When the patient wants to see you—via the phone
How to get past your doubts to make telephone medicine work for you and your patients
From the December 1998 ACP-ASIM Observer, copyright © 1998 by the American College of Physicians-American Society of Internal Medicine.
By Christine Kuehn Kelly
Internists in busy practices know the value of treating patients by telephone. After all, nearly a quarter of their patient encounters take place on the phone, allowing them to squeeze more care into their time-strapped days.
For residents still learning the basics of patient care, however, working with patients on the phone can be an intimidating part of training. "Most residents haven't been trained how to diagnose over the phone," said Anna B. Reisman, MD, clinical instructor at Johns Hopkins University School of Medicine. "They wonder if it's even possible."
Residents often have serious doubts about the value of medicine when there is no face-to-face time with the patient. "My initial impression of telephone medicine was that I was at a major disadvantage because I didn't have the opportunity to see the patient or family face to face," said Andrea Mathias, MD, chief family medicine resident at the University of North Carolina Chapel Hill Medical Center. "I wondered how much of the encounter was gestalt, my own thoughts and feelings when encountering a patient. But now I find it challenging and satisfying when I make the correct diagnosis over the phone."
Educators agree that telephone medicine is good for physicians and patients alike. "It's a time-saver for physicians, who often are able to completely manage problems by phone, and there probably is some effect on controlling costs," said Dr. Reisman. "Patients have improved access to care and often an early diagnosis of illness. And using the telephone to follow up on an office visit enhances patient/doctor rapport."
In fact, there are some distinct benefits to talking to patients on the phone. For one, less mobile patients and the elderly can get minor care without having to make a difficult journey to the office. "I have a 700-pound young woman who is not ambulatory," said Eileen Seeholzer, MD, chief resident at Cleveland's MetroHealth Medical Center, part of Case Western University's internal medicine residency program. "I'm able to treat her by telephone for two chronic health problems, using the visiting nurse as my eyes and ears."
There is even evidence that working with patients over the phone can improve outcomes and patient satisfaction. "We had a case in which a resident's patient who had a generalized anxiety disorder needed paroxetine but was afraid to take it due to the side effects," said David L. Stevens, MD, a clinical instructor at New York University School of Medicine. "The resident arranged to call her back an hour after she started the medication. She took the prescription and subsequently had no side effects."
And in a study published in the May 30, 1998, issue of the British Journal of Medicine in which rheumatology patients were surveyed by telephone, 90% of the patients said they were satisfied with the telephone follow-up that was provided. This compared with a 94% satisfaction level for those attending a clinic.
Despite these positive reactions to phone medicine, residents receive little training in working with patients over the phone. A 1997 study found that telephone medicine curricula were available in only 6% of the 250 internal residency programs that responded to the survey. Of the 15 programs that said they offered formal training in the survey, nine programs offered single lectures and seven offered reading materials.
Slowly, however, some training programs are spending more time teaching housestaff how to handle patient phone calls. Residents at NYU, for example, attend a conference early in residency to practice their telephone skills on each other. "They sit back-to-back and role-play a challenging situation to practice talking to a 'patient,'" said Dr. Stevens. "An observer gives them honest feedback. After this, they feel like they've had an actual encounter and usually feel more confident."
For some of the program's residents, a little practice goes a long way. "I was a little nervous when we got pagers so the patients could contact us," said Deborah Dowell, ACP-ASIM Associate, an internal medicine resident at NYU. "But now I feel good about using it. It makes the patients feel more cared for, especially if you only have clinic once a week."
While telephone medicine may have many benefits, it also presents physicians with some unique concerns. Here are some tips on to how to work effectively with patients via the phone:
- Take calls in a private area. This may mean you take a quick history over the phone and then later call the patient back when you have more privacy.
- Take a good history. A survey of second- and third-year NYU internal medicine residents showed that less than half felt confident taking a medical history over the phone. "Most diagnoses are made with the history," said Dr. Seeholzer from MetroHealth in Cleveland. "You can easily do this over the phone."
Just as in the clinic, you should quiz patients about age, problematic medical history, current medications, allergies and menstrual history. At NYU, where residents carry wallet cards listing these basic questions, Dr. Stevens tells housestaff to remember to ask the hard questions about sexual history, drug use or abuse.
- Let patients participate. Ask patients to help you assess their physical condition. Ask them to look at their color, measure their respiratory rate and take their temperature. They also can indicate their heart rate by calling out "beep, beep, beep" to you as they take their pulse.
- Get a family member or companion involved. If your patient seems to be having an acute asthma attack, have someone near the patient describe how she sounds or looks. Check on timelines, asking how long the patient has had the symptoms.
- Take your time . Patient phone calls last an average of between three and 15 minutes, but make sure you spend sufficient time to understand the problem. As in the office visit, patients may not discuss the real area of concern first, so make sure you end up talking about the real reason they called. Then take your time to make the diagnosis. Residents often feel rushed to make a diagnosis in the first few minutes of the patient conversation, but wait until you have enough information to come up with a working plan.
- Make your diagnosis tentative. One of the main goals of phone medicine is to manage disease, not confirm diagnoses. Tell the patient, "We may need to do tests in the morning, but since the symptoms are typical for a urinary tract infection, we can start treatment today." Ask them to call you back if there are any changes in status. And if you believe the condition is serious, it's always prudent advice to recommend the emergency room.
Lee Dunn, JD, an attorney in Boston who specializes in health care litigation, said that unless you have personally seen the patient or have the patient's medical records available, it's not a good idea to diagnose over the phone. Even if you know the patient, Mr. Dunn suggested following the "reasonable and prudent rule" when working with patients on the phone. From a legal point of view, he said, this means asking two simple questions: "What would an ordinary and reasonable resident have done, and was there sufficient reason to be cautious and not go ahead with a treatment?"
- Make sure the patient understands and agrees with the plan. "You should continually check with the patient during the conversation," said Dr. Stevens. In addition, telephone medicine means you need to look for subtle clues since you can't see facial expressions or body language. "If a patient gets quiet, it may either mean he or she is in agreement or has stopped listening," Dr. Stevens said. Residents need to confirm their perception of what the patient is thinking by asking the patient, "Can you repeat back to me what I've said so I can be sure you understand?"
- Document your calls. According to Mr. Dunn, documenting your thought process is extremely important in legal cases. That's why programs often have set up ways to make it easy for housestaff to do so. "We have little cards we carry with us and then paste in the charts," said Dr. Mathias from UNC. "We include the time, what was said and our recommendations." And at MetroHealth in Cleveland, Dr. Seeholzer said, residents use carbon forms that go into the chart.
- Talk to attendings. Attendings should be called for back up when necessary. "When I had a difficult situation with a distraught patient, I told her I would call her right back," recalled NYU resident Dr. Dowell. "I talked to my attending and confirmed that what I had been telling her was correct." And as a last-ditch attempt to convince a reluctant patient to go to the emergency room, an attending may be more persuasive.
- Give reassurance. Because most patients are looking for reassurance, explanation and advice rather than a quick trip to the emergency room, there may be a human tendency for both patients and physicians to downplay potential problems. "Both parties have a desire for things to be OK, so your recommendations have to be appropriate," said Dr. Mathias. Inform patients about the expected duration and course of the problem, which relieves patient anxiety and precludes additional phone calls. But if you feel strongly that certain patients should come in, she said, make sure you convey that effectively.
- Know off-hours resources. Dr. Mathias said she makes it a point to know what drug stores are open 24 hours, what emergency rooms might be closest and what other evening/weekend resources are available. She also asks if issues like transportation or finances will keep patients from following her recommendations. If a prescription is expensive, she checks if the patient has a prescription plan.
- Follow up. Don't stop at the initial phone conversation. Follow up the next day to see if the patient came into the emergency room or followed your other instructions. This can be especially gratifying when the diagnosis you made over the phone was confirmed, said Dr. Mathias.
Christine Kuehn Kelly is a Philadelphia-based freelance writer specializing in health care.
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