Medical editor Malachi Sheahan III, MD, makes the case for surgeon call pay, a remuneration he says should be understood more as compensation than reimbursement.

The strongest desire of my early youth was to attain an Atari 2600TM video game console. A goal I finally unlocked with the financial windfall of my First Communion. As I opened the box, visions of Pac-Man, Space Invaders and Asteroids danced in my head. The cruel reality, however, was that the console only came with some janky free games—Breakout, Combat and Basic Math (yes, really). To unlock all of the 16-bit goodness that was now at my fingertips, I would need more than my paltry allowance. I would need a job. Since I was an 11-year-old boy with no perceivable skills, my options were limited to paperboy or some kind of Artful Dodger situation. I opted for the former.

To work at that age in New York required a special permit, so my father took me down to the local government offices. A sign on the wall listed the only two exceptions to the 14 minimum-age work requirement: paper carrier and child model. Since my orthodontic situation at the time could be generously described as “unfortunate,” it wasn’t too hard for the state workers to guess which forms I needed.

My subsequent 45-year run in capitalism has taught me many lessons about the free market, but perhaps most germane to this editorial: it is hard to get paid for something you are already doing for free.

Justification for call pay

The very concept of call pay is often met by (feigned?) confusion from hospital administrators. Call pay should not be seen as reimbursement for work performed but rather compensation for the burden of being available. Call is not a passive activity; it restricts a surgeon’s freedom and imposes psychological stress, regardless of whether an operation is ultimately performed. That is the essence of surgical call: the omnipresent possibility of catastrophe. Call it Schrödinger’s retrohepatic caval injury. A vascular surgeon on call will often sacrifice sleep, family time and the ability to rest and recover. This availability is a service to the hospital, other physicians and the community at large. Like any professional service, it warrants payment.

A call pay system provides inherent compensation for surgeons who step up to cover others taking vacation, on maternity/paternity leave or taking sick time. When compensation is transparent and equitable, resentment declines. Departments stop fighting over who “covers more” or who “gets stuck” on weekends.

A brief history of unpaid heroism

Let’s rewind. In the halcyon days of medicine, call was a badge of honor. Surgeons were summoned from dinner parties, golf courses and, occasionally, their own weddings. They arrived in tuxedos, operated in loafers, and returned to the reception with blood on their cuffs and applause in their ears.

It was romantic. It was cinematic. It was unpaid.

The tradition of uncompensated call dates to the post-World War II era, when most physicians were independent contractors, and hospitals were grateful for any warm body willing to answer a page. Back then, call coverage was often tied to admitting privileges. You wanted to operate at Hospital X? You took call. No questions asked. No compensation offered.

By 1995, the rate of inpatient operations had dropped 14% from 1980, but the combined rate of inpatient and ambulatory procedures had increased by 70%. That’s not just growth—it’s a workload explosion. And who absorbed that growth? The surgical workforce.

The 1990s also marked the beginning of serious concern about surgeon supply. A longitudinal analysis of the general surgery workforce showed that between 1981 and 1991, the number of rural surgeons remained flat while urban numbers grew modestly. But the age distribution shifted: fewer young surgeons entered the field, and the average age crept upward. By 2005, only 16.2% of general surgeons were under age 40, compared to 25.1% in 1981.

This aging workforce was expected to cover more cases, more call and more administrative duties—all without additional compensation. The seeds of burnout were sown in this era, fertilized by rising malpractice premiums, declining autonomy and the slow erosion of professional respect.

Hospitals in the 1990s were under pressure to cut costs. Managed care organizations pushed for shorter stays, fewer procedures and tighter reimbursement. The shift to outpatient surgery was supposed to save money—but it didn’t reduce the need for surgical expertise. Instead, it fragmented care and increased the complexity of scheduling, coverage and continuity.

As call became more frequent and more fragmented, especially with the rise of multi-hospital systems, burnout began to rise. Until recently, however, this was dismissed as a personal failing rather than a systemic issue. But the science is clear: surgeons with more frequent call report higher rates of insomnia, depression and early retirement. The American College of Surgeons (ACS) reported in 2024 that even home call measurably disrupts sleep cycles and increases burnout risk among acute-care surgeons.

Fast forward to the 2000s. Hospitals began acquiring practices, and physicians became employees. The shift from autonomy to employment brought new expectations—and new frustrations. Call was no longer a favor—it was a line item. But unlike base salary, it remained nebulous, inconsistent and, in many cases, non-existent. The new compensation models lagged behind reality, failing to account for the expanded scope and intensity of surgical labor.

Hospitals love to talk about value-based care. But when it comes to call, the value is often one-sided. Surgical departments generate up to 70% of hospital revenue, yet surgeons are expected to provide 24/7 coverage as part of their “professional duty.”

EMTALA—the Emergency Medical Treatment and Labor Act—has also had a profound and lasting impact on surgical call coverage in the U.S. Enacted in 1986 to prevent “patient dumping,” EMTALA mandates that any hospital with an emergency department must provide a medical screening exam and stabilizing treatment to anyone who presents with an emergency medical condition, regardless of their ability to pay.

Under EMTALA, hospitals are legally required to maintain a list of on-call physicians who can provide further evaluation and treatment for patients with emergency medical conditions. This includes surgical specialists such as trauma surgeons, vascular surgeons, neurosurgeons and orthopedic surgeons.

The law doesn’t just apply to hospitals—it also places obligations on individual physicians. If a surgeon is listed on the call schedule and fails to respond in a timely manner, they can face civil penalties of up to $50,000 per violation, and even exclusion from Medicare participation. This makes call coverage not just a professional duty, but a federal legal requirement.

While EMTALA was designed to protect patients, it has created significant challenges for hospitals and physicians.

• Increased call burden: Hospitals must ensure 24/7 coverage, often relying on a small pool of specialists. This leads to frequent and intense call schedules, especially in high-acuity specialties.
• Uncompensated labor: EMTALA does not require hospitals to pay physicians for being on call. Many institutions still treat call as a “shared duty,” especially among employed physicians, despite the legal and clinical demands.
• Recruitment and retention issues: Surgeons are increasingly unwilling to accept positions with heavy call obligations and no compensation. This is particularly true in trauma and acute care surgery, where burnout rates are high.
• Legal risk: Hospitals and physicians alike face liability if EMTALA obligations are not met. This includes fines, lawsuits and reputational damage.

Data

Hospitals depend heavily on surgical departments for financial viability. Surgical services account for up to 70% of total hospital revenue and over 60% of operating margins. Elective and emergency surgeries generate substantial downstream revenue through diagnostics, inpatient care and rehabilitation. Yet, the surgeons who drive this revenue often do so without fair compensation for their on-call availability.

Only 33% of general surgeons report receiving call pay, compared to 43% of orthopedic surgeons and 39% of neurosurgeons. Only about 19% of academic surgeons report receiving call pay, compared to roughly 30% in private practice. Sources vary in terms of the prevalence of call pay, however. A 2024 SullivanCotter report showed that, between 2007 and 2012, the proportion of U.S. hospitals providing some form of on-call stipend increased from 48% to 63%.

According to the recent SVS/Phairify compensation study, the vast majority (93%, 660/708) of vascular surgeons took first call for vascular issues at their institutions, of which 64% (422/660) were on call on average one in four weekday nights and weekends. Most respondents (80%, 545/682) were not paid for primary call separate from their salary.

The Medical Group Management Association (MGMA) 2024 report based on 2023 data shows the median daily rate for on-call compensation for vascular surgeons is $1,000 per 24 hours. The same data source shows that the most popular method of call payment calculation is a daily rate (45%), followed by hourly (31%) and then an annual stipend (11%). Many systems will vary their rate by acuity metrics such as number of emergency room referrals per week or number of emergent procedures performed annually.

For a full picture of the call pay landscape, several sources are available: Specialty compensation and call-stipend surveys (SullivanCotter, MGMA DataDive) that report employer-paid stipends and on-call practices across hundreds of hospitals and dozens of specialties are the gold standard for benchmarking institutional stipends. Commercial locum-tenens and staffing reports (CompHealth, Locumstory, Barton Associates, Sermo) disclose what hospitals pay external providers for temporary coverage—a revealing market price for guaranteed availability. And there are also specialty-focused surveys on call burden and compensation (e.g., Buckhead FMV/ BFMV call surveys) that combine burden metrics (days on call, phone volumes) with stipend data.

Many of these are behind a paywall that exceeds my modest investigative journalism budget, but you can be assured your hospital administrator has access.

Call pay arrangements must comply with federal regulations, including the Stark Law and Anti-Kickback Statute. The Office of the Inspector General (OIG) has issued several advisory opinions regarding call pay. To summarize, call pay can’t be used as a kickback from the hospital to physicians for bringing their patients to that institution.

Special circumstances

Hospital employment: Hospital-employed physicians often have a minimum number of uncompensated calls per month, with additional payment for calls exceeding this number. The problem is establishing how much call is expected with base compensation. It is difficult to find an industry standard for the frequency of either general or vascular surgery call. However, an article from Kim Mobley, managing principal and physician compensation practice leader at Sullivan, Cotter and Associates, Inc., cites the average and typical frequency as one in five days. Therefore, calls exceeding six per month should be expected to be compensated in a hospital-employed model.

Trauma center coverage: In the U.S., trauma centers are designated by regional governments and most rely on the standards set by the ACS. The ACS publishes its requirements in the Resources for Optimal Care of the Injured Patient manual. It is explicitly stated that for all Level I and Level II adult and pediatric trauma centers, “expertise in vascular surgery” is mandatory and must be provided with continuous 24-7- 365 availability. This is categorized as a Type I standard, meaning verification is automatically withheld if it is not met.

Tertiary care centers: In tertiary care centers performing complex procedures, it is essential to have a plan in place to deal with vascular complications related to procedures performed by other specialties such as cardiology, radiology, general surgery, interventional nephrology, surgical oncology, orthopedic surgery, or interventional neurosurgery. A simple work relative value unit (wRVU) model undervalues this work as the assisting vascular surgeon will likely need to disrupt their own clinic and operative schedule. Therefore, additional compensation should be provided for these services. Studies have shown that cases in which a vascular surgeon assists another specialist have high contribution margins and case mix indices.

The call for call pay

Ultimately all politics are local. To make the appeal for call pay you will have to sell it to your C-suite. So, in their own terms, here is a summary of the benefits of paying vascular surgeons for call.

1. Improving surgeon retention will avoid costly recruitment and onboarding expenses. Retention also stabilizes surgical service lines that generate significant hospital revenue.
2. Preservation of trauma designation.
3. Revenue capture: surgeons on call admit and treat emergent cases rather than transferring them, which increases inpatient and procedural revenue. High-acuity cases often drive downstream revenue (intensive care unit [ICU] stays, imaging, follow-up procedures).
4. Risk mitigation by avoiding EMTALA violations and malpractice claims.
5. Cost vs. ROI: a single, high-revenue emergency case can offset weeks of call pay stipends, making the investment commercially reasonable. The locum market’s premium shows hospitals will pay to avoid gaps, supporting the argument that predictable stipends are an investment. Data from staffing and compensation reports show dramatic locum rate spikes in undercovered specialties—a market inefficiency that fixed stipends can reduce.

Malachi Sheahan III serves as the medical editor of Vascular Specialist.