“Has a Bad Cold, Please Call”

The other day I happened to talk with a colleague about our respective electronic inboxes. Office workers in other trades often spend their entire workday at their computers and sometimes the bulk of that time reading and answering emails that arrive in their inboxes. They do that because that is what they are getting paid to do.

Doctors and their employers basically get paid only when there is an encounter – face to face or via telemedicine, hardly ever when the exchange happens over the phone. Consequently, doctors, PAs and NPs are scheduled to see patients (generate revenue) all day long. Unlike office workers, we have no time set aside for managing our inboxes. Except for past payment models like HMOs and future reiterations of capitated care not yet in place, inbox management occurs at the expense of the employer or the medical provider. The general tendency is the latter – “between patients” (a post where I suggest the opposite – protected time for the inbox and then two MAs, more exam rooms and more efficient visits to make up for that computer time) or after hours without overtime or even regular pay because we are salaried.

Electronic inboxes are definitely burnout factors. I have found that medical organizations don’t have systems in place to manage this aspect of healthcare delivery. So it is typically up to each of us to figure out how we would want the flow to go. And we must then work with our support staff, whom we don’t supervise, to meet our patients needs without causing undue stress, interruptions, delays and confusion in our respective workdays.

A natural support staff response is to simply pass on questions and messages to the provider, like the title message. As a physician who generates the revenue that pays both me and my support staff, plus my bosses, I try to create a sense that my time on the phone or in the inbox needs to be as efficient as it possibly can, not because I am lazy but because I want to be efficient.

A lot of people in management are nervous about having unlicensed staff give medical advice. These are my thoughts on this: We need our staff to ask common sense questions and we need them to know when it is an obvious emergency. We can’t bottleneck everything by passing every request unfiltered to the provider – or we would have them answer every incoming call themselves already. (Or imagine a president with no admin support opening his own mail.)

We must allow and encourage all staff to use common sense. A person who has made it to adulthood, raised children or cared for a sick family member should and does know pretty well what basic self care is and what the doctor might need to know when you need advice. In the example above, why should the doctor be the first one to ask how long, what symptoms, getting worse or dragging on, what self care measures have you tried etc. See my post THE ART OF THE MESSAGE and the PowerPoint staff talk about common sense telephone triage I created a decade ago (where these slides are from).

When it comes to the most common requests, we have options: Websites, recorded messages on common topics, hyperlinks and things like that with generic advice on colds, sprains, allergies, child rearing and so on. The days are over when the family doctor was the ONLY source of medical information. 

My philosophy is that I need to mentor and support the people I work with to make them more than robot message takers. I explain what I need in order to make good decisions. If I get a good message I can give a simple answer that makes their job easier. If I get a sloppy or vague message, it will just be returned with my request for common sense information.

But I also encourage bypassing the back and forth messaging by having a running conversation: In my Van Buren clinic, my medical assistant/LPN and I share an office. This is a mixed blessing, but it allows exchanges like “Mrs. X left a message asking…” and I can say “If she says this, we’ll tell her to do A but if she says that, she needs to go to the ER”. I may still get a message about the outcome of that callback, but that is just to sign off, not to tie me up on the phone.

My support staff knows I don’t want to end up conducting visits on the phone that belong in the exam room or at least in a telemedicine session. If someone has an upcoming appointment and calls with requests for a new referral or a random blood test they’ve read about, I don’t even get a message – the patient is advised to bring it up in the next visit, or they can come in sooner.

Phone medicine isn’t just bad for the practice’s bottom line. It can also be bad medicine. A patient’s medical history is definitely the most important factor in making a diagnosis. But, very often, even the briefest of clinical exams can alert the physician to a patient’s over- or underestimation of the cause or significance of their symptoms.

It can be false economy for both the clinic and the patient.

An Anxious Man With Coronary Plaque

John Roe has plaque but no symptoms. He ended up getting an angiogram a few years ago for chest pain that ultimately turned out to be acid reflux. But somebody put him on 80 mg of atorvastatin.

He had wanted to know what his lipid numbers were, so we checked them. They were quite low. His LDL was 42. For people who believe in target numbers, under 70 is the desired target for patients with known heart disease. Would John qualify as a member of that population?

“My daughter thinks that’s too high a dose for me”, he said. Amanda, his forty something daughter, is a psychiatric nurse practitioner. “I’m worried about my liver and my kidney numbers were off last year and what if they get worse again?”

This is a conversation I find myself in very often.

“It’s all a question of how much risk you tolerate, how worried you are about having a heart attack. How much insurance, or assurance, you want. The more you take, the more protected you are. And atorvastatin does more than lower cholesterol – I’m sure we have talked about that before. It stabilizes plaque and prevents plaque rupture. And 85% of all heart attacks happen not because of plaque growth but because of plaque rupture – sometimes of plaque that are too small to make you flunk a stress test.”

“I remember you saying that”, he admitted.

“It also prevents plaque buildup, and high doses can make plaque shrink – both in the carotid and coronary arteries, we have lots of proof of that. It also has a blood thinning effect that is different from aspirin, plus it relaxes the little muscles in the walls of the coronary arteries that clamp down when you get that letter from the IRS that you’re being audited (my standard joke..).”

I continued “I’ll print a couple of articles about all this for Amanda. And also, the FDA long ago stopped recommending routine checking of liver enzymes because liver damage from atorvastatin is very rare. And it has been shown to actually protect the kidneys.”

I clicked PRINT a couple of times and went back to my office for the printouts.

When I came back to the exam room, I undid everything I had said.

“But, some people have muscle aches or joint pains, some get higher blood sugars and some get brain fog or pseudo dementia. And there are other ways to avoid heart attacks. Without drugs.”

He looked up from the papers I had given him.

“I’ll print up one more thing for you. The Hale study, many years ago, showed that people aged 70-90 who followed a healthy lifestyle and a Mediterranean diet had half the heart attack and stroke rate, half the cancer rate and half the overall death rate of people with more typical western diets and habits. That’s the same reduction you can get with atorvastatin.”

John sighed. “So what am I supposed to do?”

“Only you can decide”, I answered. “It depends on how much risk you tolerate, how many hoops you are willing to jump through to avoid a heart attack. That’s a very personal choice.”

I know he wished I would tell him what to do. If he had had a heart attack, it would be simpler – there is a “party line” for that. But primary prevention isn’t that straightforward or universally agreed on. So I only provide the evidence and the options.

I don’t babysit. I want to empower.

Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.



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