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More woes of telephone medicine. “A night call from a patient who complained of back pain. The doctor quickly established the pain was an old problem and asked the patient if he could leave the consultation until the next morning. The patient agreed but later had a mild myocardial infarction. He had not had time to report his chest pain. The researchers urge doctors to consider the possibility of a hidden concern, especially during a late night call and to give patients time to explain their chief complaint. Asking: ‘Is there anything else you want me to know about?’ can be used to uncover potentially important information.”

Is the best way to prevent such sue-worthy scenarios is just to send everyone to the ER after hours?

Comments

Anonymous
If the symptom(s) that patients have are bad enough,such as back pain,to warrant waking up anybody, a physician in the midst of his REM is useless. If you’re a patient and is tempted to wake up your doctor, just go to the ER for evaluation. If you’re a doctor, you know that your judgment is impaired because you have just been awakened from a nice deep sleep and you’re irritated or is in a state of semi-consciousness. So just tell your patients, go see a doctor at the ER.
“Asking: ‘Is there anything else you want me to know about?’ can be used to uncover potentially important information.”
Come on,people, be realistic.
Do you think any human being just awakened want to prolong the conversation? So do yourself a favor. Go to the ER.
And if you’re an ER doctor,I feel your pain.
Anonymous
Is the best way to prevent such sue-worthy scenarios is just to send everyone to the ER after hours?
I am an ER doc. This health care system is just too HARD. You really cannot give any medical advice over the phone, no matter how simple. You need to tell the patient to come to the ER, and you need to understand when they get here we will probably overtest them and likely admit them; for the same reason you sent them. We’re all in this for one reason right now. To survive and retire as soon as we can. The lawyers are just too interventional right now to take any chances,
dr john
After-hours calls for diagnoses and medicines, which we primary care doctors honor out of kindness, are performed for no payment.
Years later at trial, these acts of kindness morph into, “he was too busy to see me, and just said to take these pills”.
Anonymous
I agree with anonymous 1:46. As an OB/Gyn, I already get enough calls in the middle of the night for deliveries. Telephone consultations regarding pregnant women with headaches could represent a minor problem or it could be serious. There is no way I could triage these calls and keep sane (especially after 30 hour days). Even airline pilots get mandatory time off.
Anonymous
I am an ER doc. I sometimes answer the general phone when the secretaries go out to smoke and I am expecting a call back. Patients call for all kinds of crazy advice and questions. I kindly tell them I am a secretary and unauthorized to give any advice over the phone.
I completely understand the primary docs sending the patients in at night. I assume they understand me sending them back for follow up of their nebulous complaints.
Anonymous
Yeah, send them to the ED. It’s job security for us.
But, when you do, don’t:
a) tell them “I’ll call ahead and tell them all about you” if you’re not going to,
b) tell them “I’ll call and make sure you’re seen right away”, or
c) tell them “Have the ER doc call me when you get there”. We have better things to do, and can handle most of these complaints without waking you.
If you have a sepcial patient, come in and see them. Otherwise, they’re just another patient to us, no better, no worse.
GruntDoc
Aggravated DocSurg
I agree with Dr. John. There is little place for common sense in these situations in this day of hyperactive trial lawyers. It is safer for one’s sanity and “legal behind” to refer these patients to the ED. A large majority of such calls I receive are really about inconsequential issues, but at 2AM, there can sometimes be now way to discern that.
Greg P
One of the things I can foresee with the attitude of “sending everything to the ER” is further decline in confidence in doctors. Eventually, we can expect people to be hooked up to machines with computerized algorithms making diagnostic and treatment decisions. The only reason we are still “needed” by the system is for the liability suits, since machines and computer programs don’t “know” anything, but we “should have known” the patient was in trouble.
We have to hand back some element of responsibility to patients to use their own judgment about going to the ER, telling them, “I can’t diagnose over the telephone.”
Furthermore, a recent item in the local news (Kentucky) is that the Medicaid program is going to stop paying for “unnecessary” ER visits by Medicaid recipients – as usual decided after the fact (sorry, your chest pain was just indigestion, we’re not paying). Which will mean, hospitals won’t be able to turn them away, but they won’t get paid either.
Anonymous
“There is little place for common sense in these situations in this day of hyperactive trial lawyers.”
Another excellent physician diagnosis. Keep up the good work fellas.
CJD
Anonymous
The doctor in bed just awakened at 2 AM has a totally different concern and goal than the patient who woke him/her up. The patient wants to get rid of that pain or symptom. The doctor wants to go back to sleep and not be liable.
Neither parties are concern whether Medicaid will pay or not, or whether the hospital will go bankrupt or whether his HMO will pay or not at 2 AM. Of course the patient may not know that the physician has a different goal or concern. Self preservation is the name of the game at this hour.The patient is thinking “he’s my doctor, he can help me” while the doctor is thinking ” what time is it? oh my god it’s 2AM and this guy is waking me up for his back pain, I’m so f…. tired, I want to sleep..I don’t know why he thinks I can do something about it right now..”. It’s human nature. I think the best thing is for the patient to be advised go to the ER.
Anonymous
“Neither parties are concern whether Medicaid will pay or not”
And that’s the fundamental problem with healthcare.
Anonymous
….and if we poor slob patients just GO to the ER without calling the PCP, we can get stuck with the whole bill for not consulting the PCP first if we turn out not to be near death. THAT’s why we call. So why do you answer the phone?
Anonymous
You just can’t do any favors anymore. I get asked by nurses and other staff to write a prescription for them or a family member for various things because they don’t want to go to their doctor, pay their co-pay to be seen an as official ER patient, or have a full examination. I work for a large ER group and we used to do things like that out of kindness. Well you guessed it — two lawsuits have resulted from that type of courtesy. To make it worse there is not an official record of documentation so we are sol when it comes to our own malpractice insurance.
So sorry, no more free friendly advice. None.
OBstructed
“…poor slob patients go to ER without calling the PCP…”
That’s the system the American public, and physicians too, have bought into. The only true winners are the health insurance companies.
Anonymous
“You just can’t do any favors anymore. I get asked by nurses and other staff to write a prescription for them or a family member for various things because they don’t want to go to their doctor, pay their co-pay to be seen an as official ER patient”
It is so hard to tell these patients (usually a friend or family member of the nurse you work with)you can’t just write a “zpack” cause of the liability. “You need to sign in” Last week a nurse from the floor came down to the ED and asked for a script for her rash; it was Lyme Disease. I refused to write it, I told her to sign in; she refused to sign in. Thanks lawyers.
Anonymous
“So why do you answer the phone?”
Because if we don’t answer the phone, we’re liable.It may be considered by CJD’s buddies as patient abandonment. Damn if you do and damn if you don’t.
Anonymous
“Thanks lawyers.”
I blame the patient/friend/nurse more for this scenario. Lets get this right. You don’t want to do things the right way and inconvenience yourself, so you ask and inconvenience a doctor you know to do a favor “on the side” without a true documented exam and follow up. Then something unforseen happens and you decide to sue your doctor friends ass for trying to do you a little courteous favor.
One bad apple ruins it for the bunch.
Anonymous
Q: Why is it that CJD can sleep soundly at night without interruption?
A: Because he’s dreaming of that jackpot he might just hit tomorrow.
Anonymous
Agree with GruntDoc above.
If you are sending your patient to the ER don’t give them the impression that we are waiting for them and that they will get preferential treatment just because they are your patient. If the triage nurse sees that they have a sniffle or a hangnail they will wait for 4+ hours with the rest of the coughing, vomiting, homeless, drunken humanity.
Anonymous
Does insurance really requires one to call a doctor before going to the ER? I thought it doesn’t apply to night-time emergencies, does it?
I am a patient, and I’d never dream of waking a doctor in the middle of the night except in cases when I just had an outpatient procedure and the doctor specifically instructed me to call him/her anytime if I have specific problems such as serious bleeding that doesn’t stop (my periodontist gives his home number after surgeries, although thankfully I haven’t had to use it – it would be a difficult thing for me to do since I don’t like to bother people). If I think I have a real emergency, I’d call an ambulance or drive to the ER. To be honest, until I read this post, I haven’t even known calling a doctor off-hours is a possibility. With the exception of my periodontist, I’ve never had a doctor’s home number. Medical groups don’t usually give it.
Years ago when I had a chicken pox, I called an office on Saturday. The doctor specifically told me the day before to call the office if it starts hurting (my symptoms just started at that time – I just knew what it was because I knew I was exposed, so I wasn’t yet uncomfortable and she didn’t recommend anything). She suggested I use Aveeno bath. If she had told me during the visit “if you become uncomfortable, do this…”, I wouldn’t have needed to call the office.
I was always wondering about those “if it turns out to be non-emergency, you will not be reimbursed”. How can I know in advance if my chest/stomache/whatever pain is serious? Although most insurance policies I had, only specified certain small amount I’d have to pay that will be waived if I am admitted. Still, it is ridiculous to bother anybody in the middle of the night to save $100.
dr john
I’ve taken primary care calls for 20 years, and manipulative calls have become the norm. Callers identify themselves as loyal and regular patients of the doctor I’m covering, and ask for asthma meds, back meds, antibiotics, etc.
Monday morning I learn they haven’t seen their doctor in years, and only call in for refills when other docs cover on nights and weekends.
The answer will come when we can demand payment for telephone care.
dr john
I’ve taken primary care calls for 20 years, and manipulative calls have become the norm. Callers identify themselves as loyal and regular patients of the doctor I’m covering, and ask for asthma meds, back meds, antibiotics, etc.
Monday morning I learn they haven’t seen their doctor in years, and only call in for refills when other docs cover on nights and weekends.
The answer will come when we can demand payment for telephone care.
Anonymous
“Does insurance really requires one to call a doctor before going to the ER? I thought it doesn’t apply to night-time emergencies, does it?”
I think most states (maybe it is federal standard) have a prudent layperson standard for ER visits. That is if a patient thinks a symptom could be serious the insurance is obligated whether it turns out to be something trivial. However the insurance companies are ALWAYS trying to stiff us on this one. The insurance company will say we are not contracted with them (the ER) and say they will pay whatever they want to pay (which is often a ridiculous pittance). It is quite commonplace for the insurance company to downgrade the payment, even though it often takes extensive testing, contemplation, increased medical-legal risk to arrive at the conclusion that a patients symptom is not serious. It is often much more taxing (especially in todays legal environment) to arrive at a diagnosis of “bronchitis” or “costochondritis” than it is to see, treat, and admit the obvious MI or pulmonary embolus.
Anonymous
“Because if we don’t answer the phone, we’re liable.It may be considered by CJD’s buddies as patient abandonment. Damn if you do and damn if you don’t.”
Now here’s an expert in the law!
Anonymous
“Excuse me, How much longer is the wait gonna be” she stated as she walked up to the desk in her high heels, and fancy dress. She had been in a car accident, no identifiable injuries, just wanted to “be checked out”. “If I’m not seen in 5 minutes, I’m leaving” (We all pray she leaves) If I had a dime for every time I heard this. Meanwhile a 25 year old is being coded within her sight.
Anonymous
My favorite “What the hell is taking so long” Was a 20 year old woman who signed in at 2 am because she had swallowed some guys sperm when she was “doing him a favor” and she wanted to be treated “in case” she got an STD. After 5 minutes in the room she started yelling at us that the wait was too long!
Anonymous
That’s a heck of a favor.
CJD.
Anonymous
I hear trial attorneys do that all the time for their shameless “star” expert witnesses all the time?

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