“I had an ultrasound yesterday…”

I have been spending a lot of time in the clinic lately, which means one thing: lots of patient calls.

The latest trend goes something like this:

  • Patient sees me in clinic. I order an ultrasound (or other test) for a non-urgent concern (mostly for heavy or irregular periods). I schedule a follow-up visit for a few days to a week after the test.
  • The test is completed
  • Within 48 hours of the test, I get a call from the patient wanting to know the results and the new plan.

I imagine this is just the latest manifestation of our on-demand, instant-gratification culture. Why am I complaining? Well, the biggest reason is that thoroughly counseling a patient on their ultrasound results and discussing the options going forward is about a 20-minute conversation, which is why I schedule these patients for a follow-up visit. When the patient comes to a follow-up visit, this means that I have time blocked out in my day to discuss the results.

Phone calls, on the other hand, are squeezed into my day whenever I can find the time – usually my lunch break or after I’m done seeing patients for the day. This sometimes means staying in the clinic until 6 or 6:30pm returning patient calls.

As a resident, this is a problem because I get to the point where I just can’t possibly squeeze all of the patient calls into my day without staying in the clinic for hours after what should be the end of my day. After graduation, it’s a problem because doctors don’t get paid for phone calls, so spending 20 minutes on the phone with you instead of 20 minutes talking to you in the clinic means I am working unpaid overtime. 

I can completely understand why patients would rather talk on the phone. If you could have your doctor’s visit over the phone, for free, without having to drive, park, or sit in a waiting room, wouldn’t you? What I think a lot of patients don’t realize is that the quality of the conversation is different over the phone. In the room, I draw pictures (admittedly not very good ones). I gesture. I point. I have educational materials. None of that is available over the phone. For that reason, I try really hard to do most of my patient education in person, and to keep the phone calls to

“Hi, Mrs. So-and-so. Do you remember how we talked about fibroids in the clinic? Well, your ultrasound confirms what we thought, and you do have fibroids, which are likely causing your bleeding. We talked about treatment options when you were in the clinic. Have you thought any more about which of those treatment options you would like to try first?”

Don't you love my stellar illustrating skills?

Don’t you love my stellar illustrating skills?

I’m not necessarily opposed to doing phone visits – what I am opposed to is the idea that patients expect me to call within 48 hours of a non-emergent test (before the results even land in my inbox), and work for free doing their counseling over the phone.

One patient had a test on Tuesday and called on Wednesday because she didn’t want to wait until her follow-up visit (on Thursday) to hear about her results. The test was an ultrasound to look for the cause of her irregular periods. She wasn’t bleeding at the time, wasn’t in pain, and wasn’t anemic. Why was this so urgent that she needed me to call her during my lunch break, instead of waiting 24 hours for her follow-up visit? She was a very pleasant patient, but her expectations felt unreasonable.

I try to set appropriate expectations in my patients – I tell them to schedule a follow-up visit, and thatraindrop we will discuss all of their results at that visit. I don’t tell them to expect a call. I’m not sure where they are getting the idea that they will get immediate phone follow-up. I think often they don’t realize what they are asking for when they call me to discuss results. They think that they should have access to their doctor when they need something, which isn’t unreasonable. They might even realize that returning phone calls means that I go without lunch, or that I am missing time with my family to call them. Instead, it reminds me of something I hear several years ago:

The raindrop never thinks it is to blame for the flood.

In other words, the individual patient doesn’t see it as a problem when they call for their results the day after the test. After all, what’s one phone call? When I am on a rotation where I spend most of my time on L&D and only see patients in clinic one day a week, these calls and messages aren’t a big deal. I see about 15 patients a day in the clinic, so if 10% of them call me, that’s 1-2 patients per week. No big deal. When I’m on a clinic rotation, though, 15 patients per day x 5 days per week x 10% is 7-8 patients per week. If I spend 20 minutes on each of these patients (including reading the message from the phone nurse, finding the result before it hits my inbox, calling the patient, and writing the note), that’s an extra 2.5 hours of work per week. In other words, that’s my entire 30-minute lunch break every day. No one patient is to blame, it’s the fact that everyone thinks they need just a few extra minutes of the doctor’s time.

 

The question is, how do we change this? I see three things:

  1. I’m going to be making an effort to tell patients when tests are ordered that it may take 1-2 weeks to review test results
  2. When patients call for results sooner than that, remind them of this policy or tell them we will discuss their results at their scheduled follow-up visit.
  3. Pay doctors for time spent on phone calls, with an option to bill by level of complexity or by time.

What do you think? How soon after a non-urgent test is it reasonable to call your doctor for results? Or, maybe a better question, who gets to decide which test results are urgent?

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