ORIGINAL. RESEARCH
After-Hours Calls: A Forgotten Item of Education in Family Practice PETER CURTIS and ADDISON TALBOT
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Peter Curtis, M R C P , D.OBST, M R C G P , is Assistant Professor and Addison Talbot, M A , A B D , is Sociologist, Department of Family Medicine, Trailer 15, 269H, University of North Carolina at Chapel Hill,N C 27514, USA. After-hours care is a n essential ingredient of family practice and other primary care disciplines. I n various countries, between three and 70 per cent of all after hours calls are handled over the telephone without the patient being seen. Little medical education is provided to train medical students or physicians to deal with clinical problems that are more frequent after surgery hours and with communication and decisionmaking over the telephone. An after-hours record card, developed by the authors, has been used over the past three years for clinical care and educational activities. In the United States, after-hours care in family or ‘office’ practice forms up to 16 per cent of all medical encounters, a t the rate of approximately 500 contacts per 1,000 patients per year (Curtis and Talbot 1979: Health Interview Survey 1975). Contact rates tend to be much lower in other countries; for example, 10.7 per 1,000 patients per year in one British study (Webster et al. 1965). They also vary considerably with geographical location: stable rural populations, for instance, tend to have lower after-hours call rates than transient urban populations. In a considerable number of these contacts, care is given over the telephone without seeing the patient. In the Unites States ‘telephone care’ occurs in just over 70 per cent of contacts (Curtis and Talbot 1979), in Holland 60 per cent, and in Denmark and Sweden 65 per cent and 77 per cent, respectively (Hall 1977). In Britain this percentage ranges from three to 36 (Murray and Barker 1977). Recording After-Hours Calls Little is known about the documentation of these contacts. A survey of all the family practice training programmes in the United States revealed that only 67 per cent recorded after-hours encounters and 71 per cent provided some form of educational feedback to their Medical Teacher V o l 2 No 5 1980
trainees (Curtis et al. 1979). Patient care after surgery hours is a relatively neglected area of medical education, yet it requires good communication skills (without the benefit of nonverbal cues) and systematic questioning British Medical Journal 1978; Heagerty 1978). The physician’s performance is often coloured by anger and frustration as a result of stress and the unsocial hours, while the patient’s true motives for making the call may be hidden (Clyne 1961). Management by the physician involves not only clinical and therapeutic factors, but also the decision whether or not to ‘see’the patient. As a result of these perceived deficiencies in effective recording methods and education in this field, we have developed a simple after-hours record card which has been used, over the past three years for three purposes: 1. As a recording method for after -hours calls -the card has a peel a f f adhesive backing, enabling easy insertion into A4 (international) size record sheets. 2. As an educational tool-discussion of after-hourscalls using the cards occurs daily at a morning report session following the physician’s on call activity. 3. As a data collection instrument -the data from each card are keypunched and stored on computer discs, and used to create after-hours profiles for each trainee physician every three to four months. These profiles are used as a basis for the discussion of clinical problems and for research projects. T h e after-hours record is shown in Figure l a . It covers four main areas of data collection: 1. Factual non-clinical details, including the method by which the patient makes contact. 2. Factual clinical history and diagnosis. 3 . Management of the presenting problem with followu p plans. 4 . Assessment of the patient’s motives for calling, and the physician’s attitudes to the encounter in terms of emotional reactions, validity of the call, the presence of social dysfunction, and the degree of reassurance given. 245
Med Teach Downloaded from informahealthcare.com by UB Giessen on 12/07/14 For personal use only.
Figure l a . After-hours record card.
Figure lb. Definitions and instructionsgiuen on reuerse of record card.
The physician completes the record card after the patient contact occurs and checks the appropriate variables. Definitions and instructions on how to complete the card are shown on the back of the card (Figure l b ) and are also given individually to the physician. Before placing the record card in the medical record, the right hand section is torn off to prevent the physician’s emotional response entering the medical record.
given materials that will help them develop communication and clinical skills over the telephone (Figure 3 ) . Figure 2 . Ten most commonly recorded symptoms and diagnoses, after hours (based on 4,760 contracts).
Education The education programme centres around daily discussions of common symptoms and diagnoses and the variables identified on the record card by the physician who took calls the previous night or weekend (Figure 2). The morning report sessions are attended by faculty, trainees, and medical students. The learners are also 246
Medical Teacher V o l 2 No 5 1980
medical telephonists and crisis intervention workers (Committee on Standards of Child Health 1972). T h e evaluation of the effectiveness of the after-hours record card as a teaching tool for medical students and family practice trainees is complex and still under development. It is hoped to show changes in physicians’ attitudes and management styles over time, using tracer diagnoses and standard simulated calls.
References
Med Teach Downloaded from informahealthcare.com by UB Giessen on 12/07/14 For personal use only.
Clyne, M. B . , A Study of Night Culls in General Practice, London, Tavistock, 1961. Committee on Standards of Child Health Care 1967-72, Standards of Child Iiealth Carp, 2nd edn, Evanston, American Academy of Pediatrics, 1972, 43-54. Curtis, P. and Talbot, A . , T h e aftcr hours call in family practice, Journal of Family Practice, 9, 901 -909. Curtis, P. and Talbot, A,, The after hours call: A survey of United States family practice residency programs, Journal of Family Practice, 1979.8, 117-122. ’I‘he telephone in general practice, British Medical Journal, 1972. Editorial, 2, 1106. Hall, D. W., The off-duty arrangement of general practitioners in four European countries,,Journal of Royal College of General Practitioners, 1975.26, 19. Hcagerty, M. C.. From home calls to tclephone calls, AmericanJournnl of Public Health, 1978. 1, 14. Health Interview Survey, National Center for Health Statistics, DHEW, unpublkhed data, 1975. Katz, H. D., Pozen, J. and Mushlin, A. J., Quality assessment of a telephone care system utilising non-physician personnel, American .JournalofPublicHealth, 1978,68,31. Murray, T. S. and Barber, J. H . , The workload of a commercial deputizing service, Journal of Royal College of General Practitioners, 1977,27,209. Perrin, E. C. and Goodman, H. C . , Telephone management of acute pediatric illness, New EnglandJoumul o/ Medicine, 1978,298, 130. Webster, G. L., Ritchie, A. F., Morell. J . A. L., ct al., Night calls in general practice. British MedzcalJournul, 1965, 1, 1369.
Figure 3. Telephone call guidelines.
Addendum This paper was supported by a grant from the National Fund for Medical Education. NFME 79/78B
Discussion Recent studies have shown that physicians are not particularly good at interviewing and managing problems after hours, especially on the telephone. It appears that diagnostic decisions are made very soon after the beginning of the encounter and thereafter the doctor no longer listens’ to the patient. In fact, nurses and other ancillary staff have been shown to communicate more effectively than trainees or resident physicians using standardized test calls (Perrin and Goodman 1978; Katz et al. 1978). With the exception of paediatrics in the United States, no standards of care have been developed in telephone medicine, although protocols exist in the training of Medical Teacher V o l 2 N o 5 1980
Back Copies of Medical Teacher 1979 issues of Medical TeacheT are available at L2.50 ( $ 6 ) each. All cheques/postal orders should be made payable to Update Publications Ltd and sent to: The Circulation Manager, Update Publications Ltd. (Medical Teacher), 33/34 Alfred Place, London WC1, England. Prepaid orders only. 247
After-Hours Calls: A Forgotten Item of Education in Family Practice PETER CURTIS and ADDISON TALBOT
Med Teach Downloaded from informahealthcare.com by UB Giessen on 12/07/14 For personal use only.
Peter Curtis, M R C P , D.OBST, M R C G P , is Assistant Professor and Addison Talbot, M A , A B D , is Sociologist, Department of Family Medicine, Trailer 15, 269H, University of North Carolina at Chapel Hill,N C 27514, USA. After-hours care is a n essential ingredient of family practice and other primary care disciplines. I n various countries, between three and 70 per cent of all after hours calls are handled over the telephone without the patient being seen. Little medical education is provided to train medical students or physicians to deal with clinical problems that are more frequent after surgery hours and with communication and decisionmaking over the telephone. An after-hours record card, developed by the authors, has been used over the past three years for clinical care and educational activities. In the United States, after-hours care in family or ‘office’ practice forms up to 16 per cent of all medical encounters, a t the rate of approximately 500 contacts per 1,000 patients per year (Curtis and Talbot 1979: Health Interview Survey 1975). Contact rates tend to be much lower in other countries; for example, 10.7 per 1,000 patients per year in one British study (Webster et al. 1965). They also vary considerably with geographical location: stable rural populations, for instance, tend to have lower after-hours call rates than transient urban populations. In a considerable number of these contacts, care is given over the telephone without seeing the patient. In the Unites States ‘telephone care’ occurs in just over 70 per cent of contacts (Curtis and Talbot 1979), in Holland 60 per cent, and in Denmark and Sweden 65 per cent and 77 per cent, respectively (Hall 1977). In Britain this percentage ranges from three to 36 (Murray and Barker 1977). Recording After-Hours Calls Little is known about the documentation of these contacts. A survey of all the family practice training programmes in the United States revealed that only 67 per cent recorded after-hours encounters and 71 per cent provided some form of educational feedback to their Medical Teacher V o l 2 No 5 1980
trainees (Curtis et al. 1979). Patient care after surgery hours is a relatively neglected area of medical education, yet it requires good communication skills (without the benefit of nonverbal cues) and systematic questioning British Medical Journal 1978; Heagerty 1978). The physician’s performance is often coloured by anger and frustration as a result of stress and the unsocial hours, while the patient’s true motives for making the call may be hidden (Clyne 1961). Management by the physician involves not only clinical and therapeutic factors, but also the decision whether or not to ‘see’the patient. As a result of these perceived deficiencies in effective recording methods and education in this field, we have developed a simple after-hours record card which has been used, over the past three years for three purposes: 1. As a recording method for after -hours calls -the card has a peel a f f adhesive backing, enabling easy insertion into A4 (international) size record sheets. 2. As an educational tool-discussion of after-hourscalls using the cards occurs daily at a morning report session following the physician’s on call activity. 3. As a data collection instrument -the data from each card are keypunched and stored on computer discs, and used to create after-hours profiles for each trainee physician every three to four months. These profiles are used as a basis for the discussion of clinical problems and for research projects. T h e after-hours record is shown in Figure l a . It covers four main areas of data collection: 1. Factual non-clinical details, including the method by which the patient makes contact. 2. Factual clinical history and diagnosis. 3 . Management of the presenting problem with followu p plans. 4 . Assessment of the patient’s motives for calling, and the physician’s attitudes to the encounter in terms of emotional reactions, validity of the call, the presence of social dysfunction, and the degree of reassurance given. 245
Med Teach Downloaded from informahealthcare.com by UB Giessen on 12/07/14 For personal use only.
Figure l a . After-hours record card.
Figure lb. Definitions and instructionsgiuen on reuerse of record card.
The physician completes the record card after the patient contact occurs and checks the appropriate variables. Definitions and instructions on how to complete the card are shown on the back of the card (Figure l b ) and are also given individually to the physician. Before placing the record card in the medical record, the right hand section is torn off to prevent the physician’s emotional response entering the medical record.
given materials that will help them develop communication and clinical skills over the telephone (Figure 3 ) . Figure 2 . Ten most commonly recorded symptoms and diagnoses, after hours (based on 4,760 contracts).
Education The education programme centres around daily discussions of common symptoms and diagnoses and the variables identified on the record card by the physician who took calls the previous night or weekend (Figure 2). The morning report sessions are attended by faculty, trainees, and medical students. The learners are also 246
Medical Teacher V o l 2 No 5 1980
medical telephonists and crisis intervention workers (Committee on Standards of Child Health 1972). T h e evaluation of the effectiveness of the after-hours record card as a teaching tool for medical students and family practice trainees is complex and still under development. It is hoped to show changes in physicians’ attitudes and management styles over time, using tracer diagnoses and standard simulated calls.
References
Med Teach Downloaded from informahealthcare.com by UB Giessen on 12/07/14 For personal use only.
Clyne, M. B . , A Study of Night Culls in General Practice, London, Tavistock, 1961. Committee on Standards of Child Health Care 1967-72, Standards of Child Iiealth Carp, 2nd edn, Evanston, American Academy of Pediatrics, 1972, 43-54. Curtis, P. and Talbot, A . , T h e aftcr hours call in family practice, Journal of Family Practice, 9, 901 -909. Curtis, P. and Talbot, A,, The after hours call: A survey of United States family practice residency programs, Journal of Family Practice, 1979.8, 117-122. ’I‘he telephone in general practice, British Medical Journal, 1972. Editorial, 2, 1106. Hall, D. W., The off-duty arrangement of general practitioners in four European countries,,Journal of Royal College of General Practitioners, 1975.26, 19. Hcagerty, M. C.. From home calls to tclephone calls, AmericanJournnl of Public Health, 1978. 1, 14. Health Interview Survey, National Center for Health Statistics, DHEW, unpublkhed data, 1975. Katz, H. D., Pozen, J. and Mushlin, A. J., Quality assessment of a telephone care system utilising non-physician personnel, American .JournalofPublicHealth, 1978,68,31. Murray, T. S. and Barber, J. H . , The workload of a commercial deputizing service, Journal of Royal College of General Practitioners, 1977,27,209. Perrin, E. C. and Goodman, H. C . , Telephone management of acute pediatric illness, New EnglandJoumul o/ Medicine, 1978,298, 130. Webster, G. L., Ritchie, A. F., Morell. J . A. L., ct al., Night calls in general practice. British MedzcalJournul, 1965, 1, 1369.
Figure 3. Telephone call guidelines.
Addendum This paper was supported by a grant from the National Fund for Medical Education. NFME 79/78B
Discussion Recent studies have shown that physicians are not particularly good at interviewing and managing problems after hours, especially on the telephone. It appears that diagnostic decisions are made very soon after the beginning of the encounter and thereafter the doctor no longer listens’ to the patient. In fact, nurses and other ancillary staff have been shown to communicate more effectively than trainees or resident physicians using standardized test calls (Perrin and Goodman 1978; Katz et al. 1978). With the exception of paediatrics in the United States, no standards of care have been developed in telephone medicine, although protocols exist in the training of Medical Teacher V o l 2 N o 5 1980
Back Copies of Medical Teacher 1979 issues of Medical TeacheT are available at L2.50 ( $ 6 ) each. All cheques/postal orders should be made payable to Update Publications Ltd and sent to: The Circulation Manager, Update Publications Ltd. (Medical Teacher), 33/34 Alfred Place, London WC1, England. Prepaid orders only. 247
