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Can You Hold Please? How Internal Medicine Residents Deal With Patient Telephone Calls
Can You Hold Please? How Internal Medicine Residents Deal With Patient Telephone Calls MARK D. HANNIS, MD, D. MICHAEL ELNICKI, MD, DOUGLAS K. MORRIS, MA, MICHAEL T. FLANNERY, MD, AND THE TELEPHONE ENCOUNTERS LEARNING INITIATIVE GROUP
ABSTRACT: Little is known about the mechanisms used in internal medicine residency programs to handle patient telephone calls. To address this, a survey of internal medicine residents was conducted at 10 different internal medicine residency programs. The response rate was 76% (N = 388). Approximately 90% of the residents handled patient telephone calls. The residents saw a mean of 7 patients per week in clinic (standard deviation ± 2) and received an average of 2 patient calls daily (standard deviation ± 2). The mean number of patient calls received each night on-call was 3 (standard deviation ± 6) and on weekend call days, an average of 4 patient calls were received (standard deviation ± 8). Internal medicine residents reported spending an average of 7 minutes per call talking to the patient (standard deviation ± 5) and 8 minutes in follow-up activities (standard deviation ± 6). Residents reported documenting calls less than 35% of the time. Residents disagreed with the statements "I am very satisfied with my patient telephone call system" and "My patients are very satisfied with my telephone call system." Most internal medicine residents handle a significant amount of patient telephone calls, and the systems for handling these calls are less than satisfactory. The procedures used to manage patient calls and the training for this component of practice should be improved. KEY INDEXING TERMS: Telephone medicine; Survey; Residents; Internal medicine; Systems. [Am J Med Sci 1994;308(6):349-352.]
From the University of North Carolina-Chapel Hill, Chapel Hill, North Carolina. Supported by institutional grants from many of the collaborative institutions and by the General Internal Medicine Faculty Development Program at the University of North Carolina at Chapel Hill (PE54004, HRSA Bureau of Health Professions, Rockville, MDJ. Correspondence: Mark D. Hannis, MD, East Carolina University School of Medicine, Room 389 TA, PCMH, Greenville, NC 278584354. THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES
T
he telephone has become as much a part of the physician's standard equipment as the stethoscope. 1 Approximately 25% of all patient encounters in general internal medicine are by telephone. 2 Telephone encounters in internal medicine are complex and frequently address new or acute medical problems. These calls often result in further use of resources, such as office consultation, laboratory testing, and telephone prescriptions. 2•3 Much variability in individual physicians' practice patterns regarding such resource use has been demonstrated for telephone-based medical care. 2 ,4 Based on their studies, researchers suggest that patients and physicians are dissatisfied with their telephone encounters in primary care settings. 4- 7 Despite the obvious significance of this aspect of medical practice, no reports of internal medicine residents' telephone practice or oftheir education regarding the use of the telephone in patient care have appeared in the literature. The Telephone Encounters Learning Initiative began as a collaborative research project to address this deficiency. The primary objective of this project is to assess current practices regarding telephone-based medical care in internal medicine residency programs. In this report, we describe the findings of an initial investigation of how internal medicine residents handle patient telephone calls. The objective of this study was to describe the patient telephone call systems of 10 internal medicine residency programs. Specifically, we set out to assess procedures for handling patient telephone calls, the process of telephone call documentation, and attitudes of residents toward telephone encounters and their telephone systems. Methods A 52-item questionnaire was administered to internal medicine residents at the 10 collaborative Telephone Encounters Learning Initiative institutions (listed in appendix A) in May 1993. These internal medicine residency programs are diverse geographically and include a mixture of traditional, primary care, community, and university programs. All categorical and preliminary internal medicine, medicine-psychiatry, and 349
Residents' Patient Telephone Calls
Table 1. Resident Characteristics (N = 388) Median age (yrs) Male Female Postgraduate year one Postgraduate years 2 or 3 Other postgraduates Categorical internal medicine Primary care internal medicine Medicine/Pediatrics Medicine/Psychiatry Preliminary
30 67% 33% 40% 54% 6% 64% 15% 8% 3% 5%
(258) (129) (153) (212) (22) (247) (59) (30) (11)
(19)
medicine-pediatrics residents were surveyed in each program. Noninternal medicine residents were excluded from the study. This exclusion would have applied, for example, to family medicine or emergency medicine residents who were rotating on internal medicine services. In developing our questionnaire, we first reviewed two previously published surveys used to evaluate training programs in telephone medicine for pediatric and family medicine housestaff.8 ,9 Additional items were added as appropriate, and the survey was reviewed by experts in survey research a..'"ld a telephone medicine consultant. The questionnaire then was pretested on internal medicine residents at the University of North Carolina at Chapel Hill and revised to its final form, based on this pretesting. The questionnaire was distributed directly to the residents, usually at a noon conference, and they were contacted no more than three times by telephone to encourage their response. Questions were either single answer multiple choice, Likert scales, or fill in the blank, which were used primarily for numeric data. Questions generally fell into three categories-those dealing with the procedures and processes of handling patient calls, those relating to attitudes toward calls and the systems for dealing with them, or questions relating to residents' perceptions of their telephone medicine training. Only data from the first two categories are reported here. Analysis was performed using SAS to calculate means and frequencies. 10
doing so. In addition, 77% of residents stated that physicians "usually provided" the initial medical advice for their patients. Very few residents reported having the assistance of nurses or other personnel to deal with their telephone practice. The diversity of mechanisms for handling patient calls was striking. Approximately 60% noted that daytime patient calls were "usually handled" by the patient's own resident physician; however, a variety of other mechanisms for handling daytime calls were indicated. A cross-covering physician was noted to be responsible for daytime calls by 21 %, the emergency department by 9%, and rarely, fellows, attendings, or others. After-hours patient telephone calls were reported to be handled by the patient's own physician by 8% of respondents, a cross-covering physician by 37%, the emergency department by 21 %, and fellows, attendings, or others were responsible for the remainder. Forty-two percent of residents stated they answered faculty patient calls and 65% answered calls from physicians outside the institution. These residents spent a significant amount of time talking to patients on the telephone. The estimated number of patient telephone calls reported by the residents is shown in Table 2. They saw a mean (standard deviation ± 2) of 7 patients per week in the outpatient clinic-usually in one half-day session. An average of 2 patient calls daily (during daytime hours) was noted, and an average of 3 calls during a night on call was reported. A mean of 4 patient calls were received during a 24-hour weekend call day. A rather large standard deviation was observed for nighttime and weekend calls rates, and the distribution of responses was skewed toward higher numbers of calls. The residents estimated spending a mean of 7 minutes per call actually talking to the patient (standard deviation ± 5) and another 8 minutes per call doing follow-up management (standard deviation ± 6). Follow-up management included such activities as calling a pharmacy or scheduling an appointment. Overall, this translates into more than 30 minutes spent each day in telephone encounters or approximately 4 hours per week (assuming 1 weekday and 1/2 weekend call day per week).
Results
Questionnaires were distributed to 526 residents, with a response rate of 76% (N = 388). The respondents' characteristics are noted in Table 1. Their median age· was 30 and the male:female ratio was approximately 3 to 2. Postgraduate year-1 residents represented 40% of the sample. A few respondents in the combined programs were beyond postgraduate year 3. Most were categorical internal medicine residents. The majority of residents reported managing patient telephone calls-80% of first-year postgraduates and 93% of second-year postgraduates or beyond reported
350
Table 2. Estimated Number of Patient Telephone Calls
Type Patient clinic visits per week Daytime patient calls Weeknight on-call patient calls Weekend day on-call patient calls
Mean
Standard Deviation
7 2
2 2
3
6
4
8
December 1994 Volume 308 Number 6
Hannis et al
Daytime calls were usually from patients well known to the resident (67% of respondents); this number decreased to 30% for after-hours calls. Despite the prevalence of calls from patients unknown to the resident, only 23 % reported that the chart was "frequently available" to them during the daytime and less than 10% reported that the chart was "frequently available" after-hours. Corresponding to the poor chart availability, documentation was uncommon. Daytime calls requiring physician advice were "frequently documented" by only 33% and by only 14% after hours. When calls were documented in the chart, it was usually by a handwritten note. Very few reported use of a standardized telephone encounter record or dictation as a means of documentation. These residents thought that only approximately 50% of their patients' calls were appropriate and that less than 20% represented true emergencies. Likert scale responses for other questions about resident attitudes toward patient telephone calls and their telephone calls systems are shown in Table 3. Residents tended to disagree with the statement "I am very satisfied with my patient telephone call system," and they also tended to disagree with the statement "My patients are very satisfied with our telephone call system." They did not believe that telephone interactions with their patients were unrewarding, but appeared to be less than confident in their ability to manage these calls. Residents agreed that physicians should charge for telephone calls. Discussion
To our knowledge, this is the first published report concerning internal medicine residents' experiences with telephone medicine. Most internal medicine residents are actively involved in managing patient telephone calls and spend a significant amount of time doing so. The 4 hours per week reported here in patient telephone encounters is as much time as many residents in internal medicine spend in clinic each week.l1 Their systems for dealing with this responsibility are poorly developed and have not incorporated any of the amenities or conventions shown to be useful in this task, such as trained assistants, protocols, or encounter forms. 12-14 Systems for resident physician coverage of this responsibility appear to have developed somewhat arbitrarily and are certainly not uniform. These problems are not unique to internal medicine and also were demonstrated in pediatrics and family medicine training programs.8,9 More structured systems for handling telephone calls are important in many ways, including improvement of physician satisfaction and attitudes toward patients.6,IS The lack of proper documentation of telephone calls in internal medicine programs is disturbing. Many authors have described the medico-legal risk incurred by improper documentation of patient telephone interactions. 14,16,17 Simple maneuvers to avoid this risk, such THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES
Table 3. Residents' Attitudes Toward Patient Telephone Calls Question I am very satisfied with my patient telephone call system. My patients are very satisfied with our telephone call system. I am confident managing patient telephone calls. Telephone interactions with patients are unrewarding. Physicians should charge for patient telephone calls.
Mean*
SD
2.9
1.4
3.0
1.3
3.3
1.2
2.7
1.3
3.8
1.6
* Mean Likert scale response on scale 1 = Strongly Disagree through 6 = Strongly Agree.
as the use of a standardized encounter form and having the patient's medical record available for review, have been recommended. These appear to be used rarely by internal medicine residents. Further studies in family medicine showed that simply having a system for chart availability and standardized documentation is not enough to produce the desired results. 8,18 One author suggested that periodic simultaneous review of telephone operator records and residents' documentation forms may be necessary to ensure compliance. 18 Few studies have addressed resident attitudes toward this aspect of their practice. In one study, it was demonstrated that before a training intervention, family medicine residents had a negative reaction to patient calls approximately 12% of the time. They also believed that approximately 20% of calls from patients were unnecessary.19 In our study, it is suggested that internal medicine residents regard even a higher percentage of patient calls as inappropriate. Their degree of agreement with the need to charge for telephone encounters may reflect irritation. They did not seem to indicate that this aspect of their practice was unfulfilling, but they did appear to lack confidence in this aspect of their practice. They did not believe that their systems are satisfactory either for them or their patients. Educational programs in telephone medicine can improve self confidence and satisfaction for allied health personne1.20 In the study of family medicine residents discussed earlier, telephone medicine training decreased residents' negative attitudes and feelings that patient calls are unnecessary.19 This suggests that education and training may be important in improving internal medicine residents' satisfaction with and attitudes toward telephone medicine. Although we examined only a small sample of internal medicine residency programs, these are representative of the diversity among U.S. programs. Our study relied upon recall and self-report by the residents,
351
Residents' Patient Telephone Calls
rather than direct observation or time-motion study. This may be a minor limitation. Our response rate was quite high for this type of study, and our questionnaire reflects the previous work done in this area. Factor analysis of questionnaire items was not necessary for this report. In conclusion, in this study, we documented the telephone practices of internal medicine residents. These patient telephone management systems are a significant enterprise and clearly in need of improvement. Internal medicine training programs should follow the lead of their primary care counterparts in pediatrics and family medicine, with attempts to improve the practice and education of residents regarding telephone medicine. Specifically, better telephone call handling and documentation strategies should be implemented. Training programs should be developed that reflect the significance of telephone practice, discuss proper documentation and the appropriate uses of telephone calls, and focus on improving resident confidence and satisfaction with this aspect of their practice. Acknowledgments
The authors thank Peter Curtis, MD, Robert Devellis, PhD, and Pamela Runge Wood, MD, for their consultations in the preparation of this article. Appendix A
The Telephone Encounters Learning Initiative Group: Samuel Cykert, MD, Moses H. Cone Memorial Hospital; Micheal Elnicki, MD, West Virginia University; Micheal Flannery, MD, University of South Florida; David George, MD, Temple University; Ruth Hazard, Penn State University; Mark Hannis, MD, East Carolina University; Elizabeth Huber, MD, Medical College of Virginia; Tom Keyserling, MD, University of North Carolina at Chapel Hill; Gail Moses, MD, Medical College of Virginia; Paul Ogden, MD, Texas A&M University; Marylee Rothschild, MD, University of Louisville; and Miriam Settle, PhD, U niversity of North Carolina at Chapel Hill. References 1. Heagarty MC. From house calls to telephone calls. Am J Public Health 1978;68:14-5.
352
2. Radecki SE, Neville RE, Girard RA. Telephone patient management by primary care physicians. Med Care. 1989;27: 817-22. 3. Johnson BE, Johnson CA. Telephone medicine: a general internal medicine experience. J Gen Intern Med. 1990;5:234-9. 4. Evens S, Curtis P, Talbot A, Baer C, Smart A. Characteristics and perceptions of after-hours callers. Fam Pract. 1985;2: 10-6. 5. Darnell JC, Hiner SL, Neill PJ, Mamlin JJ, McDonald CJ, Hui SL, et al. After-hours telephone access to physicians with access to computerized medical records. Med Care. 1985;23: 20-6. 6. Fosarelli P, Schmitt B. Telephone dissatisfaction in pediatric practice: Denver and Baltimore. Pediatrics. 1987;80:28-31. 7. Fosarelli P, Katz H. Residents on the phone. Pediatrics. 1987;79:311-2. 8. Curtis P, Talbot A, Liebeseller V. The after-hours call: a survey of United States family practice residency programs. J Fam Pract. 1979;8:117-22. 9. Wood PRo Pediatric resident training in telephone management: a survey of training programs in the United States. Pediatrics. 1986;77:822-5. 10. SAS Institute Inc. The FREQ procedure in SAS/STAT user's guide, version 6.03, Cary, N.C., 1988, pp. 519-48. 11. Brook RH, Fink A, Kosecoff J, Linn LS, Watson WE, Davies AR, et al. Educating physicians and treating patients in the ambulatory setting: where are we going and how will we know when we get there. Ann Intern Med. 1987;107:392-8. 12. Katz HP, Pozen J, Mushlin AI. Quality assessment of a telephone care system utilizing non-physician personnel. Am J Pub Health. 1978;68:31-8. 13. Strasser PH, Levy JC, Lamb GA, Rosekrans J. Controlled clinical trial of pediatric telephone protocols. Pediatrics. 1979;64: 553-7. 14. Verdile VP, Paris PM, Stewart RD, Verdile LA. Emergency department telephone advice. Ann Emerg Med. 1989;18:278-82. 15. Villarreal SF, Berman S, Groothvis JR, Strange V, Schmitt BD. Telephone encounters in a university group practice. Clin Pediatr. 1984;23:456-8. 16. Willet DE. Medicine by telephone, continued: a legal opinion. Modern Medicine. May 15, 1977, pp. d73,77. 17. Killila BA. Undocumented phone calls: a liability issue. Indiana Med. 1990;83:768-9. 18. Hamadeh G. Documentation of after-hours telephone contacts by family medicine residents. Fam Med. 1989;21:305-6. 19. Fleming MF, Skochelak SE, Curtis P, Evens S. Evaluating the effectiveness of a telephone medicine curriculum. Med Care. 1988;26:211-6. 20. Marklund B, Silfverhielm B, Bengtsson C. Evaluation of an educational programme for telephone advisors in primary health care. Fam Pract. 6:263-7.
December 1994 Volume 308 Number 6
ABSTRACT: Little is known about the mechanisms used in internal medicine residency programs to handle patient telephone calls. To address this, a survey of internal medicine residents was conducted at 10 different internal medicine residency programs. The response rate was 76% (N = 388). Approximately 90% of the residents handled patient telephone calls. The residents saw a mean of 7 patients per week in clinic (standard deviation ± 2) and received an average of 2 patient calls daily (standard deviation ± 2). The mean number of patient calls received each night on-call was 3 (standard deviation ± 6) and on weekend call days, an average of 4 patient calls were received (standard deviation ± 8). Internal medicine residents reported spending an average of 7 minutes per call talking to the patient (standard deviation ± 5) and 8 minutes in follow-up activities (standard deviation ± 6). Residents reported documenting calls less than 35% of the time. Residents disagreed with the statements "I am very satisfied with my patient telephone call system" and "My patients are very satisfied with my telephone call system." Most internal medicine residents handle a significant amount of patient telephone calls, and the systems for handling these calls are less than satisfactory. The procedures used to manage patient calls and the training for this component of practice should be improved. KEY INDEXING TERMS: Telephone medicine; Survey; Residents; Internal medicine; Systems. [Am J Med Sci 1994;308(6):349-352.]
From the University of North Carolina-Chapel Hill, Chapel Hill, North Carolina. Supported by institutional grants from many of the collaborative institutions and by the General Internal Medicine Faculty Development Program at the University of North Carolina at Chapel Hill (PE54004, HRSA Bureau of Health Professions, Rockville, MDJ. Correspondence: Mark D. Hannis, MD, East Carolina University School of Medicine, Room 389 TA, PCMH, Greenville, NC 278584354. THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES
T
he telephone has become as much a part of the physician's standard equipment as the stethoscope. 1 Approximately 25% of all patient encounters in general internal medicine are by telephone. 2 Telephone encounters in internal medicine are complex and frequently address new or acute medical problems. These calls often result in further use of resources, such as office consultation, laboratory testing, and telephone prescriptions. 2•3 Much variability in individual physicians' practice patterns regarding such resource use has been demonstrated for telephone-based medical care. 2 ,4 Based on their studies, researchers suggest that patients and physicians are dissatisfied with their telephone encounters in primary care settings. 4- 7 Despite the obvious significance of this aspect of medical practice, no reports of internal medicine residents' telephone practice or oftheir education regarding the use of the telephone in patient care have appeared in the literature. The Telephone Encounters Learning Initiative began as a collaborative research project to address this deficiency. The primary objective of this project is to assess current practices regarding telephone-based medical care in internal medicine residency programs. In this report, we describe the findings of an initial investigation of how internal medicine residents handle patient telephone calls. The objective of this study was to describe the patient telephone call systems of 10 internal medicine residency programs. Specifically, we set out to assess procedures for handling patient telephone calls, the process of telephone call documentation, and attitudes of residents toward telephone encounters and their telephone systems. Methods A 52-item questionnaire was administered to internal medicine residents at the 10 collaborative Telephone Encounters Learning Initiative institutions (listed in appendix A) in May 1993. These internal medicine residency programs are diverse geographically and include a mixture of traditional, primary care, community, and university programs. All categorical and preliminary internal medicine, medicine-psychiatry, and 349
Residents' Patient Telephone Calls
Table 1. Resident Characteristics (N = 388) Median age (yrs) Male Female Postgraduate year one Postgraduate years 2 or 3 Other postgraduates Categorical internal medicine Primary care internal medicine Medicine/Pediatrics Medicine/Psychiatry Preliminary
30 67% 33% 40% 54% 6% 64% 15% 8% 3% 5%
(258) (129) (153) (212) (22) (247) (59) (30) (11)
(19)
medicine-pediatrics residents were surveyed in each program. Noninternal medicine residents were excluded from the study. This exclusion would have applied, for example, to family medicine or emergency medicine residents who were rotating on internal medicine services. In developing our questionnaire, we first reviewed two previously published surveys used to evaluate training programs in telephone medicine for pediatric and family medicine housestaff.8 ,9 Additional items were added as appropriate, and the survey was reviewed by experts in survey research a..'"ld a telephone medicine consultant. The questionnaire then was pretested on internal medicine residents at the University of North Carolina at Chapel Hill and revised to its final form, based on this pretesting. The questionnaire was distributed directly to the residents, usually at a noon conference, and they were contacted no more than three times by telephone to encourage their response. Questions were either single answer multiple choice, Likert scales, or fill in the blank, which were used primarily for numeric data. Questions generally fell into three categories-those dealing with the procedures and processes of handling patient calls, those relating to attitudes toward calls and the systems for dealing with them, or questions relating to residents' perceptions of their telephone medicine training. Only data from the first two categories are reported here. Analysis was performed using SAS to calculate means and frequencies. 10
doing so. In addition, 77% of residents stated that physicians "usually provided" the initial medical advice for their patients. Very few residents reported having the assistance of nurses or other personnel to deal with their telephone practice. The diversity of mechanisms for handling patient calls was striking. Approximately 60% noted that daytime patient calls were "usually handled" by the patient's own resident physician; however, a variety of other mechanisms for handling daytime calls were indicated. A cross-covering physician was noted to be responsible for daytime calls by 21 %, the emergency department by 9%, and rarely, fellows, attendings, or others. After-hours patient telephone calls were reported to be handled by the patient's own physician by 8% of respondents, a cross-covering physician by 37%, the emergency department by 21 %, and fellows, attendings, or others were responsible for the remainder. Forty-two percent of residents stated they answered faculty patient calls and 65% answered calls from physicians outside the institution. These residents spent a significant amount of time talking to patients on the telephone. The estimated number of patient telephone calls reported by the residents is shown in Table 2. They saw a mean (standard deviation ± 2) of 7 patients per week in the outpatient clinic-usually in one half-day session. An average of 2 patient calls daily (during daytime hours) was noted, and an average of 3 calls during a night on call was reported. A mean of 4 patient calls were received during a 24-hour weekend call day. A rather large standard deviation was observed for nighttime and weekend calls rates, and the distribution of responses was skewed toward higher numbers of calls. The residents estimated spending a mean of 7 minutes per call actually talking to the patient (standard deviation ± 5) and another 8 minutes per call doing follow-up management (standard deviation ± 6). Follow-up management included such activities as calling a pharmacy or scheduling an appointment. Overall, this translates into more than 30 minutes spent each day in telephone encounters or approximately 4 hours per week (assuming 1 weekday and 1/2 weekend call day per week).
Results
Questionnaires were distributed to 526 residents, with a response rate of 76% (N = 388). The respondents' characteristics are noted in Table 1. Their median age· was 30 and the male:female ratio was approximately 3 to 2. Postgraduate year-1 residents represented 40% of the sample. A few respondents in the combined programs were beyond postgraduate year 3. Most were categorical internal medicine residents. The majority of residents reported managing patient telephone calls-80% of first-year postgraduates and 93% of second-year postgraduates or beyond reported
350
Table 2. Estimated Number of Patient Telephone Calls
Type Patient clinic visits per week Daytime patient calls Weeknight on-call patient calls Weekend day on-call patient calls
Mean
Standard Deviation
7 2
2 2
3
6
4
8
December 1994 Volume 308 Number 6
Hannis et al
Daytime calls were usually from patients well known to the resident (67% of respondents); this number decreased to 30% for after-hours calls. Despite the prevalence of calls from patients unknown to the resident, only 23 % reported that the chart was "frequently available" to them during the daytime and less than 10% reported that the chart was "frequently available" after-hours. Corresponding to the poor chart availability, documentation was uncommon. Daytime calls requiring physician advice were "frequently documented" by only 33% and by only 14% after hours. When calls were documented in the chart, it was usually by a handwritten note. Very few reported use of a standardized telephone encounter record or dictation as a means of documentation. These residents thought that only approximately 50% of their patients' calls were appropriate and that less than 20% represented true emergencies. Likert scale responses for other questions about resident attitudes toward patient telephone calls and their telephone calls systems are shown in Table 3. Residents tended to disagree with the statement "I am very satisfied with my patient telephone call system," and they also tended to disagree with the statement "My patients are very satisfied with our telephone call system." They did not believe that telephone interactions with their patients were unrewarding, but appeared to be less than confident in their ability to manage these calls. Residents agreed that physicians should charge for telephone calls. Discussion
To our knowledge, this is the first published report concerning internal medicine residents' experiences with telephone medicine. Most internal medicine residents are actively involved in managing patient telephone calls and spend a significant amount of time doing so. The 4 hours per week reported here in patient telephone encounters is as much time as many residents in internal medicine spend in clinic each week.l1 Their systems for dealing with this responsibility are poorly developed and have not incorporated any of the amenities or conventions shown to be useful in this task, such as trained assistants, protocols, or encounter forms. 12-14 Systems for resident physician coverage of this responsibility appear to have developed somewhat arbitrarily and are certainly not uniform. These problems are not unique to internal medicine and also were demonstrated in pediatrics and family medicine training programs.8,9 More structured systems for handling telephone calls are important in many ways, including improvement of physician satisfaction and attitudes toward patients.6,IS The lack of proper documentation of telephone calls in internal medicine programs is disturbing. Many authors have described the medico-legal risk incurred by improper documentation of patient telephone interactions. 14,16,17 Simple maneuvers to avoid this risk, such THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES
Table 3. Residents' Attitudes Toward Patient Telephone Calls Question I am very satisfied with my patient telephone call system. My patients are very satisfied with our telephone call system. I am confident managing patient telephone calls. Telephone interactions with patients are unrewarding. Physicians should charge for patient telephone calls.
Mean*
SD
2.9
1.4
3.0
1.3
3.3
1.2
2.7
1.3
3.8
1.6
* Mean Likert scale response on scale 1 = Strongly Disagree through 6 = Strongly Agree.
as the use of a standardized encounter form and having the patient's medical record available for review, have been recommended. These appear to be used rarely by internal medicine residents. Further studies in family medicine showed that simply having a system for chart availability and standardized documentation is not enough to produce the desired results. 8,18 One author suggested that periodic simultaneous review of telephone operator records and residents' documentation forms may be necessary to ensure compliance. 18 Few studies have addressed resident attitudes toward this aspect of their practice. In one study, it was demonstrated that before a training intervention, family medicine residents had a negative reaction to patient calls approximately 12% of the time. They also believed that approximately 20% of calls from patients were unnecessary.19 In our study, it is suggested that internal medicine residents regard even a higher percentage of patient calls as inappropriate. Their degree of agreement with the need to charge for telephone encounters may reflect irritation. They did not seem to indicate that this aspect of their practice was unfulfilling, but they did appear to lack confidence in this aspect of their practice. They did not believe that their systems are satisfactory either for them or their patients. Educational programs in telephone medicine can improve self confidence and satisfaction for allied health personne1.20 In the study of family medicine residents discussed earlier, telephone medicine training decreased residents' negative attitudes and feelings that patient calls are unnecessary.19 This suggests that education and training may be important in improving internal medicine residents' satisfaction with and attitudes toward telephone medicine. Although we examined only a small sample of internal medicine residency programs, these are representative of the diversity among U.S. programs. Our study relied upon recall and self-report by the residents,
351
Residents' Patient Telephone Calls
rather than direct observation or time-motion study. This may be a minor limitation. Our response rate was quite high for this type of study, and our questionnaire reflects the previous work done in this area. Factor analysis of questionnaire items was not necessary for this report. In conclusion, in this study, we documented the telephone practices of internal medicine residents. These patient telephone management systems are a significant enterprise and clearly in need of improvement. Internal medicine training programs should follow the lead of their primary care counterparts in pediatrics and family medicine, with attempts to improve the practice and education of residents regarding telephone medicine. Specifically, better telephone call handling and documentation strategies should be implemented. Training programs should be developed that reflect the significance of telephone practice, discuss proper documentation and the appropriate uses of telephone calls, and focus on improving resident confidence and satisfaction with this aspect of their practice. Acknowledgments
The authors thank Peter Curtis, MD, Robert Devellis, PhD, and Pamela Runge Wood, MD, for their consultations in the preparation of this article. Appendix A
The Telephone Encounters Learning Initiative Group: Samuel Cykert, MD, Moses H. Cone Memorial Hospital; Micheal Elnicki, MD, West Virginia University; Micheal Flannery, MD, University of South Florida; David George, MD, Temple University; Ruth Hazard, Penn State University; Mark Hannis, MD, East Carolina University; Elizabeth Huber, MD, Medical College of Virginia; Tom Keyserling, MD, University of North Carolina at Chapel Hill; Gail Moses, MD, Medical College of Virginia; Paul Ogden, MD, Texas A&M University; Marylee Rothschild, MD, University of Louisville; and Miriam Settle, PhD, U niversity of North Carolina at Chapel Hill. References 1. Heagarty MC. From house calls to telephone calls. Am J Public Health 1978;68:14-5.
352
2. Radecki SE, Neville RE, Girard RA. Telephone patient management by primary care physicians. Med Care. 1989;27: 817-22. 3. Johnson BE, Johnson CA. Telephone medicine: a general internal medicine experience. J Gen Intern Med. 1990;5:234-9. 4. Evens S, Curtis P, Talbot A, Baer C, Smart A. Characteristics and perceptions of after-hours callers. Fam Pract. 1985;2: 10-6. 5. Darnell JC, Hiner SL, Neill PJ, Mamlin JJ, McDonald CJ, Hui SL, et al. After-hours telephone access to physicians with access to computerized medical records. Med Care. 1985;23: 20-6. 6. Fosarelli P, Schmitt B. Telephone dissatisfaction in pediatric practice: Denver and Baltimore. Pediatrics. 1987;80:28-31. 7. Fosarelli P, Katz H. Residents on the phone. Pediatrics. 1987;79:311-2. 8. Curtis P, Talbot A, Liebeseller V. The after-hours call: a survey of United States family practice residency programs. J Fam Pract. 1979;8:117-22. 9. Wood PRo Pediatric resident training in telephone management: a survey of training programs in the United States. Pediatrics. 1986;77:822-5. 10. SAS Institute Inc. The FREQ procedure in SAS/STAT user's guide, version 6.03, Cary, N.C., 1988, pp. 519-48. 11. Brook RH, Fink A, Kosecoff J, Linn LS, Watson WE, Davies AR, et al. Educating physicians and treating patients in the ambulatory setting: where are we going and how will we know when we get there. Ann Intern Med. 1987;107:392-8. 12. Katz HP, Pozen J, Mushlin AI. Quality assessment of a telephone care system utilizing non-physician personnel. Am J Pub Health. 1978;68:31-8. 13. Strasser PH, Levy JC, Lamb GA, Rosekrans J. Controlled clinical trial of pediatric telephone protocols. Pediatrics. 1979;64: 553-7. 14. Verdile VP, Paris PM, Stewart RD, Verdile LA. Emergency department telephone advice. Ann Emerg Med. 1989;18:278-82. 15. Villarreal SF, Berman S, Groothvis JR, Strange V, Schmitt BD. Telephone encounters in a university group practice. Clin Pediatr. 1984;23:456-8. 16. Willet DE. Medicine by telephone, continued: a legal opinion. Modern Medicine. May 15, 1977, pp. d73,77. 17. Killila BA. Undocumented phone calls: a liability issue. Indiana Med. 1990;83:768-9. 18. Hamadeh G. Documentation of after-hours telephone contacts by family medicine residents. Fam Med. 1989;21:305-6. 19. Fleming MF, Skochelak SE, Curtis P, Evens S. Evaluating the effectiveness of a telephone medicine curriculum. Med Care. 1988;26:211-6. 20. Marklund B, Silfverhielm B, Bengtsson C. Evaluation of an educational programme for telephone advisors in primary health care. Fam Pract. 6:263-7.
December 1994 Volume 308 Number 6