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Internal medicine physician Corinne Sundar Rao discusses her article “Physician on-call compensation: the unpaid labor driving burnout.” Corinne argues that the term “call” is a euphemism used to extract free labor from employed physicians who no longer own their practices. She highlights the discrepancy between the historical obligation of private owners and the modern reality of hospital employees who face legal responsibility and sleep deprivation without compensation. The conversation contrasts the regulated rest of pilots and truck drivers with the expectation that surgeons work overnight and operate the next day. Corinne calls on administrators to treat call as measurable, billable work with mandatory post-call rest to stop the exodus of medical professionals. Discover why changing the language of labor is the first step to fixing the burnout crisis.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome back Corinne Sundar Rao, internal medicine physician. Today’s KevinMD article is “Physician on-call compensation: the unpaid labor driving burnout.” Corinne, welcome to the show.

Corinne Sundar Rao: Kevin, thank you for having me. It is a pleasure to be on.

Kevin Pho: All right, so what is your latest article about?

Corinne Sundar Rao: So the latest article actually was first a post that I made on LinkedIn. I was a little bit surprised when it started generating comments and reactions and I started receiving messages. When I wrote that, I wasn’t trying to be provocative. I was just trying to name something that most physicians have lived for years, but we rarely articulate it.

When it resonated, it was not because the experience was new, but because it is shared. It is shared across specialties, across different practice models, and across generations. Physicians recognized it and they started reaching out, at which point I then turned it into a KevinMD article because I thought that it needs more reach. So here I am today to talk about that.

Kevin Pho: Now for those who didn’t get a chance to read your LinkedIn post or the article in KevinMD, what about the article generated such a reaction?

Corinne Sundar Rao: Looking back, I think there was a couple of things. One, as I mentioned, it is such a shared experience that it is largely something that is invisible to those that are outside of medicine. But when you name it, physicians recognize it immediately. The other thing about it, Kevin, and this part maybe surprised me a little bit, was that a lot of physicians linked it to burnout.

We talk about burnout a lot. We have talked about different factors such as losing autonomy with physicians getting employed, long hours, EMR systems, metrics, and a whole bunch of different factors. But what I heard from a lot of the physicians was that call was something that was somewhat of a driving factor when they tried to look back and see what it was about their burnout. They asked themselves what it was that made them so tired and so discouraged, and it emerged as call. Like I said, that kind of surprised me a little bit.

Kevin Pho: And you specifically mentioned that the term call is just a euphemism to extract free labor from employed physicians who no longer own their practices, right?

Corinne Sundar Rao: Yes. And it actually extends even across that spectrum. When you look at certain specialties, mostly our surgical specialties, Kevin, they aren’t always employed. It could be a large group that is providing certain specialty coverage to the hospital. But in order to do that and in order to operate, they have to be part of call. They have to take unassigned patients from the emergency room. The reason being obviously the hospital needs those patients taken care of. So that is kind of how it grew. It has become something where it is just baked into the system and it has just been absorbed. It has become something that physicians are finding is not really sustainable for them long term.

Kevin Pho: There is not a lot of choice for a lot of these physicians when they are asked to take call because hospital privileges are tied to them taking call for that hospital, right?

Corinne Sundar Rao: That is correct. So it is one of those things that is just so unique. Just to practice what you are trained to do, you need to be taking call. What emerges is that to make it OK or to make it so that it is sustainable, it needs to be a defined shift. It needs to be compensated as labor. I think that is what was coming out about the article.

Because what it is currently is basically invisible work. It is work. You are on standby. You show up and you have to be ready to do what it is you do. The next day you just kind of carry on. You carry a full patient load and you are expected to just keep going. I cannot think of any other profession where this occurs. An analogy I made in an earlier post was about pilots, just to show that pilots have defined rest periods because they carry a lot of lives in their hands. One could say it is the same for surgeons. They have high-stakes decisions. They are carrying a lot of weight behind that. Why is it OK for surgeons to work without rest and without sleep and be expected to just perform?

Kevin Pho: Now, of course, historically, physicians have taken call pretty much forever. Why does the historical justification for being on call no longer apply to today’s physician? What do you say to those physicians who say we have always done it and ask why you can’t do it now?

Corinne Sundar Rao: For a lot of reasons. In the seventies and eighties, hospitals started having 24/7 availability. In order to have that, they required physicians. Now things are not as simple as they were even earlier. You know about family physicians that took care of their own patients, whether it was in clinic or rounding in the hospital. Then they went and did an entire clinic day and then they came back and saw their patients.

But if you look at it today, Kevin, it is not sustainable. A very good example of this, which I do mention in my article, is the hospitalist model. That grew not because it was a philosophical thing, but it was just not working. It was not a function of the system. No longer could we expect physicians to do both.

That is where the distinction began. It was actually in 1996 that the word hospitalist was first defined in a New England Journal of Medicine article. I mean, it was occurring before that, but then it started becoming more popular. I think what is really important is what the hospitalist model did is it turned the same work into a defined shift.

So that shift became finite. Like it ends at some point. The thing about call is it is endless. You are tethered. You are taking call for yourself and your group of physicians and one day goes into the next and it is just not doable. So to answer your question, I think the hospitalist model is a really good example because yes we did it a certain way, but that way can no longer work in today’s complexity of medical care.

Kevin Pho: Well let me say I do agree with a lot of the feedback that you have received about call simply being uncompensated work. From a practical standpoint, you can anticipate some of the responses from the hospital if physicians don’t take call. The hospital would likely have to find someone who takes that overnight shift, not only for procedures but also for primary care as well. Given the clinician shortage, that is going to cost money and it is difficult to find someone to take those overnight shifts. So what are some of the answers you could give to these anticipated responses that I am sure you are going to hear from hospital administrators?

Corinne Sundar Rao: Let me start in reverse. If we don’t make any changes, what we are seeing is that physicians are burning out and they are quietly disappearing. A lot of them are finding other things to do. They are going part-time or going into direct care models, concierge, or nonclinical medicine.

So they are just quietly going to disappear and that is not going to help your shortage either. I think it would be better to have that narrative more defined and more spoken about because this is what the physicians are telling you now. When it comes to the cost, one thing that often gets missed but is true is that physician compensation is actually only around 8 to 8.6 percent of the total health care costs in this country. So to anybody who thinks that we make up the majority of this cost, it is not true.

Again, I am going to refer back to the hospitalist model. Rather than expecting primary care physicians to do everything, which you just cannot do anymore, the system did make those functional changes. There is no reason why other specialties couldn’t start to do that. In fact, we are already seeing some of them doing it. They are just not as widely accepted as the hospitalist model.

Kevin Pho: And I know that just as hospitalists were invented back in the nineties, now we have nocturnists, right? People taking overnight shifts for obstetrics, for instance, that tend to get a lot of calls at night.

Corinne Sundar Rao: Yes. So obstetrics is a great example, Kevin, because it is a high-risk specialty. It is very labor-intensive. You are doing surgeries, you are doing clinic, you are doing GYN, and then you are also delivering babies.

What they call it is actually a laborist model where there is a physician who is just going to take care of the laboring patients in the hospital so that the other physicians are able to take care of their clinic patients and their elective surgeries. This has actually already been ongoing since I want to say early 2000. It is again not widely accepted, but there are certainly high-volume and high-acuity hospitals that have adopted this.

Kevin Pho: Now, whenever physicians say they should be compensated by taking call, you are going to get pushback from people who think that physicians value the money more and the calling of being a doctor includes taking care of patients all hours of the day. How would you advise physicians to respond to that typical pushback by those who don’t understand the nuances of the situation?

Corinne Sundar Rao: So it is true that our altruism and because most of us went into medicine, we felt like we needed to help people and that is what we wanted to do. That is absolutely true, but on the other hand, we can’t expect that that resource is just infinite. We are also human beings and we have the same needs as any human being to rest and to recover. We cannot simply just continue to do work that is not compensated and that is a pain point.

Call, Kevin, has been either without any compensation or minimally compensated. It shouldn’t have been that way, but we absorbed it and we kept going. This is where we are at today. It is actually labor and labor has to be paid and has to be fairly compensated. So it is no different. That does not take away from the fact that we still want to help patients. It is just not doable in the current way that it exists.

Kevin Pho: Are you aware of any systems that compensate for call or hire overnight physicians to take over call for a primary care group or a surgical group? Are we making inroads of getting that call time better valued?

Corinne Sundar Rao: I think there are places where they do this basically out of necessity because they find it so difficult to recruit. Let’s face it, if you are a smaller rural or community hospital and you are trying to recruit one specialist, it is going to be really hard.

So you have to balance what you are losing. You are losing access to that care that that specialist would provide to the patients in your community because you just want to continue in a model that doesn’t work in this current system. So you would be better served to answer your question directly. Yes. I think some larger groups do have some leverage and some negotiating power to say: “Look, it is not that we do not want to take care of your unassigned patients. Medicine is 24/7. It is not a daytime thing or weekday thing, but this is what we are willing to do for our group to be available.” There has to be some reciprocal meeting back at that point.

So I think those conversations are happening. Are they happening a lot? I don’t know, but I do hope that the narrative starts to shift, especially when we keep talking about burnout. Physicians are telling me that this is one of the big factors that led them to burn out. They didn’t want to stop seeing patients or leave medicine, but they also could not just continue to be on call.

Kevin Pho: We are talking to Corinne Sundar Rao, internal medicine physician. The KevinMD article is “Physician on-call compensation: the unpaid labor driving burnout.” Corinne, as always, we will end with take-home messages that you want to leave with the KevinMD audience.

Corinne Sundar Rao: Kevin, the take-home message is that call is not an infinite resource. Call is labor and labor must be paid fairly, transparently, and with built-in rest protections. So I think it is time to legitimize that narrative.

Kevin Pho: Corinne, as always, thank you so much for sharing your perspective and insight, and thanks again for coming back on the show.

Corinne Sundar Rao: Thank you, Kevin, for having me.