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Telephone Calls and Emails as Key Components of Primary Care

Posted May 19 2010 12:00am

This news will come as no surprise to readers of this blog. KevinMD reports that telephone calls and e-mails occupy a large component of the time of a primary care physician according to a recent paper in the NEJM (see: Calls and e-mails to patients is a big part of primary care ). Below is an excerpt from his note:

There’s been a lot of commentary on a recent article from the New England Journal of Medicine, detailing the undocumented tasks that a typical primary care physician performs. For those who haven’t read the piece, entitled, What’s Keeping Us So Busy in Primary Care? A Snapshot from One Practice ....To summarize, primary care doctors are responsible for much more than seeing patients in the exam room. In the cited practice, which has a fairly typical makeup, physicians were responsible for an average of over 23 telephone calls and 16 e-mails per day. Many practices don’t engage their patients over e-mail, so it’s conceivable that the number of telephone calls is lower than average here. It’s interesting that this practice, until recently, employed no nurses (they hired one to do “information triage”)....It’s also important to note that the doctors in the study were incentivized to communicate with patients outside the exam room, which is uncommon....[They] have redefined “full-time physician” as one who offers 24 scheduled visit-hours per week, and our internal compensation system now recognizes telephone calls and e-mails as part of our productivity metric. This piece quantifies the bureaucratic responsibilities that primary care doctors increasingly face. Many of these services are not valued by Medicare or most private insurers, who pay doctors based solely on face to face visits. Consider that primary care practices are often run like small businesses, and most are not financially viable without help from an associated hospital or large health system. So, for patients who wonder why it’s so difficult to communicate with their doctor, hopefully this study will starkly illustrate the uncompensated pressures they face.

Here are some of my off-the-cuff reactions to some of the ideas in this note:

  • I am impressed with the job description of "information triage" for an office-based nurse who provides front-line triage for all incoming patient calls and emails. My guess is that such an employee could manage a large percentage of all queries and thus be an invaluable resource for satisfying requests and referring patents to relevant medical articles on the web.
  • I am obviously enthusiastic about the concept of "incentivising" physicians to "communicate with patients outside of the exam room," which is to say via telephone and email. So.we need to substitute the concept of patient-contact-time, regardless of the type, with face-time for reimbursement purposes. As noted in the first point above, nurses should function as the initial triage agent for all incoming queries and turf to physicians the more complex or critical issues.
  • I believe that patient communication with a nurse/physician team via email and telephone can and will be more effective for many patients. Sitting in an exam room, patients can interpret a multitude of non-verbal cues that the physician is rushed and wants to complete the visit as quickly as possible. Significant issues may not be addressed. Nurse and physician responses via email provide a slower-paced exchange during which a patient can ponder the responses and even engage in web searches to better understand issues such as adverse drug reactions or the signs and symptoms related to a particular disease.
  • Although the blog note quoted above did not make reference to patient-physician/nurse interactions via video calls, I personally believe that this will become the norm for many patient "visits" in the future. Such calls enable a rapid assessment of the anxiety level and body language of a patient. They could be also recorded such that the patient, or physician, could review them  later if part of the discussion needs to be reinforced or recalled. I will resist the temptation to call such interactions telemedicine because the term carries so much unnecessary baggage. The sooner we can refer to this as simply an "office visit" the better off we will be.
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