At a certain point, we’ve all got to go home.
Whether it’s the end of the shift when the factory whistle blows and the assembly line stops rolling for a brief period while new people take our place, or late in the day after the last patient has been seen and our notes are all written and our portal messages have all been answered, we all want to go home, the day is done.
Or is it?
In health care, especially, things don’t always follow the clock. We have early morning hours, we have late evening hours, we have weekends where we see patients, and lots of patient care is often required after the last doctor has left the office.
What you’ve got is doc around the clock. Care never ends.
Administratively, when our practice closes, our telephones roll-over to an answering service. Patients who call our office after the appointed hour receive a recording that says something along the lines of the office is closed, if this is a medical emergency, please hang up and dial 911 right away, but if you’d like to speak to a provider, please continue to hold for the next available operator.
At which point, the call is routed to the telecommunications office at our main hospital, where those operators are standing by.
The operators sitting at their desks in the basement collect some information from the patient, including their name and a contact phone number, and then they page the on-call provider for practice.
Other calls besides clinical calls from patients come in to these same operators as well.
These include doctors at outside hospitals who wish to reach us about our patients who may have presented to them, and even specialists within our own institution trying to reach us.
Many people have also learned that it’s much easier to reach the practice at night. During the day, the calls get left on sometimes interminable hold, but at night they can quickly reach an operator and then get to the doctor on call.
This system often leads to lots of nonemergent phone calls, such as patients who want to get their routine lab results, pharmacies seeking routine refills, and sometimes people who just want to talk.
Our telephone operators are also tasked with receiving critical results from the labs, results that have finally come back from specimens collected at the practice during the day that need to be addressed by a provider immediately.
The potassium of 2.0 or 7.0, the glucose of 650 or 38. The positive blood cultures, the multilobar pneumonia on the chest X-ray, the blood clot on the lower extremity ultrasound, the acute MI, and so much more.
(What the lab actually does and does not call us about is a column for another day.)
Most of these clinical items are taken care of in the first few hours after the practice’s phones have closed, as the lab runs its specimens, or as radiology images get read.
In the hours between midnight and 8 a.m., most of the calls are of a much more clinical nature, an individual patient calling up saying they haven’t been feeling well, something’s the matter, I’m sick, and I need to know what to do next.
For these patients, there are basically only a couple of options.
We can recommend some treatment they should try for the next few hours, and see how they do, and then have them call us back.
If it sounds like something that can wait till the morning, we can dispense some advice of things to watch out for and tell them to come in for an appointment to be seen first thing.
Or if this is something for which we really need to lay eyes and hands on them in the next few minutes or hours, then the usual recommendation is that they should call 911, or hop in a taxi with someone, to proceed to the emergency room for a complete clinical evaluation to make sure this isn’t a stroke, a heart attack, internal bleeding, or other potentially life-threatening and time-sensitive health matters.
As we’ve reviewed these types of issues, these different things that patients call us for, that the lab calls us about, that other providers are reaching out to us to seek information and guidance about our patients on, it’s occurred to us that perhaps we can figure out a way to use technology and maybe even some artificial intelligence to get most of these things taken care of without waking up the doctor on call.
After having done this for many years, we all know that feeling of those middle of the night phone calls, when your pager goes off, your cell phone rings, and you’re jarred awake and out of bed to suddenly have to begin using your clinical brain.
Perhaps if we can figure out automated and other ways to selectively deal with most of these calls, and weed out only those that we really need to be clinically involved with, perhaps we can improve the lives of our patients, and the providers working in our practice as well.
We’re trying to figure out how to get the lab to contact us earlier in the day about items that are most likely going to turn into a critical-lab-value call later in the night.
If we do more part of point-of-care testing, especially for those things we suspect might need urgent attention, then perhaps fewer will turn into surprises at 11:30 at night.
If we can create an electronic medical record that’s the same for all providers all over the country, then we won’t need to be roused from our beds to look up a patient’s medication list or allergies or prior surgeries when they’ve presented to an emergency department somewhere out of state.
And if we can create a telephone tree that provides patients and pharmacies with a group of intelligent choices, a series of ways to leave non-urgent messages and request refills, and request their results, then maybe we can take care of these during our usual business hours.
Perhaps we can design and implement some effective screening questions and decision analyses to get the right call to the right person at the right time.
We’ve all been woken by the operator at 2:30 in the morning with a call from a patient who says she’s having trouble sleeping, at which point it inevitably runs through our head, “Great, now two of us are awake.”
But no matter what, we’re going to want to wake up and talk to our patient who is sick in the middle of the night.
I don’t want some automated system sending my patient to the emergency room or telling them to take two aspirin and call me in the morning.
If I have someone who’s at home and feeling bad and feeling scared, then all the electronic tools in the world won’t replace our clinical brains and the comfort we can provide to our patients in helping them make it through the night.
It’s your call.
Fred N. Pelzman is an internal medicine physician who blogs at MedPage Today’s Building the Patient-Centered Medical Home.
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