Call Coverage: 6Strategies for Thrivingin Challenging Times

Mark Glass-Royal, a radiologist in suburban Washington, D.C., and Jerry Fosselman, COO of a 63-physician imaging practice in Sacramento, Calif., work on opposite coasts, but agree on one point: Radiology has never faced more challenging times. At issue isn't just ballooning workloads, shriveling reimbursements, or sluggish recruitment. It's managing call coverage in an era of do-it-now, 24/7 expectations.

"When I started working 18 years ago, things were laughable compared to today," recalls Glass- Royal. "There were nights when I didn't get called at all - not once. These days we get called 10 or 15 times a night."

Providing 24-hour coverage to a Maryland hospital that's growing fast keeps the 50-year-old radiologist busy. When he and his eight partners aren't tethered to the emergency department by pager, fax, or PACS, they are awaiting rotation on evening and/or weekend duty. It's a grueling schedule, yet one that thousands of radiologists sustain daily.

With coverage demands at an all-time high, we asked several radiologists to share their strategies for success. Here are the six best.

1. Serve your customers. Nighthawk's global reach - and the long-awaited emergence of Dayhawk - have fundamentally changed the landscape of radiology forever. No longer is a practice an island, nor a hospital part of its fiefdom. Groups that once dictated coverage terms to hospitals today find hospitals rewriting the rules with a perform-or-perish bottom line. The key to making coverage work in our 24-hour world thus begins and ends with exceptional customer service.

"Radiology is a service business that serves a number of masters, be they hospitals, referring doctors, or patients," Glass-Royal observes. When a hospital requests 24-hour radiology coverage, successful practices find a way to make it happen, knowing competition can come from the next city, next state, or a continent away.

Today's patients are similarly demanding. Educated and empowered, they expect "special" treatment, Fosselman observes. Treatment that's "good enough" just isn't. Customer service guru and radiologist Thom Meyer agrees. He champions customer service in radiology as a win-win proposition that "makes everyone's job more pleasant and less complicated." Don't do it for others, he says. Do it because it will make your life so much easier.

Practices that provide outstanding coverage inoculate themselves against outsourcing. A slow, lackluster response invites opportunistic competitors. Glass-Royal asserts that radiology long ago "dropped the ball" when cardiac catheterization and noninvasive vascular imaging hit the scene, and as a result other specialists today crowd the field. 2. Be a problem solver. Providing effective coverage goes beyond plugging holes in schedules. It means problem-solving with referrers in a cooperative, collaborative, collegial manner.

Communication is key. Practices that take time to educate hospital staff about the who, what, when, where, and how of sending and receiving reports reduce their own headaches down the road. A reporting system that is fast, simple, and bulletproof will always win the day over high-tech bells and whistles. Fosselman traces part of the coverage success of Radiological Associates of Sacramento (RAS) to its reliable fax system and request that hospitals send paperwork and pertinent notes with their images. RAS serves six counties, employs more than 60 physicians, and provides radiology services at 25 sites.

Be accountable. Anticipate problems. Keep hospital staff informed about the identity and location of coverage radiologists to eliminate those wild ED goose chases that torpedo reputations and contracts. Fosselman's Sacramento group keeps staff at five hospitals constantly updated about the location of its coverage doctors, "including who is on ‘mini-roost' coverage from 5 to 10 p.m.," he says.

Solving medical problems also means going the extra mile, says Birmingham radiologist Bibb Allen, vice chairman of the ACR Task Force on International Radiology. Radiologists faced with "concerning results" on a study should directly notify the referring physician or medical staff doctor. On a related note, maintaining a strong hospital presence and being available for consultation are fundamental to solving problems. 3. Hammer out the details. When today's newly minted radiologists identify lifestyle issues as paramount, it's no surprise many bristle at overnight or weekend call. The solution, experts say, is to begin employment screening by communicating expectations clearly. Reliable, flexible, and equitably apportioned coverage tends to yield a happier, more productive team. Conversely, coverage that is resented, crisis-oriented, and unfairly allocated sets the stage for conflict.

"All radiologists in our practice have to take some form of call," notes Arl Van Moore, Jr., MD, president of Charlotte (N.C.) Radiology and chair of the ACR Board of Chancellors. "If you're not working the overnights, you're certainly working until 2 a.m. on various shifts for things like interventional radiology." At its smaller hospitals, the North Carolina group maintains its own internal Nighthawk. This overnight person - a permanent shareholder - "is in the house reading and looking at exams from emergency practices for the enterprise," he notes.

Some radiologists naturally gravitate toward night work. Cullen Ruff, a radiologist with 70-member Fairfax Radiological Consultants in northern Virginia, says that "a handful of staff radiologists actually want to do the majority of our night work, with more time off [as compensation]." Typically, he says, these night owls work one week on and get the next week off. Other partners "take turns filling in the gaps." Ruff's group staffs three hospitals, and places at least one radiologist in house, overnight at Inova Fairfax Hospital until 8 a.m. He says all of the group's doctors routinely work weekends but "it could be every several days or infrequently." When a radiologist works both Saturday and Sunday, "they usually get a day off the next week. The idea is to share the load." In addition, all radiologists do occasional overnights until "at least they become partner."

Glass-Royal says Radiology Associates of Frederick, Md., approaches coverage with an egalitarian mindset. "Everyone works during the day, then most go home at 4:30 or 5 p.m., except for the person who stays on call, who remains in the house and available until 8 p.m." At 8 o'clock, the hospital's ED staff takes over responsibility for preliminary interpretations of plain films, while the practice provides late-night, at-home PACS coverage, and next-morning over-reads. So far, he says, Frederick Memorial Hospital hasn't asked for 24/7 on-site coverage - nor has the practice offered. "That's a lifestyle decision," he says. "If I have a choice between having the ED doctors do the preliminary or have [one of us] sitting there 24/7 looking at plain films, which would you choose?"

Radiological Associates of Sacramento long ago opted for internal Nighthawk coverage. "Doing anything less would open the door for the hospitals to find alternatives," Fosselman says.

4. Rally together. Coverage demands, large workloads, and a famously litigious society translate into significant, cumulative stress for radiologists. Practices that promote esprit de corps and a sense of "we're all in this together" tend to weather these challenges. By contrast, those prone to infighting and divisiveness are on borrowed time.

The willingness of each member to adapt to unexpected events makes coverage far less onerous for all members. Fosselman says the complexity of scheduling coverage at his Sacramento practice cannot be underestimated. Beginning six months before the next year, it entails coordinating the movements (and backup availability) of dozens of radiologists responsible for covering 16 imaging centers and several hospitals both day and night. "We also have to make sure the right specialty is at the right place and time," he says.

When a radiologist tweaks her vacation plans, needs to attend a son's football game, or is too ill to work, each member's exceptional camaraderie allows the team to flex as needed.

5. Know your group's limitations. Radiologists are an industrious lot, but all have their limits. Push too hard, too long and breakdown is inevitable.

While 24-hour coverage is not easy for any practice, its demanding, often unpredictable nature tends to affect smaller teams harder.

Before jumping into the 24-hour arena, members of small, rural practices should ask the big questions: Does our group have the wherewithal to meet the ongoing rigors of coverage? When staffing needs increase, will we be able to find a suitable candidate before tempers fray and "misses" notch upward?

There's no user's manual for call coverage. But if there were, accurately calibrating your group's strengths, weaknesses, and priorities would be on page one. If recent outsourcing history teaches anything, it is this: Bigger, though not always better, does confer competitive advantages. Small practices that lack the depth and resilience for 24-hour coverage may be forced to obtain Nighthawk relief. For some practices, this is a hard decision. For others, Nighthawk arrives as nothing short of a liberating army.

Teleradiology via PACS has revolutionized medical care, but small groups need to do their homework. "The big factor of taking call at home is the hospital waking you up in the middle of the night," Allen says. "Many people do not feel they're as good the next day, but small practices often don't have the luxury of giving you the next day off, nor can they always hire an additional partner." 6. Be sustainable; avoid burnout. Successful call coverage requires radiologists to think like marathon runners. John Cronan, MD, chairman of radiology at Brown University Medical School, believes burnout is a growing problem in radiology, owing to a production-line atmosphere, isolation, and maddening red tape. The more negative stressors in a radiologist's life, he says, the greater the need for soul-nourishing counterbalances.

Left to run its course, burnout can wreak havoc on clinical accuracy, reputation, health, and home life. "[Call coverage] is like everything in life - it's a balance issue," Glass- Royal observes. "You have to strike a balance between lifestyle, making money, and carrying heavy responsibilities for your hospital."

Often, the biggest battle is simply getting gung-ho radiologists to consider that something might be out of whack. Some radiologists may be able to put the kibosh on burnout by making a few minor lifestyle tweaks here and there. But in serious cases, reinventing one's professional and/or personal life may be in order. Warding off burnout also means getting proper nutrition and regular exercise, setting realistic work limits, getting adequate administrative support and, if warranted, seeking professional help.