My nurse regularly gets at least 50 voicemails every day, many saying “please call me back”.
I have one patient who frequently tests the patience of our clinic staff by calling multiple times for the same thing. He is the most dramatic example of what seems to be a widely held belief that physicians, nurses and medical assistants sit at their desks and answer phone calls all or most of their time. But when we do, we are often hampered by busy signals, phone tag or “voice mail not set up”. Electronic messaging isn’t a panacea, because patients don’t necessarily know what we need to know in order to answer their questions correctly and efficiently at first contact.
Pharmacies, too, create duplicate requests that bog down our workdays. In my EMR, if an electronic refill request doesn’t get a response the day it comes in, the “system” sends a repeat request every day until it gets done. This is one reason I look like I am further behind on “tasks” than I really am. To top it off, every single refill request generated by the “system” comes with a red exclamation point next to it. This happens even when a patient has just picked up their last 90 day refill – a case where I theoretically should have 89 days to respond. Meanwhile, my system has no way of flagging truly urgent refill requests. This “alarm fatigue” is common in EMRs today.
The business model in today’s healthcare is that reimbursable activities (seeing patients in person or via telemedicine) are scheduled back to back, all day long. There is a universal assumption that this will still provide enough slack to deal with prescription refills, phone calls, incoming reports and the further ordering and feedback to patients prompted by them. And did I mention EMR documentation? Multitasking, or rather, constantly switching between different kinds of tasks, is not a sane or efficient way to work.
Providers, as salaried employees, are universally expected to get their work done on their own time (jokingly called “pajama time”). This creates varying degrees of stress and burnout. But nurses and medical assistants have a different stress. As hourly employees, they are theoretically entitled to overtime pay if they can’t finish their work during their normal working hours. But that is expensive for healthcare organizations and often discouraged or forbidden.
In Sweden, known for its somewhat stodgy bureaucracy, clinics almost universally have “telefontid”, a portion of the day when patients can call, or when staff are not seeing patients but returning calls – the details can vary. This may not be ideal customer service, but it at least acknowledges that multitasking in healthcare isn’t always necessary and certainly not healthy.
A growing trend in this country, mysterious to me and a generator of patient frustration and employee stress, is that in spite of all our expensive computers and phone systems – or perhaps because of them – most clinics, even large organizations, can’t afford to have someone answer the telephone.
St Joseph Hospital in Bangor usually answers on the first ring, and the main operator (I know her voice well) is efficient and helpful. My mother worked as an operator for a big hotel and also at one point the phone company. I remember watching her efficiency plugging in those little cables to transfer callers to the right department. Most clinics and hospitals tell you to hang up and call 911 if you’re in trouble and make you “listen carefully” to all the options, threatening that they “may have changed” and eventually you end up in somebody’s voicemail.
When everybody is talking about patient centeredness, customer experience and such things, why isn’t it obvious that incoming calls and other types of requests need to be prioritized as they arrive and not just dumped, unsorted, in someone’s voicemail or inbox?
Organizations appear to be paranoid about being held responsible if non-clinicians are put in a position to “triage” incoming calls. But it isn’t rocket science – everybody does it at home, with their kids, pets and themselves. I believe it may be an even greater liability to have an automated telephone system people get lost or stuck in.
Here are two slides from a staff education talk I gave 10 years ago about common sense telephone triage.
The telephone used to be a powerful tool, connecting people with businesses, services and each other. It no longer works like it used to, because nobody’s answering.
A Country Doctor Writes: 
At the engineerng/geoscience company where I spent most of my career, at one point we were overwhelmed, so we set aside the time from 9-12 every morning when we did not take calls. The receptionist, who did not want to lie, simply said we were unavailable at the moment, and requested a call back number. We did not want and did not have a robot in the line. The calls were all to be returned as soon as lunch break was over. This worked very well, as long as we needed the system. We were not generally working with life and death situations, although we were dealing with construction sites.
A person answers our phone. Even with 3 lines you may hear a busy signal and know to call back. When we have ended the day, you may go to voice mail or call an emergency after hours number which is also answered by a person.
A couple of months ago I was charged by an unfamiliar dog while out walking. It nipped me, breaking the skin. The wounds were minor. I didn’t know if rabies was an issue so I called my doctor’s office purely for reassurance. I pressed 1 to “speak to a nurse” as instructed. I was told by the one who answered that I should wash and watch my wounds. I then asked about possible danger of rabies, which was really my only concern. She said she would have to ask the MA. The MA said I needed to go to urgent care. I put in an online “hold my place” appointment and they responded almost immediately. I was told that I needed to go to the urgent care at the hospital because they had the necessary immunoglobulin. So I asked again if I really needed to get rabies shots. The answer was yes. I headed over to the more expensive urgent care connected to the ER. Eventually I was given a tetanus shot (it had been almost ten years, although I see now some are questioning the need for boosters) and after all the hassle that doctor said there was minimal risk of rabies, so I would not be getting the shots. In the meantime I verified lack of risk with a local veterinarian who said there hadn’t been a case of rabies in dogs in many years in this area. Oh, how I wish I had called the veterinarian first!!! Then AFTER I got back to work the health department called and said CDC guidelines indicate I definitely need to get the rabies shots! I didn’t get them, even knowing rabies is fatal. And it looks like there is now a possibility that my insurance may not cover any of the expenses. I confess my opinion has been lowered after this experience and I will not ever again press 1 to “speak to a nurse” at my doctor’s office. I’ll just consult Dr. Google and embrace the one answer among many that matches most closely what I want it to be.
WOW! bow wow pun intended. Did you receive a lot of right and wrong information. Any bite by any rabid animal that breaks the skin can transmit rabies. Quick wash with soap and water is the best prevention. Biggest missing information is whether the dog is vaccinated. Is the dog restrained? The dog should be isolated and observed for 2 weeks if it is not showing any signs of rabies. If the dog is gone, again pun intended, rabies vaccine is a valid option. Rabies absence in the geographic area is a relative information to let you ‘off the hook”. Hope you stay well, and bet you do. You have some risk, but the vet is insightful that it is small.
Thanks! I did find out about the dog’s owners a few days after the incident and the dog was then quarantined with no signs of illness.
Great! Hope the dog was vaccinated or soon will be. Stay well.