that your contract spells out what compensation you will receive for taking call. Don’t do the heavy lifting and let your employer pocket the money the hospital is paying them.

The bottom line is that call duties shouldn’t discourage you from going solo. Just like if you worked in a group, someone can cover for you.

If I have a patient case that clinically don’t know what to do, how do I handle it as an attending? If I am solo does it mean that I manage everything myself without any help?

During my internal medicine residency internship, my program director had a favorite saying: “the two years you learn the most are in your internship and your first year as an attending.” I don’t remember much about internal medicine, but I found this to be absolutely true.

Residency isn’t a be all end all for ophthalmic knowledge. There’s no way you’ll learn everything. Rather, it should be a solid foundation of knowledge that you can continually to build on as the the practice of medicine evolves. Without the knowledge and expertise acquired in the many hours committed and numerous cases seen in a rigorous residency and perhaps fellowship, there’s no way you can continually to keep up with current techniques, clinical trials, and surgical methods.

While you must acquire enough knowledge during residency training to be able to work independently as an attending, one important thing is to know the limits of your knowledge- you need to know what you don’t know so you won’t do anything dangerous- and to refer it out to someone appropriate.

Other times, there is a debate in the art of medicine and it helps to hear different opinions from different docs; once you try several methods you’ll find out what works best in your hands.

Working in a group my first two jobs, I definitely took advantage of the knowledge of my colleagues. During my first government job I sometimes had another surgeon about ten years out of training observe my cases and give me tips to make my surgeries more efficient. He also helped me out with patients in clinic I had questions on. But the quality of the people in your group may vary. There were definitely some that I actively avoided seeking help, and in fact was frequently called on to fix their mistakes.

Even if you are in a group, if you are the only glaucoma specialist in the group, or the only oculoplastics doc in the group, who are you gonna run your tough cases by? It’s not like the cataract surgeon in the group is going to discuss the nuances of blepharoplasty with you.

In addition to practicing comprehensive ophthalmology, I also do some medical retina. In my government job, we didn’t have a surgical retinal specialist on board. I was constantly picking the brains of the surgical retina specialist we referred to for knowledge about medical retina.

There is a fear that if you’re solo, you won’t have anyone to run cases by. But nothing could be further from the truth. Your mentors from residency and fellowship, your colleagues in the community, your co- residents and fellows, are all a phone call or email away. And in private practice, other doctors are usually more than happy to see your patient if you refer them. You can see at nationwide conferences even department chairmen need to sometimes run cases by each other, or have debates over the best way to handle a clinical situation.

There are also many resources on the internet available such as the ASCRS listserv or kera- net for cornea. Indeed, one of the best things about our google group for solo eye doctors is that we run our difficult cases or clinical conundrums by each other.

We are constantly asking each other questions such as the best premium lens to use for a specific case (or whether to use one at all), whether my psuedotumor cerebri patient needs to be referred for a shunt, about surgical techniques for glaucoma, etc. The discussions we have are on a very high level, and I am constantly amazed at how much my colleagues know about details and nuances in the various ophthalmic subspecialties.

Regardless of whether you are solo or in a group, find like- minded colleagues who are willing to share information to help each other out.

Again, the bottom line is that you while you need to take every advantage of residency and fellowship to gain a strong base of clinical knowledge and decision making, this base evolves as you practice and perform surgeries. This is true whether you are solo or in a group, and there will always be people in your specialty or even sub specialty willing to help you, regardless of whether you are solo or in a group.

It is a myth that being in a group means you will always get useful help for every difficult case, and that if you’re solo, you’re on your own. Fear of not getting help with difficult cases shouldn’t dissuade you from going into solo practice.