I hope everyone is doing well out there and having a blessed day. I wanted to start a discussion to see what others thought about calling the MD at night and what has worked for them when night shift doctors are crankier than usual as well as prioritizing when to call and when not to call. I recognize that day shift nurses have more direct access than night shift nurses so calling the MD or speaking to an MD can be frustrating at night when they are off their sleep schedule. We, the rest of the nurses, try to group our calls together so we can minimize the number of pages, but also end up endorsing some of our items to day shift depending on how important it is. I just notice that real world is not always like NCLEX and wanted to get more of an idea on what works and what does not.
The way I see it, the on-call docs are being paid to be on call. Why not call them after hours?
Many, if not MOST, providers are actually not directly compensated for time on call, because call is a money suck and most small practices cannot afford to pay. Yes, their overall salary is high, but on call hours are not usually factored in to the average "hourly wage" that providers make. Obstetrics is an expection, as it is a specialty with one of the highest on-call demands in terms of actual presence in the hospital. The CNMs I work with as a student are compensated 18 hours for every 24 on call, and we spend the entire 24 at the hospital probably 85% of the time. My full time work week (I am a student CNM, following a FT CNM) is 50 scheduled hours (averaged over 4 weeks). And of course, being salary, we can usually count on a minimum of 4 additional hours a week of charting/paperwork etc. When I graduate, I hope to start at at least 80K. Which, when you count the true number of hours I am scheduled, works out to less per hour than probably 90% of the nurses I work with. Hell, I've been an RN for 3 years and I make more than that per hour!!! And sometimes that is a bitter pill to swallow, 18 hours into a 24 with 3 active labors and no end in sight.
That's not to say you should hesitate to call a provider when needed. But, it is nice to be considerate by ensuring you have all your ducks in a row before calling. And yes, if it can wait till morning, then pass to the day shift or tack your call on to a coworkers's. It is also helpful to be clear and direct with your SBAR at 4 in the morning, as it is hard to wake up from a dead sleep and try to figure out what the heck is going on!
I am an LDRP RN and student CNM so I am coming at this from both sides. But yes, I chose this specialty freely and I would never, ever want someone to NOT call me with a concern at 3am. But I do appreciate the RNs who will just enter that damn tums order that I forgot, instead of calling me at 2am.
Typically, unless the matter is urgent, I won't wake up a MD at 3am. Urgent matters include changing the plan of care to keep the patient out of ICU, to ensure the patient's condition remains stable or if the patient is in pain. Otherwise, I will cluster all my calls and contact the MD's at 0630 or so. This has worked for me, I have not been a NOC RN forever, just about 4 years. But MD's are typically more responsive while they are awake and drinking a cup of coffee in the morning. At times though, some MD's can just be unprofessional when they are woken up, even if your patient is about to code. From my experience, waking up most surgeons after the midnight hour has created many unprofessional conversations.
The way I see it, the on-call docs are being paid to be on call. Why not call them after hours?
Actually incorrect in the vast majority of cases.
Barring certain specialties like some anesthesia docs, some l&D docs and residents on teaching services, no they are not getting paid for call. Though it should be an accepted part of the job that they chose.
In the case of residents in teaching hospital sometimes they are paid extra, some shifts are part of one of their 30 hr shifts as part of their residency. Take into account they are required to pull these 30 hr shifts and work 80 hrs a week, and are often making much less than the senior 40 wrk nurses on the floor. Yes, I will call them when needed but I will also treat them with kindness and consideration when I call.
Many, many years ago, a less-than-friendly surgeon was called in the middle of the night by a fairly green new nurse (me) IThe nurse began by apologizing for waking the surgeon. His response was "Never apologize, I work for the patient, not the other way around." Wise words.
I always dreaded calling the doctor no matter what time of day it is. My experiences with it are too numerous to list but most of them were helpful. I try not to take up too much of their time and to condense whatever I have to say so I do not keep them on the phone too long.
also remember- the providers who bite your head off for calling at 3am are the same ones who will bite your head off at morning rounds when they find out you didn't call! If you think something warrants a 3am call, make the call. Be professional and courteous about it, and just hope the person on the other end does the same.
I would agree that if it's not a critical issue, wait until morning or until someone else happens to call. Remember your I-SBAR-R - this will save your butt! And yes on the vitals, but I would add also have the pt's I&O ready as well for any call. A few of the docs I work with are adding urinary output to the list of vital signs as a measure of renal perfusion. Also any pertinent critical lab values (even if they've already been reported). The physician needs a pretty clear clinical picture to guide his/her decision-making process, and at night the clearer you make the picture the easier the doc's job will be.
I didn't see a post from anyone who receives calls, so I thought I would add my thoughts.
I am a nurse practitioner, and often take call. Most physicians/practitioners don't mind phone calls. Its part of the job. And if something isn't addressed in the night, it will become a problem the next day. I would rather have a 2 minute phone call at night, than hear about it for 5 minutes the next day when the patient and family have to tell you why they are pissed off.
And please don't set us up by telling the patient/family "I won't call at night unless I have to because.....". I like my patients. I don't want them to think I am not there for them.
On to the call.
The call I prefer goes something like this: "Hi ....., this is Debbie Nurse from Community Hospital, ICU. I am calling about Bill Board. Are you familiar with him?
If yes: "Good. He is complaining of pain/He is very tachycardic/He is nauseated/He is running a fever.
If no: "He is a 68-year-old gentleman who was admitted yesterday and was found to have GI bleeding/pneumonia/NSTEMI.
Now this is the part where it can changed quickly. Excellent nurses will say something like "He has been nauseated and tells me he used zofran in the past with a similar complaint." or "He has been lightheaded, and is blood pressure is 90/40".
When you make the call, try to think about a solution, or at least more information that would be helpful.
Remember, we work together. You are calling because there is an issue, we want the patient cared for.
I've been a night nurse for 8 years. My previous job calling only attendings and surgeons was much less pleasant than my calls to interns and residents at my current position, although even the attendings I call at night at this current job are more receptive generally.
I've found some doctors want a full rundown of history while others want only chief complaint, age, any pertinent conditions(like COPD if you're calling about an O2 sat.), vitals. I have a script pretty much down now and I do offer suggestions if I have them. I have the confidence now to push a little for things if I think they are necessary(like the attending who argued with me about a C diff test on a LOL pouring liquid stool all night. She finally said I could do the test "if it would make me feel better." The test? Was positive.)
I was phone phobic before taking my first nursing field job. With experience it becomes part of the routine. It helps if there is a collaborative vs antagonistic environment to work within.
The SBAR tool for communication has been mentioned here and it is very helpful as an organizational tool. It is great when you can cluster the phone calls together. When there is an acute change and you need orders, you call. Never feel that it is against your patient's interest to wake up an MD. Yes, they are paid for on-call and they need to be woken up for urgent matters. If it is something that has been going on for over 24 hours and no one called the MD, then that is something you need to decide. If it is urgent enough or is now causing some negative impact on your patient, call. When you have that "gut feeling" go with it and call. And remember, the MD does not know how to treat the patient if he is never called and that can fall on you as the nurse. I really don't care if they are offended or get sarcastic, I am prepared and ready when I call them, very succinct in what I need and what is going on with the pt. I don't waste their time and when I call it is because I need to. Don't ever apologize for calling an MD, that is your job and you are doing it.
Barring certain specialties like some anesthesia docs, some l&D docs and residents on teaching services, no they are not getting paid for call. Though it should be an accepted part of the job that they chose.
In the case of residents in teaching hospital sometimes they are paid extra, some shifts are part of one of their 30 hr shifts as part of their residency. Take into account they are required to pull these 30 hr shifts and work 80 hrs a week, and are often making much less than the senior 40 wrk nurses on the floor. Yes, I will call them when needed but I will also treat them with kindness and consideration when I call.
As a Resident Physician, I want to say thank you to all the RNs that take into account the situation some of us residents are in when we receive those 3 AM phone calls. I too always answer the phone with kindness and consideration when an RN calls me in the middle of the night, however, there are certain things that irk me and I'll share.
As many of the above posters have noted, it is extremely wise to have an SBAR type of situation. For example, Too often I get this phone call, 'Doc, patient in 32B is in pain', and followed by me asking them who the patient is, what service they are on and some basic questions followed by the RN saying to me 'I don't know' to a lot of these questions. I value the RN's judgement, skill and experience, however, when I am covering 50 patients, taking admissions in the ED, transfers from the ICU, screening patients into the ICU etc, it would be nice for you to formulate an SBAR to give the intern something to work with on the patient. RN's are valued for their bedside clinical skills, and I listen, so please have this ready when you call me. I have no issue coming down to see the patient, however, if you give me a half-hearted description where you just want me to come down to basically relieve you for some complaint you did not even try to fully understand from the patient and then you completely disappear from the picture, then I will not be pleased.
The first thing I learned in residency is to always trust your RNs. The bottom-line is if an RN asks me to see a patient because they feel the patient warrants an evaluation by a physician for whatever reason, I go and see the patient. Like the posters above mentioned, the worst thing that can happen is you not calling the physician, and the patient crashes later on from something preventable that you and the physician could have sorted out during the night.
As a Resident Physician, I want to say thank you to all the RNs that take into account the situation some of us residents are in when we receive those 3 AM phone calls. I too always answer the phone with kindness and consideration when an RN calls me in the middle of the night, however, there are certain things that irk me and I'll share.
As many of the above posters have noted, it is extremely wise to have an SBAR type of situation. For example, Too often I get this phone call, 'Doc, patient in 32B is in pain', and followed by me asking them who the patient is, what service they are on and some basic questions followed by the RN saying to me 'I don't know' to a lot of these questions. I value the RN's judgement, skill and experience, however, when I am covering 50 patients, taking admissions in the ED, transfers from the ICU, screening patients into the ICU etc, it would be nice for you to formulate an SBAR to give the intern something to work with on the patient. RN's are valued for their bedside clinical skills, and I listen, so please have this ready when you call me. I have no issue coming down to see the patient, however, if you give me a half-hearted description where you just want me to come down to basically relieve you for some complaint you did not even try to fully understand from the patient and then you completely disappear from the picture, then I will not be pleased.
The first thing I learned in residency is to always trust your RNs. The bottom-line is if an RN asks me to see a patient because they feel the patient warrants an evaluation by a physician for whatever reason, I go and see the patient. Like the posters above mentioned, the worst thing that can happen is you not calling the physician, and the patient crashes later on from something preventable that you and the physician could have sorted out during the night.
Cheers!
Spot on! In the ICU you need to know your stuff, if you page a pulmonologist at 3am. Many are covering multiple hospital and have no idea who your patient is unless there was some sort of hand off with a new admission. SBAR is essential to getting your point across and receiving appropriate/needed orders. I talk fast and succinctly to get the deed done with parameters so I don't have to call again. Or better yet we create a contingency plan if the first intervention doesn't work so I don't have to call back over and over.
1. Critically think, reread notes and MAR with standing orders
2. Troubleshoot
3. Form SBAR
4. Call and give a decisive report
5. Get orders
6. Execute orders
7. Be confident.
I have had cranky docs refuse to act even when I implore them and when they notice my confidence and unrelenting will to back down most will heed my suggestions. I have overheard some embarrassing pages/calls to docs so please people know your stuff first!
cayenne06, MSN, CNM
1,394 Posts
Many, if not MOST, providers are actually not directly compensated for time on call, because call is a money suck and most small practices cannot afford to pay. Yes, their overall salary is high, but on call hours are not usually factored in to the average "hourly wage" that providers make. Obstetrics is an expection, as it is a specialty with one of the highest on-call demands in terms of actual presence in the hospital. The CNMs I work with as a student are compensated 18 hours for every 24 on call, and we spend the entire 24 at the hospital probably 85% of the time. My full time work week (I am a student CNM, following a FT CNM) is 50 scheduled hours (averaged over 4 weeks). And of course, being salary, we can usually count on a minimum of 4 additional hours a week of charting/paperwork etc. When I graduate, I hope to start at at least 80K. Which, when you count the true number of hours I am scheduled, works out to less per hour than probably 90% of the nurses I work with. Hell, I've been an RN for 3 years and I make more than that per hour!!! And sometimes that is a bitter pill to swallow, 18 hours into a 24 with 3 active labors and no end in sight.
That's not to say you should hesitate to call a provider when needed. But, it is nice to be considerate by ensuring you have all your ducks in a row before calling. And yes, if it can wait till morning, then pass to the day shift or tack your call on to a coworkers's. It is also helpful to be clear and direct with your SBAR at 4 in the morning, as it is hard to wake up from a dead sleep and try to figure out what the heck is going on!
I am an LDRP RN and student CNM so I am coming at this from both sides. But yes, I chose this specialty freely and I would never, ever want someone to NOT call me with a concern at 3am. But I do appreciate the RNs who will just enter that damn tums order that I forgot, instead of calling me at 2am.