As we think about improving access to care, one of the issues that often comes up is after-hours care: how we provide it, whether we should provide it, how much of it we should provide, and what forms it might take.
First and foremost, we should ensure that our patients can reach us throughout the day, that someone always answers the phone, and that a live human being picks up in a timely manner and is able to get our patients to the right care at the right time, no matter what they need.
Our patients call for a myriad of reasons: for refills, new complaints, or urgent needs; to get their results or talk to their doctor.
But once the practice closes, how do we best see to the needs of our patients, in a way that is equitable and safe?
There have been many different versions of after-hours care that have developed through the years, and there are certainly opportunities to create new ways to handle this, as our ability to access our patient’s records, to e-prescribe medications, and even to do video visits in the middle of the night has evolved.
I have many friends who when their practices close roll their phones over to an answering service where patients are greeted with a pre-recorded message that says the practice is closed, please call back in the morning; if this is a medical emergency, hang up and dial 911 or go to the nearest emergency department.
No option to get to a live covering provider.
Some have another option, to speak to an on-call provider, but it is often made quite clear that this should be reserved for certain specific medical situations. God forbid the doctor is roused from sleep to refill someone’s antihistamine.
I know practices where the phone operators are given language meant to encourage the leaving of a message and discourage the waking up of the doctor on-call.
But how do our patients know whether this is the right time to wake the doctor up to talk to them about what’s going on?
The reasons patients call in the middle of the night vary widely. Sometimes they’ve been unable to reach us during the day, or forgotten that they are out of a medicine they need. Sometimes it’s that they are having trouble sleeping and need someone to talk to.
We’ve all been on call and had patients call up and tell us they’re having what sounds like a serious potentially life-threatening event, and they want our reassurance that it’s okay that they wait until the morning. (No, hang up, and call 911.)
As technology develops further, perhaps we will be able to do more over the phone at night, including physical examination through video and remote monitoring, and maybe even lab testing.
Patients may someday be able to do their 12-lead ECG from home, and transmit it directly to our office, or prick their finger and touch it to their smart phone so we can instantly check a highly sensitive troponin test to see if they’re having a heart attack.
We’ve all taken calls overnight where we felt we did a lot of good, where we saved someone a trip to the emergency room, where we were able to reassure someone that they’re going to be all right, or insisted that they come in for care to make sure they’re safe.
It strikes me as somewhat crazy that we still have people sitting inside answering phones in the basement of the hospital, who then call us on our cellphones and tell us that the patient wants to talk to us.
I think it would make a lot more sense if we just forwarded calls to a dedicated on-call cellphone (or at least a dedicated voicemail on our personal phones), or if we were able to find some other better way of electronically or clinically screening these calls.
Personally, I don’t get a lot of sleep on the nights I’m on call, not because we get that many calls, but on those nights I’m taken back to the time when I was an intern, trying to get a couple of hours’ sleep in the call room of the hospital with my pager next to me, waiting for that sound tattooed on all our brains grabbing me up from the depths of sleep.
Being so much older now, I’m already up a couple of times as it is to use the bathroom during the night, so I pretty much know that I’m going to be a wreck the next day at work after a night on call, even if no calls come through at all.
Perhaps much of the answer is providing the best care we can through the day, making sure our patients can reach us, making sure they can easily get their prescriptions refilled, making sure they can do same-day appointments and video visits for acute complaints, and then what happens at night will end up only being the serious stuff that really needs to be attended to during those hours when the practice is closed.
If we can address our patients’ needs, from their durable medical equipment prescriptions and home-care forms through their mental health care during our usual office hours, then perhaps the nights can become a quieter time reserved for major acute events that need someone to be woken up from slumber.
Let’s sleep on it and see what we can change.
Fred N. Pelzman, MD, of Weill Cornell Internal Medicine Associates and weekly blogger for MedPage Today, follows what’s going on in the world of primary care medicine from the perspective of his own practice.
Last Updated July 26, 2021
Source: MedicalNewsToday.com
