Letters from Maine



I had a little unexpected time on my hands. A double well-child checkup turned into a no-show. (We are still fine-tuning our appointment reminder system.) Instead of going back to my office to check my e-mails, I decided to hang out next to the triage nurse’s desk while I waited for the next family to arrive.

I didn’t keep an exact tally but I am guessing that I listened to the nurse’s side of a half dozen phone calls. It sounded as though at least two (or a third) of the calls were call backs. Although I was interpreting conversations based on only half of the dialogues, my perception is that these two incoming calls could have been prevented if during the original encounter one additional fragment of anticipatory guidance had been provided.

I suspect if I had eavesdropped for the entire day, maybe a third of the calls could have been prevented with more complete advice during the initial office visit or phone call. However, I am sure that considering the volume of incoming calls we receive each day, the number of preventable ones is significant.

I know that most physicians are frustrated by the phone calls they must deal with after hours and in the course of a busy day in the office. The calls are more than a nuisance. They can create a significant drag on the bottom line. The physician must either sacrifice productive time when she could be seeing patients or pay someone else to field those calls – or in many cases both.

Years ago, I learned two phone-related strategies that helped me survive the years when I practiced solo and took call three or four nights a week. The first is to finish each unstable office encounter with a promise to call the next morning to check on how things are going. An unstable visit is one in which either the parents or I am not confident that the patient will be better the next day. The classic example of an unstable visit is one in which the presumed diagnosis is viral gastroenteritis. Otitis media in a child who doesn’t appear sick is an example of a stable encounter.

If parents are expecting a call from me, they are more likely to hold a question until I have called them, saving an incoming call. In some cases, the morning follow-up call might allow me to intervene early in a situation that seems to be worsening, preventing a call from the ED.

The second strategy is to give that extra bit of anticipatory guidance that I suspect had been forgotten in those calls on which I had eavesdropped. Here are just a few examples of some two- or three-liners that have helped keep my incoming calls more manageable:

• "While I was cleaning the wax out of Jason’s ear, I scratched his ear canal. You might notice a spot or two of blood later today. Call if there is more than that."

• "Swimmer’s ear takes a day or two longer to get better than the middle-ear infections you have been familiar with. So, she may not feel better tomorrow. But, she shouldn’t be worse."

• "When his umbilical cord falls off, there may be a spot or two of blood. Call if there is one bigger than a quarter."

• To the parent whose toddler has just run into the door jamb and sounds fine, you could say: "He may vomit once from the excitement, but if he vomits more than once or isn’t acting himself, call immediately.

• "Her temperature is a 102 F now. It may go up, even to 104 F, but as long as everything else is the same as it is now, you don’t have to call. Remember, I will be calling you in the morning."

Thirty seconds of anticipatory guidance at 3:00 o’clock in the afternoon may save you one 10-minute call at 3:00 in the morning. It sounds like a good investment to me.

This column, "Letters From Maine," regularly appears in Pediatric News, a publication of Frontline Medical Communications. Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at pdnews@elsevier.com.

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