After-hours telephone calls in a family practice residency: volume, seriousness, and patient satisfaction

BACKGROUND: After-hours calls are common in primary care physicians' practices. Calls may be unnecessary from the physician's perspective, but patients may have a different concept of the importance of reaching their physician immediately. This study's purpose was to compare physician and patient perceptions of the same telephone call episode. METHODS: Family practice residents (n = 19) recorded all patient-initiated after-hours telephone contacts (n = 192) during July 1993. Study personnel then telephoned, within 1 week of their call, the patients who made the calls. Patients were asked about the reason for their call, its seriousness, and their satisfaction with the handling of their problem. RESULTS: During the study month, 1.1 after-hours calls were received for every 10 office visits. A substantial minority of patients (29%) rated their problems in the highest severity category, while physicians assigned only 8% of calls the highest severity rating. The majority of patients (76.7%) were satisfied with how their after-hours calls were handled. CONCLUSIONS: In matched cases, physicians and patients perceive about the same proportion of calls to be routine versus more severe. Although patient satisfaction was high, further research into causes of dissatisfaction is needed.     

Physician attitudes regarding telephone medicine

OBJECTIVE: To measure physicians' attitudes regarding telephone medicine and identify determinants of these attitudes. DESIGN: Cross-sectional survey. SETTING: Ten internal medicine residency programs in the United States. PARTICIPANTS: Graduates from 1988 through 1992. The response rate was 62% (n = 356). MEASUREMENTS AND MAIN RESULTS: Survey items were assigned to one of four types of variables: demographic, attitude, training, or system variables. We used factor analysis to consolidate information from the individual questions about attitudes. Six scales describing attitudes toward telephone medicine were identified. Cronbach's alpha was greater than 0.70 for all scales. One scale measured physicians' satisfaction and confidence with the management of patient calls. Other attitude scales measured the helpfulness of personal experience or informal education and the importance of formal training in telephone medicine. Three of the scales measured how comfortable the physician felt prescribing over the telephone. We used regression analysis to predict physician attitudes towards telephone medicine using the demographic, training, and system variables. Availability of the patient's chart, feeling prepared for telephone medicine by one's residency training, and being comfortable prescribing narcotics by telephone predicted satisfaction and confidence with the management of patient calls (R2 = .25). CONCLUSIONS: Several physician attitudes regarding telephone medicine can be measured reliably. Our findings suggest that improving systems for managing patient calls and improving telephone training for physicians will improve physician satisfaction and confidence with the practice of telephone medicine.     

Primary care: nurse-led telephone triage and advice out-of-hours

In this article the authors report on the evaluation of an out-of-hours telephone triage and advice service in general practice. A computer-based decision support tool was used to guide nurses in the assessment of patients and outcome for calls. Data from the computer system were analysed for all calls over a six-month period. The researchers found that the nurses were able to handle just over half the calls received by giving advice alone. Overall, the service appeared to be remarkably consistent in the decisions taken by nurses, and training and organisational issues to be considered in the future development of the service were identified.     

A telephone survey of day-surgery eye patients

The objective of this research study was to evaluate the nursing care processes and patient satisfaction with the new day-surgery services. Forty-five adult day-surgery eye patients were selected at random to take part in a telephone survey. The response rate was 84.4% (38). Patients were contacted 48 hours post-surgery to obtain their view of the entire surgical experience. The research result found that the majority of the patients were satisfied with the day-surgery services. The main problems experienced by patients were long waiting times to see the doctor during pre-operation assessment, unsatisfactory journeys to and from theatre, and difficulty in remembering verbal advice. Twenty-eight (73.6%) of the day-surgery patients would prefer day-surgery again for a similar operation, but 10 (26.3%) would prefer a longer stay in hospital. The main implications for practice are that realistic assessment time should be allocated to reduce waiting time, verbal advice should be accompanied by written leaflets or audio-tape, and patients should be encouraged to make an informed choice about day or in-patient surgery. A regular survey of day-surgery eye patients should be part of a general audit.     

General pediatricians, pediatric subspecialists, and pediatric primary care

OBJECTIVE: To assess the respective roles of general pediatricians and pediatric subspecialists in the provision of primary pediatric care. DESIGN AND METHODS: A practice characteristics questionnaire that included questions about primary care was sent to a random sample of 1616 board-certified and board-eligible active Fellows of the American Academy of Pediatrics; 1145 (70.9%) responded. Analyses pertain to those pediatricians who provided ambulatory patient care and were not in graduate medical education training at the time of the survey. Respondents were divided into 2 groups for purposes of analysis: the 527 pediatricians whose practice was primarily in general pediatrics (defined as 80% of time spent in general pediatrics or any time spent in adolescent medicine) and the 213 pediatricians whose practice was subspecialty focused (all others). These groups were then further stratified according to whether they provided primary care. The resultant subgroups contained 518 general pediatricians and 98 subspecialists who provided primary care. RESULTS: Among the entire sample, general pediatricians indicated that general pediatricians provide 93% of the primary care delivered by their practice and that pediatric subspecialists provide 2% of the primary care. In contrast, pediatric subspecialists reported that general pediatricians provide 53% of the primary care delivered by their practice and that subspecialists provide 32% of such care (P<.001). Among the subsample of pediatricians who provide primary care, general pediatricians reported delivering 88% of the primary care received by their patients and subspecialists reported delivering 74% of the primary care received by their patients (P<.001). CONCLUSION: Perspectives on the degree to which pediatric subspecialists provide primary pediatric care vary depending on generalist vs subspecialist self-identification.     

Improving home care. A survey on physician and nurse communication

Home health care is growing, and phone calls between physicians and home care nurses are essential to successful home care patient management. This preliminary study analyzed several aspects of the physician and home health nurse telephone communication, including effectiveness, time expenditure, percentage of calls resolved by physicians, and documentation of phone contacts between 90 medical/surgical physicians and six home health nurses in Cleveland, Ohio. The phone conversations involved 154 patient contacts during a 3-month period. Overall, we found 75% of the home calls were effective. Eighty-five percent of calls required 15 minutes or less for completion, 47% of nurse-generated calls were resolved by physicians, and 26% of calls were documented in the patient's medical record. Our results illuminated several aspects of home care communication amenable to improvement.     

Sharing care: the psychiatrist in the family physician's office

OBJECTIVE: One way of strengthening ties between primary care providers and psychiatrists is for a psychiatrist to visit a primary care practice on a regular basis to see and discuss patients and to provide educational input and advice for family physicians. This paper reviews the experiences of a program in Hamilton, Ontario that brings psychiatrists and counsellors into the offices of 88 local family physicians in 36 practices. METHOD: Data are presented based on the activities of psychiatrists working in 13 practices over a 2-year period. Data were gathered from forms routinely completed by family physicians when making a referral and by psychiatrists whenever they saw a new case. An annual satisfaction questionnaire for all providers participating in the program was also used to gather information. RESULTS: Over a 2-year period, 1021 patients were seen in consultation by one full-time equivalent psychiatrist. The average duration of a consultation was 51 minutes, and a family member was present for 12% of the visits. Twenty-one percent of the patients were seen for at least one follow-up visit, 75% of which were prearranged. In addition, 1515 cases were discussed during these visits without the patient being seen. All participants had a high satisfaction rating for their involvement with the project. CONCLUSIONS: Benefits of this approach include increased accessibility to psychiatric consultation, enhanced continuity of care, support for family physicians, and improved communication between psychiatrists and family physicians. This model, which has great potential for innovative approaches to continuing education and resident placements, demands new skills of participating psychiatrists.     

Nurse triage for house call requests in a Tyneside general practice: patients' views and effect on doctor workload

BACKGROUND: Demand for consultations in primary care has risen recently, necessitating a change in working practices. As part of this process, the possible contribution of practice nurses in the telephone assessment of home visit requests merits attention. AIMS: To survey the views of our patients encountering our nurse triage system for home visit requests, set up in June 1995, and to plot its effect on the routine visiting workload of our doctors and thus their availability at the surgery. METHOD: The outcome of each request was categorized as: doctor to visit (DV), surgery consultation with doctor (SC), nurse advice given and accepted (NA), or call passed to doctor for advice (DA). Frequency data from September 1995 to December 1996 were recovered. Questionnaires for self-completion were sent to all those requesting a routine weekday house call during two four-week periods in 1995 and 1996. RESULTS: Analysable activity data revealed 1764 house call requests, with 41% DV, 18% SC, 24% NA, and 8% DA. In the first survey, 121 questionnaires were sent out and 84 returned (69% response rate) and, in the second, the corresponding figures were 113, 85, and 75%. About 80% of responders reported that they were satisfied with the help received from the nurse. CONCLUSIONS: Nurse triage of house call requests has led to more efficient care for our patients, as we have increased the availability of surgery consultations by reducing the number of house calls made by our general practitioners.     

Firearm injury prevention counseling by pediatricians and family physicians. Practices and beliefs

OBJECTIVES: To ascertain and compare beliefs, attitudes, and counseling practices of primary care physicians of children and adolescents regarding firearm injury prevention counseling. DESIGN: Cross-sectional survey. SETTING: State of Washington. SUBJECTS: All active members of the state chapters of the American Academy of Pediatrics and American Academy of Family Physicians. A total of 979 pediatricians and family physicians (53%) responded to the survey after two mailings. MAIN OUTCOME MEASURES: Attitudes, beliefs, and current practices with regard to firearm safety counseling among families of child and adolescent patients. RESULTS: Only 25% of pediatricians and 12% of family physicians currently counsel more than 5% of their patients. Pediatricians were more likely than family physicians (70% vs 46%, P < .001, chi 2 test) to believe that physicians have a responsibility to counsel families about firearm safety. Pediatricians recommended removing guns from the home more frequently than family physicians (32% vs 19%, P < .001, chi 2 test), but most physicians of both specialties perceived that parents are rarely receptive to this advice. However, 97% of physicians from both specialties agreed that firearms should be stored locked separately from ammunition, and a substantial majority believed that parents would be receptive to this advice. Compared with physicians who owned guns (32%), non-owners were 15 times more likely (odds ratio, 15; 95% confidence interval, 10 to 23) to agree that families with children should not keep firearms in the home. CONCLUSIONS: Few primary care physicians who see children and adolescents currently counsel families about firearm safety, although many agree that they have such a responsibility. At least half of these physicians would potentially benefit from an intervention to improve their knowledge of and counseling skills on this topic.     

Modalities of transition of diabetic adolescents from pediatrics to the adult care in the Paris-Ile-de-France region: an appeal to cooperative work for improving quality of care. Paris-Ile-de-France Section of DESG (Diabetes Education Study Group) in French language

AIM: The purpose of this study was to evaluate the conditions in which diabetic adolescents are transferred from pediatric to adult health care, and to record the opinions of the physicians about this issue. METHODS: A questionnaire-based study was performed among all the pediatricians in the hospital setting and all the diabetologists from the Paris-Ile-de-France area. Questionnaires from 50 pediatricians and 51 diabetologists were completed (response rate: 68%). RESULTS: 1) Not enough information was transmitted: a quarter of the diabetologists were visiting for the first time without any information on the adolescent, and only half the pediatricians received feedback information from the internists after the first visit. And yet, when considered, it was important to be kept informed after the first visit and the following ones. 2) Medical relationships were poor: more than three out of four pediatricians and diabetologists had none or very few professional meetings, and two thirds of them were not aware of the way the others were working. 3) Eighty percent of pediatricians and diabetologists considered that the transfer of diabetic adolescents had to be organised in order to keep the coherence of medical follow-up, to minimise the psychological effects of the transition, and to avoid a complete break in the patient follow-up. 4) The expectations of the pediatricians were: the validation of their previous follow-up through the feedback information from diabetologists and the continuity of the medical follow-up; those of the diabetologists were: to gain the patient's confidence and to master the patient's previous history, in order to provide a better follow-up. 5) According to the opinion of both pediatricians and diabetologists, the main errors to avoid were, by the paediatricians, to miss the time and the preparation of the transfer and, by the diabetologists, to denigrate the previous pediatric management and to change the insulin regimen immediately. CONCLUSION: This study demonstrates a lack of communication between physicians of pediatric and adult health care centres. But it also underlines their recognition of the importance of the transition's stakes and their common motivations in order to improve it.     

A strategy for improving patient satisfaction by the intensive training of residents in psychosocial medicine: a controlled, randomized study

PURPOSE: To use a controlled, randomized design to assess the effect on patient satisfaction of an intensive psychosocial training program for residents. METHOD: Twenty-six first-year residents, in two internal medicine and family practice community-based programs affiliated with the Michigan State University College of Human Medicine, were randomly assigned during 1991 and 1992 to a control group or a one-month intensive training program. Experiential teaching focused on many psychosocial skills required in primary care. A 29-item questionnaire administered before and after the residents' training evaluated their patients' satisfaction regarding patient disclosure, physician empathy, confidence in physician, general satisfaction, and comparison of the physician with other physicians. Analyses of covariance with groups and gender as factors and pre-training patient satisfaction scores as the covariate evaluated the effect of the training. RESULTS: The patients of the trained residents expressed more confidence in their physicians (p = .01) and more general satisfaction (p = .02) than did the patients of controls. The effect of training on patient satisfaction with patient disclosure (p < .01) and physician empathy (p < .05) was greater for female than for male residents. CONCLUSION: The intensive psychosocial training program for residents improved their patients' satisfaction.     

Predicting patient satisfaction: a study of two emergency departments

To identify perceptions that predict overall patient (dis)satisfaction with Emergency Department (ED) care, we studied responses to a survey mailed to all discharged patients over a 6-month period (Academic Hospital), and to a telephone interview of a random sample of discharged patients over a 1-year period (Community Hospital). The survey and interview both assessed overall satisfaction, as well as satisfaction with perceived waiting times, information delivery, and expressive quality of physicians, nurses, and staff. Data for 1176 patients (training sample) and 1101 patients (holdout sample) who rated overall satisfaction as either "very good" or "very poor" (Academic Hospital), and for 856 patients (training sample) and 431 patients (holdout sample) who rated overall satisfaction as either "excellent" or "poor" (Community Hospital), were retained for analysis. For both hospitals, nonlinear tree models efficiently achieved overall classification accuracy exceeding 98% in training analysis and 95% in holdout analysis (all p < .0001). The findings suggest that overall patient (dis)satisfaction with care received in the ED is nearly perfectly predictable on the basis of patient-rated expressive qualities of ED staff, particularly physicians and nurses. Interventions designed to reinforce positive (and extinguish negative) expressive health-care provider behaviors may cut the number of extremely dissatisfied patients in half.     

Minor head injury in children: current management practices of pediatricians, emergency physicians, and family physicians

OBJECTIVE: To describe variation in the clinical management of minor head trauma in children among primary care and emergency physicians. DESIGN: A survey of pediatricians, family physicians, and emergency physicians drawn from a random sample of members of the American Academy of Pediatrics, the American Academy of Family Physicians, and the appropriate American Medical Association specialty listings, respectively. Physicians were given clinical vignettes describing children presenting with normal physical examination results after minor head trauma. Different clinical scenarios (brief loss of consciousness or seizures) were also presented. Information was gathered on initial and subsequent management steps most commonly used by the physician. RESULTS: Surveys were returned by 765 (51%) of 1500 physicians. Of these, 303 (40%) were pediatricians, 269 (35%) family practitioners, and 193 (25%) emergency physicians. For minor head trauma without complications, observation at home was the most common initial physician management choice (n = 547, 72%). Observation in office or hospital was chosen by 81 physicians (11%). Head computed tomographic (CT) scan was chosen by 7 physicians (1%) and skull x-ray by 24 physicians (3%) as the first management option. Most physicians (n = 445, 80%) who initially chose observation at home would obtain a CT scan if the patient showed clinical deterioration. In the original scenario, if the patient had also sustained a loss of consciousness, 383 physicians (58%) altered management. Of these, 120 (18%) chose CT, 13 (2%) chose skull x-ray, 1 (1%) chose magnetic resonance imaging, 141 (21%) chose inpatient observation, and 125 (19%) chose a combination of CT scanning and observation. With seizures, 595 (90%) altered management, with 176 physicians (27%) choosing CT scan, 5 (1%) skull x-ray, 60 (9%) inpatient observation, and 299 (45%) a combination of radiological evaluation and observation. CONCLUSIONS: Most physicians surveyed chose clinic or home observation for initial management of minor pediatric head trauma. Clinical management was more varied when patients had sustained either loss of consciousness or seizures. Further study of the appropriate management of minor head trauma in children is needed to guide physicians in their care.     

Ambulatory obstetrical care: strategies to reduce telephone liability

The telephone will become the centerpiece of ambulatory care services. As such, a pertinent aspect of office procedures will necessarily include a protocol to manage and document telephone calls. Encourage your office staff to use good telephone manners, as listed in Table 5. The net result should be a reduction in telephone liability risks and an enhanced reputation for your office.     

Are pediatricians ready for the new guidelines on lead poisoning?

In 1991 the Centers for Disease Control established new guidelines for the definition of and screening for lead poisoning. OBJECTIVE. To assess: (1) pediatricians' knowledge of lead poisoning including the most recent literature on the subject, and (2) their screening practices. DESIGN, SETTING, SUBJECTS. A 22-item questionnaire was developed and validated. The survey was mailed to 1183 physicians in Virginia who were self-designated as pediatricians in the state medical registry. RESULTS. Sixty-nine percent (391/556) of those responding They were evenly distributed throughout the state. Of the respondents, 62% were male, 86% were white, and 72% trained at a university program. The median year for training completion was 1978. Demographic differences were not demonstrated (chi 2) between primary care pediatricians and subspecialists. Responses demonstrated an overall deficiency in physicians' knowledge of lead poisoning with specific deficiencies in knowledge of the literature, with mean +/- SD correct responses of 15.7 +/- 3.4. Primary care pediatricians scored significantly better than subspecialists: 16.2 +/- 3.0 vs 14.7 +/- 4.1 (P < .001, t-test). Twelve percent of the total group and 13.5% of primary care physicians were screening all their patients. CONCLUSIONS. Although primary care pediatricians (self-designated) are more knowledgeable about lead poisoning than their subspecialist colleagues, there are still deficiencies, and screening practices must be modified in both groups. To successfully implement the new Centers for Disease Control and Prevention guidelines, physician education must be a priority.     

Diabetic nephropathy and isolated hyporeninemic hypoaldosteronism

OBJECTIVE: The objective of the Florida Trauma Triage Study was to assess the performance of state-adopted field triage criteria. The study addressed three specific age groups: pediatric (age < 15 years), adult (age 15-54 years), and geriatric (age 55+ years). Since 1990, Florida has used a uniform set of eight triage criteria, known as the trauma scorecard, for triaging adult trauma patients to state-approved trauma centers. However, only five of the criteria are recommended for use with pediatric patients. This article presents the findings regarding the performance of the scorecard when applied to a pediatric population. DESIGN: We used state trauma registry data linked to state hospital discharge data in a retrospective analysis of trauma patients transported by prehospital providers to any acute care hospital within nine selected Florida counties between July 1, 1991, and December 31, 1991. We used cross-table and logistic regression analysis to determine the ability of triage criteria to correctly identify patients who were retrospectively defined as major trauma. We applied the field criteria to physiologic and anatomy/mechanism of injury data contained in the trauma registry to "score" the patient as major or minor trauma. To make our retrospective determination of major or minor trauma we used the protocols developed by an expert medical panel as described by E. J. MacKenzie et al. (1990). MAIN OUTCOME MEASURES: We calculated sensitivity, specificity, and the corresponding over- and undertriage rates by comparing patient classifications (major or minor trauma) produced by the triage criteria and the retrospective algorithm. We used logistic regression to identify which triage criteria were statistically significant in predicting major trauma. RESULTS: Pediatric cases accounted for 9.2% of the total study population, 6.0% of all hospitalized cases, and 6.8% of all trauma deaths. Of the 1505 pediatric cases available for analysis, the triage criteria classified 269 cases as expected major trauma and 1236 cases as expected minor trauma. The retrospective algorithm classified 78 cases as expected major trauma and 1427 cases as expected minor trauma. The resulting specificity is 84.8% (15.2% overtriage), and the sensitivity is 66.7% (33.3% undertriage). Logistic regression indicated that, of the eight state-adopted field triage criteria, only the Glasgow coma score, ejection from vehicle, and penetrating injuries have a statistically significant impact on predicting major trauma in pediatric patients. CONCLUSIONS: Although the state-adopted trauma scorecard, applied to a pediatric population, produced acceptable overtriage, it did not produce acceptable undertriage. However, our undertriage rate is comparable to the results of other published studies on pediatric trauma. As a result of the Florida Trauma Triage Study, a new pediatric triage instrument was developed. It is currently being field-tested.     

Telephone triage of cardiac emergency calls by dispatchers: a prospective study of 1386 emergency calls

OBJECTIVES: To evaluate the handling of potential cardiac emergency calls by dispatchers, to determine their final diagnosis and urgency, and to determine the value of the main complaint in predicting urgency and the ability of the dispatchers to recognise non-urgent conditions. DESIGN: Prospective data collection and recording of main complaint of emergency calls placed via the 06-11 alarm telephone number with follow up to hospital when the patients were transported and the general practitioner when they were not. SETTING: Dispatch centres of the emergency medical services in Amsterdam (urban area) and Enschede (rural area). PATIENTS: 1386 consecutive adult subjects of emergency calls placed by citizens about chest problems or unconsciousness not caused by injury. MAIN OUTCOME MEASURES: Frequency of characteristics of the calls, outcome in diagnosis, and assessment of urgency. RESULTS: 69 (5%) patients were dead when the ambulance arrived. Diagnosis was established in 1071 patients (77%). The disorders most often reported were cardiac, with acute ischaemia in 15% of all subjects. In 28% of cases and for each presenting complaint no organic explanation was found. Overall 39% of all emergency calls were urgent; the urgency rate was lowest for calls for people with abdominal discomfort. Dispatchers correctly identified 90% of the non-urgent calls, but 55% of the calls that they identified as urgent proved to be non-urgent. CONCLUSION: Currently, direct dialling for an ambulance without the intervention of a general practitioner imposes a high work load on emergency systems and hospitals because triage by dispatchers is not sufficiently accurate. It may be possible to increase the accuracy of triage by developing and testing decision algorithms.