NOV 01, 2023
Question: Our regional hospital is the busiest Level 1 trauma center in the state. In order for it to maintain Level 1 status, it needs ophthalmology coverage, so we have negotiated generous payments in exchange for those services. Even with the pay-for-call situation, very few of us provide coverage, but we do it because of our ethical obligation to our patients and the community.
I know that some colleagues refuse to take call or provide ER coverage because of the time commitment and red tape involved. However, that freedom from responsibility ignores community needs, penalizes under- and uninsured patients, and unjustifiably overburdens those of us who feel morally obligated to care for all patients, regardless of their ability to pay or the time of night that they need care.
Additionally, because of ophthalmologists who will not accept Medicaid patients, approximately 20% of the local population is without any ophthalmic care. These underserved patients end up in the ER seeking care. Can on-call/ER coverage be mandated?
Answer: Not surprisingly, this is a question that comes up again and again. An enforceable mandate could only come from an entity that contracts for those physicians’ services, such as a local hospital or health care system. It is not per se unethical if one wishes to avoid on-call or emergency coverage and is willing to relinquish hospital privileges. However, withdrawal may diminish the local health care system's ability to provide emergent eye care with particular impact on vulnerable populations. For the individual ophthalmologist, there may be implications for recredentialing from certain third-party payers and potentially adverse effects on practice volume, professional reputation, and collegiality with nearby colleagues.
Hospitals have a certain level of responsibility in this situation. If hospitals have the resources to support considerable payments for on-call arrangements, then they likely have the resources to tangibly support minimum standards in terms of equipment and technical staff, to hire hospitalists (hospital-based ophthalmologists) or locum tenens to fill the on-call/ER coverage gaps, and to develop creative and sustainable models for after-hours care – all of which might make on-call service more appealing.
It is an ethical precept that a physician’s fiduciary duty is to hold patients’ interests above those of the physician. Ideally, physicians’ responsibilities would extend beyond care provided during business hours in medical offices or hospitals to any patients who are in medical need in times of emergency. Ophthalmologists should certainly provide after-hours care for their established patients, or arrangements for such by others. To routinely direct their own patients to an emergency room for after-hours care is likely not in the patient’s best interest nor in the interest of preserving a meaningful physician-patient relationship.
While there are no specific ethical guidelines for those who choose not to provide on-call or after-hours care for their patients, the potential for important consequences should be considered when making this decision.
Learn more at aao.org/clinical-education/redmond-ethics-center.
To submit a question, contact the Ethics Committee at ethics@aao.org.