Telephone Management and E-medicine
Emily Borman-Shoap, MD, FAAP, and Iris Wagman Borowsky, MD, PhD, FAAP
The mother of an otherwise healthy 10-month-old girl calls and tells you that her daughter has a fever. The girl’s rectal temperature has been 39.4°C to 40.0°C (103°F to 104°F) for the past 2 days. Although she is fussy with the fever, she plays normally after receiving acetaminophen. The girl is eating well and has no runny nose, cough, vomiting, diarrhea, or rash.
Mother also mentions 2 other concerns that she has been meaning to bring up with you. The first involves questions about feeding and how to introduce table foods; the other is sleep problems. Her daughter has been waking up several times a night for the past month, and mother feels exhausted.
1. How do telephone and face-to-face encounters between physicians and patients differ?
2. What are some general guidelines for effective doctor-patient communication via telephone?
3. What historical information is necessary for appropriate telephone management?
4. What points are important to cover in home treatment advice?
5. For nonurgent issues, what are the possible roles of telephone encounters or e-medicine in patient care?
Parents and guardians are increasingly accessing their children’s health professional through avenues other than a typical office visit. Telephone management and electronic communications make up a substantial portion of a primary care physician’s time. It is estimated that pediatricians spend more than 25% of their total practice time engaged in telephone medicine. Telephone management includes triage of acute illness symptoms as well as ongoing preventive care and management of chronic conditions. Electronic communication also plays an increasing role in acute, chronic, and preventive care.
Telephone Management for Acute Illness
The main components of a telephone management encounter for acute illness mirror those of an office visit: establish rapport, gather a complete history, formulate an assessment and plan, ensure adequate follow-up, and document the encounter. The key difference is that often a telephone call offers no opportunity for a physical examination or direct observation of the child; however, video conferencing and the ability to send photographs electronically is beginning to minimize this difference. Obtaining a thorough history remains the critical component of telephone management, however. Closed-loop communication, with the parent/guardian or patient repeating back to the physician the plan of care, is also an important component of the telephone consultation.
Telephone Communication Skills: Establishing Rapport
Parents and guardians commonly call their pediatric health professional because they are worried about their child. The friendly voice of a staff member in the health professional’s office has a substantial role in reassuring an anxious parent. Each call should begin with a “verbal handshake.” Staff should identify themselves and the place in which the call is received and offer to help. They should learn the caller’s name, the caller’s relationship to the child, and the child’s name. Using the child’s name in conversation helps establish rapport and creates a more personal atmosphere.
Telephone calls for medical advice are often received in busy environments, such as emergency departments (EDs) or clinics, in which other patients are waiting to be seen. It is easy to be abrupt under these circumstances and not give complete attention to a caller. If a call is not an emergency, staff members can take the caller’s telephone number and return the call as soon as possible. The health professional who is returning a call to a patient should ensure it is a good time for the patient to receive a return call. Unsafe practices, such as talking while driving, should be avoided by both the health professional and the patient.
Studies show that the length of a patient visit does not correlate with patient satisfaction. Telephone encounters need not be lengthy; the average length of a call is reported to be 3 to 5 minutes, depending on the setting. Each call must be pleasant, however, and address the caller’s concerns. Open-ended statements and questions, such as, “Tell me about your child’s illness,” or “Are there any other symptoms?” are useful at the beginning of a call because they give the caller an opportunity to explain the situation without interruption.
Establishing rapport is more difficult on the telephone than in person because on the telephone the health professional is limited to verbal communication. In face-to-face encounters, the health professional can use words as well as means of nonverbal communication, such as facial expressions, eye contact, gesturing, and touch, to convey warmth and empathy. The health professional should use various aspects of verbal communication to convey sincere interest in a caller’s concerns and should pay attention to these verbal cues from the caller. Many components of verbal communication, including vocal expression, pace, articulation, tone, volume, and pauses, affect telephone interactions. The health professional should speak clearly and use vocabulary that the caller understands. Medical jargon should be avoided. A friendly yet respectful tone and a calm, professional manner should be maintained.
Careful listening is crucial to obtaining the information necessary to make medical decisions over the telephone. One of the major goals of the health professional is to recognize and respond to the caller’s main concerns and expectations. Researchers have found the following questions useful in the identification of parents’ chief concerns: “What worries you the most about [use child’s name] illness?” and “Why does that worry you?”
In interacting with a caller who rambles, it may be necessary for the health professional to focus the conversation. Asking the question, “What can I do to help?” should clarify the reason for the call. If it is necessary to verify information, the professional can summarize what has been heard and ask if they have understood correctly. Using a triage protocol book or similar resource can help the health professional streamline questions and aid in correct disposition of the patient.
The angry caller may elicit defensive or confrontational behavior from the health professional. Responding to anger with arguments is time-consuming, stressful, and pointless. The health professional should be warm and understanding to create an environment in which a caller who wishes to discuss his or her feelings is comfortable. Acknowledging anger may encourage open discussion and problem-solving (eg, “You sound upset. I am ready to help you. What can I do?”). Empathizing with the caller (eg, “I don’t blame you for being upset”; “That must have been very frustrating.”) and apologizing if the caller has experienced delays or barriers in accessing care is also helpful.
The health professional can build confidence in the caller by validating the steps that individual has already taken, such as, “You did the right thing by giving your child acetaminophen for the fever. That is exactly what I would have done.” “I’m glad that you called about this.” The health professional may even be able to offer reassurance to a parent or guardian who is not managing the child’s illness correctly by commenting that many parents and guardians try the same treatment. After providing that reassurance, a different treatment approach can be suggested.
Before the end of the conversation, the caller should be asked to “teach back” or summarize what the health professional has recommended and encouraged to call again if additional problems occur. For example, the physician might say, “I want to be sure I explained myself clearly. Can you tell me what you are planning to do now for your child?” Giving clear guidance about reasons to seek emergency care is particularly important.
Telephone History Taking
Most calls for triage of an acute problem are about upper respiratory symptoms, fever, rash, trauma, or gastrointestinal symptoms, that is, the same problems most commonly encountered in the office. With standardized history taking and home care advice, many patients with these chief concerns can be safely managed at home. Several excellent published telephone management protocols can aid the health care team in advising patients efficiently and appropriately. Many practices use nurses as the first point of contact for telephone triage, with the pediatrician serving as second-tier triage for more complex or worrisome concerns.
For the history obtained via telephone, it is necessary to gather sufficient information to make an appropriate decision. Questions should be asked with the aim of determining whether an emergency exists and making a diagnosis. The health professional should follow the same organized approach that would be used in the office setting (Box 5.1). Key features, such as patient age and past medical history, should guide questioning. For example, if the mother of a 20-day-old girl reports that the neonate has a temperature of 38.9°C (102°F), it is necessary to see the newborn in person immediately. An older child with the same chief report of fever may be safely managed at home, however, depending on the answers to other questions about additional symptoms. Similarly, knowledge that a child who has been exposed to chickenpox has a compromised immune system is crucial in providing appropriate telephone advice.
Additional specific questions should be asked to clarify the child’s condition and obtain all the information necessary to make a good decision. Many physicians can access electronic medical records (EMRs) remotely to review the child’s record, which can greatly aid in obtaining a thorough history. If review of the medical record is possible, it is reassuring for the health professional to share that information with the child’s caregiver by stating, for example, “I am reviewing your child’s medical record in the computer so that I can be sure I have all the information I need to give you good advice.”
Box 5.1. What to Ask
•How old is the child?
•What is the child’s chief problem? What are the child’s symptoms?
•How long has the child had these symptoms?
•How is the child acting?
•Does the child have any chronic illnesses?
•Is the child taking any medications?
•What are you most worried about?