Friday, December 9, 2011

Help us help you!

Hello.  This is Dr. Stuppy.  I'm returning your call about...

That is how my phone calls start, then they take various turns.  Some are easy, some not so easy.  I'd like to discuss what makes a phone call to the doctor's office more productive, so we can help you better.  All examples are entirely fictitious, made up of 12 + years of phone call experiences.

Many calls start off like this:
Hi. This is Mary Sue. My son has a rash and I want to know what to do.
Me: ????? I must ask many questions for more information.  
Some callers don't seem to know what to say, so they only answer direct questions.  How old is your son? When did the rash start? What does it look like? Has it changed? Does it itch or hurt? Any other symptoms? What have you used to treat it? Did that help? Has he had any new ingestions, lotions, or creams? Does he have a history of allergies? Anyone else with a rash that looks like this? On and on...

Or like this:
Hi.  Thanks for calling back. My son Jack is 3 years old.  Well, really his birthday isn't until next month, but he's almost 3.  He has had a fever for 2 days, maybe 3 days because he felt warm but he wasn't acting funny or sick that first day he felt warm.  He actually was fussy last week, but I don't think he ever had a fever then.  I was thinking maybe he didn't sleep well last week, but I don't know why.  I took his temperature and it was 100.3, that was on Tuesday around 7am.  I gave Tylenol, and it went down to 97.9, but then 4 hours later it was back up to 99.7....  
My thoughts so far: Get to the point. 
Sorry, but that's true.  I care about my patients, but so far this phone call has taken me quite a bit of time and I really know nothing except this almost 3 year old has an elevated temperature (not even a true fever).  

When parents call, they need to summarize with pertinent facts.  While they shouldn't leave out important helpful information, they don't need to mention every time they took a temperature.
Much like the evening news: they can't do a play by play of every football game.  There's no time and it serves no purpose.  A few highlights of the game and the score.  That works well.  People get a pretty good idea of how the game went.  

It's the same thing with phone calls to your doctor's office or on call provider.  We have thousands of patients.  Not all call the same day, but during peak cold and flu season last year our office took 50-90 calls/day (the highest numbers on Mondays).  One phone nurse has 8 hours to answer up to 90 calls in addition to filling out insurance forms and other tasks.  (We have great nurses that help out if they have time, but if the phones are busy, I guarantee the office is busy too!)  They simply can't spend 15 minutes chatting about every detail.  That's for your friend and you to discuss over coffee.

After hour phone calls during the winter are also more frequent.  It is not uncommon for me to be on the phone with one parent and another call comes in.  This is at the same time I am trying to watch my son's game or go to the grocery store.  I really don't want to sit and chat.  I don't have time for play by play action.  Again, I really care about my patients, but I can do a better job at answering your questions if you are clear and concise.

Things that help us help you over the phone:

  • Know what is going on.  When a parent calls and the child is at daycare or grandma's so the caller doesn't know details, we can't really help.  Write down the pertinent facts to get them straight if you need to.
  • Start with your child's full name and birth date.  Include any significant past history, such as your infant was born at 28 weeks gestation, or your coughing 3 year old has a history of wheezing.
  • Give pertinent facts related to the concern.  
  • If your child has a fever, give the number of days of fever, the maximum temperature, and how it was taken.  If you have given a fever reducer, share that.
  • Briefly describe symptoms and what you have done to help them as well as if your child responded or not to the treatment.  Remember treatments are not only medicines, but if you use a vaporizer or saline for a cold, or have stopped dairy and used G2 for vomiting, let us know. 
  • If your child has a rash, it is typically best for us to see the rash, but if you call about a rash describe it in terms of location, color, and size (many find it helpful to relate to common objects, such as quarter-sized).
  • Note if there is a pattern to the symptoms, such as headache every day after school or barky cough only at night.
  • Let us know any medications your child typically takes in addition to ones you have tried for the current symptoms.  
  •  Leave out details that don't help.  Trends and generalizations work well.  If we want more details, we can always ask. 
Examples of good call starters:
  • I am calling about Joe Smith, birth date 9.12.08. He has had a fever for 3 days, up to 101.3 under the arm. It comes down with ibuprofen, but is right back up in 6 hours.  He also has sore throat and headache. He's drinking well but not eating much for 3 days.
  • Sally Smith, birth date 9.12.11, has vomited 6 times in the past 12 hours. If I give formula it immediately comes up. She is now dry heaving and hasn't had a wet diaper in 12 hours. She doesn't have a fever but looks tired and it is hard to wake her to drink. She doesn't have diarrhea. Her older brother had the stomach flu a few days ago but is now better.
  • John Smith, birth date 9.12.11, was in the NICU for 2 months due to prematurity. He has been fussy all day and is now breathing fast and hard and is not able to drink more than a few sucks at a time. He doesn't have a fever, but I'm really worried. 

Remember:  Our website has many pearls of wisdom.  Often when we give advice it is already stated on our site.  Parents sometimes call multiple times because they can't remember what we said.  This is frustrating on both ends of the phone.  We wrote it down for a reason.  Use our site!

Things that cannot be done by our on call providers:

  • Prior authorization for an ER or urgent care visit.  These must be done during office hours, and most of the time our office is not involved.  These are typically done by the location at which your child is seen.
  • "Allow" you to leave a busy ER.  It sounds silly, but I have had many calls from the waiting room at ER/Urgent Cares with parents asking if I think it okay that they leave due to a long wait. If you thought it necessary to go in the first place, I would be open to a malpractice lawsuit if I told you to go home without being seen.  You should ask their triage nurse who can make that assessment.
  • Refill medications.  We typically expect that your child is seen prior to most prescription refills for best medical care.  If it is urgent that your child have a refill, such as an inhaler, they should be seen to evaluate the concern. There are exceptions to every rule, but don't be upset if the on call provider refuses to call out a prescription. 
  • Make a diagnosis.  We cannot see the ear, listen to the lungs, or feel the belly over the phone.  A physical exam and sometimes labs or radiology studies are needed to make a diagnosis.  If your doctor claims to be able to diagnose by phone to call out prescriptions, I would suggest that they are not doing the best of care.

Some things are best done with a visit for further evaluation.  

  • Difficulty breathing.  If a child is having difficulty breathing and you don't have treatments at home that work, he needs to be seen as soon as possible.
  • Dehydration.  An infant who hasn't urinated in 6-8 hours or an older child who hasn't urinated in 12 hours might be dehydrated and should be seen as soon as possible.
  • Some fevers. Temperature above 100.4F under the arm in an infant under 3 months or under immunized child can be serious and should be seen as soon as possible.  Fevers lasting more than 3-5 days or with other concerning symptoms require an evaluation.
  • Uncontrollable pain.  If you have used standard pain relievers and your child is still hurting, we cannot do anything by phone that will improve the situation. A careful exam might find a treatable cause of pain.
  • Most rashes.  Though these don't necessarily need to be seen emergently unless there are other concerns, rashes cannot be evaluated on the phone and a physical exam is needed.
  • Chronic problems.  If your child has been dealing with anything for more than a few days, it might help to schedule a visit with your usual provider.
  • Diagnosis vs information.  If you want a diagnosis, we need to see your child.  We cannot tell if the ear is infected or if your child has Strep based on symptoms alone.  If you want advice of what to do with symptoms, we can generally give advice.  Remember that our website also has most of this information too!
  • Behavior problems.  These are best discussed with your usual provider, not an on-call provider who doesn't know your child. Most of these build up over time and are not emergent issues.
  • Injuries.  If your child has a moderate or severe head injury, possible broken bone, laceration, or other injury symptoms they require evaluation.  Lacerations must be repaired as soon as possible, so don't wait until office hours the next day!
Help me help you!  Let me know what else you need to know to be an educated caller.  I'd be happy to answer questions about when to call, what to ask, and what to expect.  If I left any questions unanswered, please ask!

Dr S

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