American College of Physicians: Internal Medicine — Doctors for Adults ®

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Balancing the pros and cons of telephone care

From the June 2001 ACP-ASIM Observer, copyright 2001 by the American College of Physicians-American Society of Internal Medicine.

By William Hoffman

Atlanta—Telephone consultations with patients can be a great patient pleaser, but physicians need to make sure that they treat patients on the phone as carefully as individuals they see in the office.

At an Annual Session workshop on telephone consultations, panelists discussed the benefits and liabilities of telephone medicine. While they talked about ways to use the phone as a tool to improve care for patients, they emphasized that physicians must be careful to avoid liability problems.

D. Michael Elnicki, FACP, director of general internal medicine at Shadyside, University of Pittsburgh, said that physicians need to remember that they are liable for what they say—or don’t say—when patients call for prescriptions or advice. That’s why practices must organize their phone operations and oversee the advice that is offered over the phone.

Communication

A receptionist can be trained to quickly answer, triage and route calls to the appropriate resource at your office, the panelists said, but you should consider assigning a nurse to the task. The job often requires a certain level of medical knowledge to work with patients via the telephone, such as asking appropriate questions, pulling medical records and making decisions about prescriptions.

Only designated and trained office personnel should answer consult calls, the panelists emphasized. A triage nurse and a physician should evaluate high-risk patients and problems. Patients who call a second time within 48 hours or aren’t improving should come to the office.

The panelists noted that handling patient phone consults often requires a higher level of skill than seeing patients during a routine office visit. You can’t visually inspect a phone caller who may be nervous, distracted or even deceptive.

Screeners should speak directly to the patient when possible instead of a surrogate like a spouse, parent or child, the panelists said. No one knows the patient’s problems better than the patient.

Use open-ended questions (as opposed to simple yes-no queries) to elicit detailed responses. Asking, “What are your symptoms?” usually elicits more information than “Do you have a cough?” Dr. Elnicki said.

When questions start to elicit repetitive responses, Dr. Elnicki suggested asking patients if there is anything else they want to talk about. This line of questioning often uncovers information patients would not have otherwise shared.

Offer patients an opportunity to be seen at your office the same day, if possible, the panelists suggested. If the patient declines, ask whether the course of action you’ve advised is satisfactory. If it isn’t, ask what the patient would consider satisfactory.

Offer patients a follow-up call or appointment, even if they begin to feel better. You should also chart a treatment contingency plan during the first call so that both the patient and physician have some idea of what to expect next.

If the patient calls back, try asking, “What’s different now?” The panelists said that this question focuses on the patient’s real agenda, saving time for both patient and physician.

The panelists also suggested creating a policy that prohibits writing narcotics prescriptions requested by phone, except for known chronically or terminally ill patients. Substance abusers are likely to call your practice late at night, just before closing or during especially busy periods.

Substance abusers will also call doctors they know are unavailable and try to take advantage of empathetic, harried or less vigilant partners. Insisting on an office visit before prescribing narcotics can help avoid these exploitative situations.

Avoiding liability

The panelists emphasized that physicians and their staff need to remember that phone consults pose the same level of malpractice risk as office visits. The duty to provide care is legally established from the moment the physician or designated representative offers medical advice, explained Paul E. Ogden, FACP, director of graduate medical education at Texas A&M University College of Medicine in Temple, Texas.

For malpractice purposes, Dr. Ogden said that any of the following actions constitutes negligence: giving a patient inadequate time for a full, accurate consultation; evaluating a patient based on incomplete information; or lacking appropriate training to evaluate over the phone.

Assigning the right screener is critical to protect your patients and your practice. To make sure that screeners are not putting the practice in danger, physicians should carefully monitor the quality of their phone consults.

All significant advice and actions should be concisely and precisely documented, Dr. Ogden said, preferably when screeners give information to patients. Dictate records into a recorder for later transcription, he suggested, or draft a standardized form that screeners can complete quickly during or after the call.

It’s especially important to document high-risk and after-hours calls. Physicians should set aside time—preferably at a regular hour each day—to review the status of phone consults and determine whether any follow-ups are needed.

William Hoffman is a freelance writer in Fairfax, Va.

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