Triage pathways make patients feel disconnected from their doctors

There are things we (the providers) do to health care that are hurtful. We make protocols and rules that divide us from our patients. Protocols that sometimes make patients feel alone, distant, and disconnected from their doctors. I don’t mean algorithms of care (safe, standardized ways of how and why to treat pneumonia, for example), I mean clinic rules for helping patients schedule and get in to see doctors appropriately.

Triage pathways, if you will.

I hear about these protocol-type irritations from patients all the time. Because I’m a part-time practicing pediatrician, it’s often hard for families to see me when they want. Yesterday, a patient informed me about calling one time while in route to her daughter’s appointment. She had been at a trauma hospital with a family member who was receiving care for a life-threatening condition. She was trying to make it on time to the appointment, but wanted me to know she’d be a few minutes late. She called the clinic and the receptionist said, “No, Doctor Swanson won’t see you.” Of course, this is untrue on some level. In her state of stress, I would always love to make allowances. I work in clinic to help families, precisely when life is upside down. But because of a script and protocol, she was pushed away. Of course, if we saw everyone who arrived late, we’d never be on time or reliable, ultimately rendering us less useful. Protocols do make sense. But they don’t take outliers (life) or individual patients into account.

Many things clinics do in efforts to improve care for all, hurt individuals. The utilitarian-like clinic doctrines I tend to hate. I think of these protocols as walls. Tall structures built up to protect us all from the abuse that only a few people will commit. On occasion, these walls break down the relationship that exists between doctors and patients.

This hit home recently.

Around noon, I was interrupted while writing a post about Tylenol and immunizations. O was having another self-hitting-frantic-mega-tantrum. These started about 5 days ago and can last up to an hour or more.  They have become increasingly alarming to me. After a recent event, I wanted to talk with my son’s pediatrician. She’s in clinic today, but knowing that (for hundreds of reasons) it’s impossible in the year 2010 to call your doctor, I called to schedule an appointment. I’m worried about O, as is my husband. Over the last 5 days he has had a huge shift in behavior. We wonder if he’s hurting, ill, or worse. We’ve had a busy few weeks; I’ve been working late into the evenings and the boys are rising early with the sun. We’re all very tired. Hopefully I’m blowing this way out of proportion.

I call to make the appointment. The scheduler (receptionist) and I get through the name spelling, the date of birth, the doctor I want to see. She asks why I want an appointment and I say, “behavior problem.” This comes out of my mouth, I think, only because I often see patients for this exact complaint in my own clinic. She asks me to clarify, which I do. Then, I get put on hold.

The scheduler returns to ask if this is the first time O would be seen for this issue.

“Yes,” I say. Then, another hold…

She returns with the kicker, “Well, I’ll have to get a good phone number for you. I’m going to forward this to the nurse and she will call you later today to discuss.”

All I wanted to do was schedule an appointment! I wasn’t calling for advice; I wanted an appointment for my son to be examined by the pediatrician who knows him.

Some red-hot word I used (tantrum, I suspect) pushed the scheduler down a protocol. I get it. I know why this happened. But it’s not what I (as parent) and I (as doctor) feel is right. If I were a health administrator, I may feel differently. Thankfully, I’m not.

The thing is, instantly, I was more alarmed and more alone than before. Feeling pushed apart from the pediatrician, I felt more vulnerable and scared for my son. Less a part of a team that cares for him and ultimately isolated. Of course, in these moments, patients often turn to the internet. I see why. And although I have the fortune of many friends (and pediatricians) to call, I wanted to do discuss this more formally.

This may seem like a silly example.There is no imminent threat. No urgent care problem. I bring it up as yet another example of the distance we need to travel in health reform to facilitate caring for patients again. The more we centralize, standardize, and protocolize, the more space we find between doctors and patients. Really, all I wanted to do was schedule an appointment. Centralized scheduling and a protocol got in the way.

Evolving electronic medical records, “e-charts,” e-mail, and other advances will help. Yet, in health care, sometimes it really does feel like we’re trying to build businesses instead of care for patients.

As I always say to patients in clinic, when it comes to health care in America, don’t be afraid to be a squeaky wheel. Often to get what you or your children need, you may need to be loud and insistent.

I’ll calm down and I’ll get back to the Tylenol post. But I do hope to talk and see O’s pediatrician. Would like to bring the divide back together again.

Wendy Sue Swanson is a pediatrician who blogs at Seattle Mama Doc.

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  • HJ

    “Often to get what you or your children need, you may need to be loud and insistent.”

    So you want patients to complain?

    • Wendy Sue Swanson, MD

      Not complain, but advocate. Complaining isn’t productive but advocacy and insistence are.

      • HJ

        “…advocacy and insistence are.”

        You mean nagging? Or perhaps some passive aggressive behavior?

        What happens when all the wheels squeak?

        • Wendy Sue Swanson, MD

          I really don’t mean nagging. I mean taking the time to explain, in detail, what your concerns are.
          I mean explaining to staff and providers what your fears/concerns are so that they can work to help.
          I mean speaking up when (or if) you’re intimidated by a provider or staff member, system, or protocol.
          I mean…
          “It’s always okay to ask” any question until you feel you understand and have been heard.
          When all the wheels squeak? I don’t know if I have ever seen it. Even in the “most difficult” families.

  • Keegan Duchicela

    As a fellow parent and a physician, I sympathize with your frustration.

    I’m concerned that the push for the medical home model will foster the use of more triage trees.

    We should first work on the 4 “A’s” (and I credit my father for teaching me these): Ability, Accessibility, Affordability, and Affability.

    • Kim Lucas

      The 4 “A’s”: Ability, Accessibility, Affordability, and Affability.
      Love the simple brilliance of it. Bravo to your Dad-and you.
      My daughter has to memorize her schools mission statement. This should be the mantra all medical students, residents and physicians recite on a regular basis.

  • jsmith

    Uh, the whole point of the PCMH is to disconnect pts from doctors because doctors cost too much and are too scarce for routine care. I suspect Dr. Swanson won’t be a fan.

  • Sandra

    I’m a huge fan of having inoming patient needs triaged appropriately by skilled RNs. The US public’s health literacy level is 8th grade at best. We don’t have the luxury of having everyone make appointments with MDs regardless of the reason when a third to a half of all appointments could’ve and should’ve been handled by an RN or other non-MD team member. As an MD who has been doing this for 25+ years in Int Medicine, i do not want to have appts wherein I give basic RN or basic PT advice. I want to do MD-level work! So I want my appts triaged, as Sweden does (world’s #1 health care system).

    • HJ

      I suffered for 2 years while the medical assistants and nurses triaged me to the physicians assistants. I have learned it is better to triage myself because my literacy level is higher than the 8th grade. And it sure beats nagging and all those negative feelings I had pleading for help.

      If the differential diagnosis is made over the phone by a non-MD, then why should I spend the extra money to see an MD when I can get cheaper care from a retail clinic.

      • Sandra

        All I am saying is that about half of the US public’s medical needs don’t require MD level expertise and those issues can and should be filtered out by competent RNs (of which not every RN is competent for this triaging role). Those issues that don’t require MD expertise can actually be addressed well in retail clinics. I’m sorry you suffered for 2 yrs, don’t know your situation but about 2-3 months into it you could’ve at that point demanded to see an MD.

        • HJ

          “don’t know your situation but about 2-3 months into it you could’ve at that point demanded to see an MD.”

          I don’t have a medical degree.

          Yes, nag and complain. I ended up finding the information I needed and referred myself to a specialist.

  • HealthAdmin

    I AM a healthcare administrator and I could not agree more with this post. I was highly offended, however, by the implication that we (healthcare administrators at all levels–private practice, public hospitals, etc) create the problem and, thus, are among the chief causes of the patient-physician divide.

    I finally left the practice I was most recently managing after my attempts at changing the long-standing barriers to encourage better patient care were consistently–and in no uncertain terms–shut down. The two physician owners did not want to be bothered with any inconveniences that would prevent them from getting to the golf course after scheduled tee-off. (I don’t mean this in a condescending manner–that was literally their automatic, canned response). After 17 months of banging my head against the wall over and over and over and over again–the only place I found myself was further in the hole that I found myself digging. The lack of ethics was appalling and I could not hide my disgust: they were going to fire me, an administrator with a masters degree, for a placating mouse-like office manager soon enough and so I left.

    My efforts to enable urgent messages to be delivered to doctors immediately, to consider patient circumstances on a case-by-case basis, and for patients to be treated as people rather than charts were not just a professional goal, but a personal vendetta. At 31 years old, I am 18 months in remission from a nearly-fatal cancer. 6 months of highly toxic chemotherapy, multiple transfusions and human growth factors, several anaphylactic shocks, 3 life-threatening infections, and two hospitalizations for PCP pneumonia and MRSA rendered my relationship and access to my oncologist absolutely crucial to my survival. I was utterly shocked, then, to see a group of endocrinologists give the impression of being extremely put out when a patient in diabetic crisis demanded –in tears from a hospital bed–to speak to his/her own doctor because the physician on call was a complete stranger and they were frightened. I understand that my example is likely a problem of corrupt practice culture (and a very toxic and contagious sense of self-importance as in, “we’re the best GD endocrinologists in the region. They had better be damn lucky we even see him!”), but the same existed when I consistently tried to make f/u appointments with my own primary care doctor. During my cancer treatment, we had grown close. After relaying frequent instances of her staff refusing to pass along a message to her (much like your own example of attempting to get your son seen), the scheduler would discuss the issue with the M.A. The M.A. would then recommend an office visit (even if I was calling for a simple question), and that office visit would be scheduled for two months out because they are chronically overbooked AND booked out). My doctor would then wonder why I waited so long to ask her a very simple question and finally–FINALLY–began to realize that she had a very loyal set of gatekeepers/sentries who thought they were protecting her time and therefore doing right by her. It took my PCP hiring a consultant to re-train the staff that such behavior was only alienating the patient. In fact, statistics proved that a not insignificant percent of the patient volume had left for that reason. Eventually, the doctor gave me her private e-mail address and I now schedule appointments through her directly. Just another example of improper training and misguided goals.

    My father was a cardiologist and is of the mindset that Administration is “the enemy.” That is a very divisive and antiquated way of thinking. We are your allies–particularly in this uncertain time of healthcare reform. Any administrator who challenges that belief should be seriously counseled and perhaps fired. However, I think you will find that we (physicians and administrators) share more common values and goals than you had perceived.

  • Wendy Sue Swanson, MD

    I agree we are aligned. I work with a great practice manager and a well intentioned facility medical directory (MD) and with exceptional medical directors, all with good intentions. NO ONE in my office is running out the door for a golf game. And we remain in high demand…

    As I said in the opening sentence, “There are things that we (the providers) do in health care that hurtful.” I believe the final decisions for these protocols fall on MDs shoulders, not administrators. I didn’t mean to imply there was a villain.

    I am appreciative of your story, and I am sorry for your difficulty in seeing your doc. But you did just what I recommended:
    You spoke up, explained your case, you squeaked wheels and now have figured out a system that works for you.

    I agree with you that physicians and administrators are allies. I am thankful for the expertise in my clinic–without their leadership I wouldn’t get to see patients as fluidly as I do.
    Thank you for your comment. I hope you can find a group of docs with more parallel goals to your own. I can assure you there are many out there…

  • minutemoon

    I’ll tell you another protocol that annoys some patients — the way chaprones are often handled. Often, patients are not asked if they want a chaperone. A chaperone just shows up with the doctor. Most often there’s no choice of chaperone gender — thus, men will most often get female chaperones. Often, chaperones are disguised as “assistants,” although, these “assistants” do nothing more than watch and/or hand something now and then to the doctor. When asked why a chaperone, the answer is often for patient comfort or for patient protection — when, in fact, the real reason is for the protection of the doctor or nurse. This needs to change. Patient autonomy and choice needs to be respected. See the following website for a discussion of this issue:

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