My general feeling on phone medicine is this –
If it’s important enough to call me for treatment, then it’s usually important enough for you to take the time to come in so that I can diagnose you properly.
That goes whether it’s a vaginal infection, irregular menstrual bleeding or what you think is menopausal symptoms. I have found after years of experience that a phone call is a poor substitute for a good old fashioned in-person history and physical.
Although most patients are grateful to be offered an appointment, not every patient likes to hear this. These are generally those whose calls start out something like this – “I need you to call in….”. For such patients, any attempt from me to get even a little history is treated like an annoyance. This in turn really annoys me, and I have to count to 10 before explaining patiently that I need to hear a little bit about what is going on with them so that I can prescribe properly, and that in some cases it may be necessary for them to come in. Thankfully, all but a few patients understand this once I explain it to them.
The Exceptions
One notable exception to my rule is the patient calling with an uncomplicated UTI. Research has shown that phone diagnosis and treatment is both timely and effective, and most guidelines allow for phone treatment if the diagnosis is clear and there are no other complicating factors. Not to mention that the symptoms can worsen rapidly over several hours, so that timely treatment is important. But I always offer an immediate appointment, and find that many women are grateful for the chance to see me or my nurse personally for the problem.
Notable for not being an exception are calls for yeast infections. That’s because by the time they call me for this problem, most patients will have already tried an over the counter regimen themselves. And self-diagnosis of vaginal yeast infections is notoriously inaccurate.
What about contraceptive problems? Well, I’ll play around with your pills over the phone for problems like nausea or moodiness or acne, and am more than willing to call in whatever brand your new plan covers. Irregular bleeding can be a tougher problem – sometimes it’s from missed pills, or an expected side effect of the method a patient is on (such as Depo Provera or the IUD). That’s where a few more questions can be helpful. Hopefully you are in a place where you can talk about private matters – not the coffee shop or your cubicle at work. If not, then you’re better off calling me back later or coming in so we can talk personally.
Menstrual irregularities? Well, I generally let everyone have one off-cycle a year provided they have a negative pregnancy test and there are no red flags like very heavy flow or severe pain. But honestly, if your cycle was different enough for you to pick up the phone and call me, it’s probably worth coming in, don’t you think? Because I’d really prefer to see you in person. And if there is any chance that you are pregnant, there’s no way we’re handling anything over the phone. So come on in. Today.
What about Money?
I like to think my view on phone treatment is not affected by reimbursement. But I can’t honestly say that if I worked in a high-volume managed-care practice, I might not be more willing to treat more over the phone.
Not surprisingly, money often affects the patient’s decision to come in or not. It’s not unusual to get a call from a patient asking for phone treatment because I am not in her plan and she does not want to have to pay for a visit. In these cases, I will do what I can for her over the phone provided I can do so safely, but encourage her to change to an in-plan doc so that finances don’t affect her healthcare decisions.
The Future
It’s interesting to hypothesize how tele-medicine might change my practice someday. Or reimbursement for phone calls. But somehow I can’t quite imagine that I’ll ever be able to do a pelvic exam over the phone, so I wouldn’t predict my practice to change much…
I totally agree with you. Even if I could charge for “phone consults” with patients, most evaluations are much better done in person than over the phone.
You missed the advice most often given: go to the ER.
GruntDoc
I wish my doctor were more like you! But, I’m with an HMO (Kaiser Permanente), and it seems like phone appointments are pretty normal. I called for an appointment and was told that I could only have a phone appointment the next day.
It sucked.
I usually tell women, “Periods have a mind of their own. It’s proof that God is a man.”
If I call my physician, it’s almost always beceause I’m not sure whether or not my problem warrants an appointment. I want to be told to come in if that’s appropriate.
The last time I called my physician, it was because I was having an extrodinarily heavy period. It was my first period after two babies with no period in between. I figured it was probably okay, but wanted to make sure. They told me to come in right away, so I cancelled the afternoon class I was supposed to teach and drove 45 minutes so the physician could look at my chart and tell me it was normal. She did not ask any questions beyond my intake form, nor did she examine me.
I’d have been happy to pay a small fee for a phone consult, but I was pretty annoyed about the lost work time and gasoline in addition to the cost of an office visit that I apprently didn’t need. Perhaps it wasn’t mercenary, but it came off that way.
Scruggling says:
1-976-doctors!
Serious business could be had here. People call in (1-976-DOCTORS) and have a warm, nurturing voice on the other end.
“Hi, this is the Nurse, Veronica. tell me your name”
“Hi, I am Bill.”
“Hi, Bill, can I get your credit card so we can chat about what’s wrong?”
“Sure…”, Bill willingly hands over his card number.
“Thanks, Bill, tell me how I can help you…”
You see where the value proposition is here, right?
or better yet…
“Hi, this is the nurse, Bill”
“hi, this is Veronica”
Bill goes on to collect the history…
“OK, Veronica, just a few questions for you that I need to help oout, OK? Please tell me your height and weight.”
“I am 5’5 and 150 lbs.”
Bill replies, “that sounds, great, Veronica, nicely proportioned…”
And the time clicks away in either case. You can charge by the minute, and with good telemarketers, you can make a fortune!
On a serious note, I always prefer the office visit over the phone screen unless it is a routine and expected prescription refill. I don’t love it when my doc can’t see me that day though. It’s great tohear that you make the effort to give someone the appointment. It’s just simply better if there is a face to face interaction and dialogue. I am sure that my non-medical descriptions of what is wrong won’t help the doc at all. I am sure that YUCK is far too vague a term, and that “…it’s sort of a sharp, dull pain” won’t help over the phone.
By the way, I am happy to pay for the office visit if the doc gives me the chance for a last minute appointment.
Schruggling adds:
Perhaps a few phone tricks from Lilly Tomlin might help the phone service…
http://members.aol.com/nrb409/ernestine.wav
http://members.aol.com/nrb409/assistnc.wav
http://members.aol.com/nrb409/brochure.wav
http://members.aol.com/nrb409/snick.wav
“One notable exception to my rule is the patient calling with an uncomplicated UTI.”
Bless you. I’ve practically sent my doctor roses because he’s willing to do the same.
I’ve read the studies on uncomplicated UTIs, but in my experience it’s not that easy. I don’t know if it’s my patient population (young, uninsured) but I’d estimate that a third of what is billed as a UTI is not (herpes, yeast, cervicitis, dysuria). So I tend to have them come in, usually same day. Some are annoyed.
I do call diflucan in for antibiotic associated vaginitis, but for other cases I usually see.
The one I feel worst about bringing in is head lice. But I’ve had so many parents convinced their kid has lice who doesn’t. Makes me feel like an ass tho, when a mom calls in for lice, hauls the kid in, and I say “Yup, it’s lice”.
MWAK: There is a pilot program for phone call fees going on in our place – it’ll be interesting to see what comes of it.
GD: 🙂
Amanda: Frustrating – an appointment for a phonecall? Hope it wasn;t an urgent problem….
Anonymous: Bleeding is always the hardest thing to triage it could be nothing, it could be something not so good…An exam would have been nice, though…
Schtrugglin- Out of control, as usual, and I’m lovin it as usual. How much do I love Ernestine???
Anonymous: Hey – no one ever sent me roses for treating their UTI…Can I be your doctor?
Dr Smak: I find the most important symptoms are those of urgency and frequency along with the dysuria. Without those, dysuria could be anything, and herpes is right up there at the top of the list. I agree, and almost always bring them in. But for those who can’t (and on weekends, where those post-coital UTI’s tend to flare on Sunday mornings) I call in if it’s straightforward.
Linked your blog, BTW. Nice.