Help Us Help You! Make the most out of phone calls

Hello.  This is Dr. Stuppy.  I'm returning your call about...

That's how my phone calls start, then they take various turns. Some are easy, some not so easy. I'd like to discuss what makes a phone call to the doctor's office more productive, so we can help you better.

All examples are entirely fictitious, made up of 18 + years of phone call experiences.

Many calls start off like this:

Hi. This is Mary Sue. My son has a rash and I want to know what to do.

Me: ?????

I must ask many questions for more information.

Some callers don't seem to know what to say, so they only answer direct questions.  How old is your son? When did the rash start? What does it look like? Has it changed? Does it itch or hurt? Any other symptoms? What have you used to treat it? Did that help? Has he had any new ingestions, lotions, or creams? Does he have a history of allergies? Anyone else with a rash that looks like this?

On and on...

Other calls start like this:

Hi.  Thanks for calling back. My son Jack is 3 years old. Well, really his birthday isn't until next month, but he's almost 3. He has had a fever for 2 days, maybe 3 days because he felt warm but he wasn't acting funny or sick that first day he felt warm so I didn't check his temperature. He actually was fussy last week, but I don't think he ever had a fever then. I was thinking maybe he didn't sleep well last week, but I don't know why. His temperature was 100.3, that was on Tuesday around 7am. I gave Tylenol, and it went down to 97.9, but then 4 hours later it was back up to 99.7....

My thoughts so far: Get to the point.

Sorry, but that's true. I care about my patients, but so far this phone call has taken me quite a bit of time and I really know nothing except this almost 3 year old has an elevated temperature (not even a true fever). I don't even know what the parent's main concern is.

just the facts, MA'AM.

When parents call, they need to summarize with pertinent facts. While they shouldn't leave out important helpful information, they don't need to mention every time they took a temperature.

Much like the evening news: they can't do a play by play of every football game. There's no time and it serves no purpose. A few highlights of the game and the score. That works well. People get a pretty good idea of how the game went.

It's the same thing with phone calls to your doctor's office or on call provider.  We have thousands of patients. Not all call, but during peak cold and flu season, there are many calls all day and night. The phone nurse or on call provider simply can't spend 15 minutes chatting about every detail. That's for your friend and you to discuss over coffee.

During the cold and flu season, it's not uncommon for me to be on the phone with one parent when another call comes in. This is at the same time I'm trying get groceries or do other things I need to do for my family on evenings and weekends. (Being on call after hours doesn't mean that I don't have to work during the day.) I really don't want to sit and chat. I don't have time for play by play action. Again, I really care about my patients, but I can do a better job at answering your questions if you are clear and concise. 

Things that help us help you:

Know what's going on.

When a parent calls and the child is at daycare or grandma's so the caller doesn't know details, we can't really help. Yes, parents have called for advice when they're on their way to daycare but don't know any more than the child has to be picked up due to a symptom such as vomiting, fever or pink eye.

See your child first or have the person with the child call us. When you pick up the child, ask for details of their day. Learn how they ate/drank, how they acted, etc.

Sometimes you've been up several nights in a row with a sick child and things get jumbled in your head. It happens.

Write down the pertinent facts to get them straight if you need to.

Start with your child's full name and birth date.

I can't tell you how often parents jump right into their worries without stating who their child is. This is important not only for chart documentation of the call but also so we know how old your child is.

Include any significant past history, such as your infant was born at 28 weeks gestation, or your coughing 3 year old has a history of wheezing.

Give pertinent facts related to the concern.

If your child has a fever, give the number of days of fever, the maximum temperature, and how it was taken.

If you have given a fever reducer, share that.

Find a quiet place to talk.

When my kids were little they always wanted to be held when they were sick. I get it.

If you're on the phone and they're crying in your arms, it's very hard to have a conversation.

Please find a safe place for your child to rest while we talk if possible.

If they won't leave you or stay quiet, have another adult talk to us after they've been briefed about all the symptoms.

Summarize symptoms and treatments.

Briefly describe symptoms and what you have done to help them as well as how your child responded to the treatment.

Mention All treatments

If you use a vaporizer or saline for a cold, or have stopped dairy and used gatorade for vomiting, let us know. If you use a traditional home remedy, please let us know.

Let us know any medications your child typically takes in addition to ones you have tried for the current symptoms.

Signs and symptoms can be tricky to describe

When there's a rash, it's typically best for us to see it, but if you call about a rash describe it in terms of location, color, and size. Many find it helpful to relate to common objects, such as quarter-sized.

Note if there is a pattern to the symptoms, such as headache every day after school or barky cough only at night.

Summarize, don't tell a novel

Leave out details that don't help. Trends and generalizations work well.

If we want more details, we can always ask.

Avoid words that could be interpreted other ways, use facts.

Commonly misused words are "lethargic" and "fever."

Lethargy in a medical sense is ominous. Many parents use it when their child is only mildly ill and tired. Describe what you're seeing instead. Saying "Johnny won't even wake enough to drink or hold his cup," gives me the thought he is lethargic. Saying "Johnny wants to sit on my lap and read books instead of playing with his sister," shows that he's not well, but definitely not lethargic.

Fever is a temperature over 100.4 F. Many parents use the word fever if their child feels warm to touch. It's more clear if you state that they're warm to touch or what the thermometer says and how you took it.

Dr. Christina has a great blog discussing commonly used terms that can be confusing to your physician and alternative word choices.

Examples of good call starters:

Start with name, birth date, summary

I'm calling about Joe Smith, birth date 9.12.08. He has had a fever for 3 days, up to 101.3 under the arm. It comes down with ibuprofen, but is right back up in 6 hours. He also has sore throat and headache. He's drinking well but not eating much for 3 days.

I know this child's name, age, pattern of fever and associated symptoms. The only thing I need now is the parent's concern - so far they've been doing everything right. What made them call today? What's their question?

Describe

Sally Smith, birth date 9.12.17, has vomited 6 times in the past 12 hours. If I give formula it immediately comes up. She is now dry heaving and hasn't had a wet diaper in 12 hours. There's no fever but she looks tired and it is hard to wake her to drink. She doesn't have diarrhea. Her older brother had the stomach flu a few days ago but is now better.

Again, I know the child's name and age and main problem - especially the fact that she sounds dehydrated. The parent didn't use this word, but described dehydration (no wet diaper in 12 hours and it's hard to wake her to drink). 

Include pertinent history

John Smith, birth date 9.12.17, was in the NICU for 2 months due to prematurity. He has been fussy all day and is now breathing fast and hard and is not able to drink more than a few sucks at a time. He doesn't have a fever, but I'm really worried.

Here I know the child's age and that he was significantly premature - a big risk factor. He's distressed because he can't feed. Note: I made this baby not have a fever on purpose. He's sick even without a fever. 

Getting More Information

Knowing where to get reliable information is important. There's a lot of bad advice online. Fancy websites aren't always reliable.

Sites I recommend:

The AAP has many resources on HealthyChildren.

KidsHealth is another great resource.

My office's website, PediatricPartnersKC, also has many pearls of wisdom. Often when we give advice it's already stated on our site. Parents sometimes call multiple times because they can't remember what we said. This is frustrating on both ends of the phone. We wrote it down and made it easily available for a reason. Use our site! (For patients in other practices, check out your own pediatrician's site.)

Things that cannot be done by on call providers - at least not well:

Prior authorization for an ER or urgent care visit that is already done.

Prior authorizations are not usually needed, but if they are required, we should talk to you to be sure the visit is necessary before you go.

If I didn't send you to the ER, I can't fill out paperwork saying I did. That's lying and using my license inappropriately. Often I would have chosen another location or given home care instructions to get you through the night.

Of course if you do talk to me (or one of my partners) overnight and we do send you to an urgent care or ER, we are happy to fill out forms if needed by insurance.

"Allow" you to leave a busy ER.

It sounds silly, but I have had many calls from the waiting room at ER/Urgent Cares with parents asking if I think it okay that they leave due to a long wait. If you thought it necessary to go in the first place, I would be open to a malpractice lawsuit if I told you to go home without being seen.

You should ask their triage nurse who can make that assessment.

Refill medications.

I typically expect that your child is seen prior to most prescription refills for best medical care. If it's urgent that your child have a refill, such as an inhaler, they should be seen to evaluate the concern.

There are exceptions to every rule, but don't be upset if the on call provider or phone nurse refuses to call out a prescription.

This is in the best interest of your child, not to be difficult. It's easier to just call in the script than it is to argue this point, believe me. But easier isn't better care, and that's what's important.

Make a diagnosis.

We cannot see the ear, listen to the lungs, or feel the belly over the phone. A physical exam and sometimes labs or radiology studies are needed to make a diagnosis. If your doctor claims to be able to diagnose by phone to call out prescriptions, I would suggest that they're not doing the best of care.

An example of a poor diagnosis by phone:

Just this week another child was seen in my office for a sore throat that wasn't better on the amoxicillin prescribed by a telemedicine doctor through their insurance company. The exam clearly showed blisters on the child's throat. The sore throat was from these blisters, which are from a virus, not a bacteria.

The antibiotic was never needed. In this case the child simply didn't get better as expected with a presumed case of Strep throat, but fortunately she didn't get diarrhea or have an allergic reaction to the antibiotic. Who knows if this contributed to more bacterial resistance and superbugs?

Not only did the family waste money on an unnecessary treatment, they also exposed their child to a treatment that could have caused harm.

I worry with the increasing use of telehealth that we will see more problems related to improper diagnoses and delay of proper diagnoses - some of which could be significant.

Swallowed poisons or medicine / drug overdose.

The United States has a great poison control system. They can give rapid advice that most doctors don't have easily available.

Call (800) 222-1222 if you suspect your child has ingested something. PUT THIS NUMBER IN YOUR PHONE RIGHT NOW.

A visit's better than a phone call for:  

Difficulty breathing.

If a child is having difficulty breathing and you don't have treatments at home that work, he needs to be seen as soon as possible.

Dehydration.

An infant who hasn't urinated in 6-8 hours or an older child who hasn't urinated in 12 hours might be dehydrated and should be seen as soon as possible.

Some fevers.

Temperature above 100.4 F in an infant under 3 months or in an under immunized child can be serious and should be seen as soon as possible.

Fevers lasting more than 3-5 days or with other concerning symptoms require an evaluation.

Fevers are scary and can make kids miserable. There is no "magic" temperature that we worry about more. Look at how your child is acting, not the thermometer, to determine if they are sick. Not every child with a fever needs to even be treated. There is benefit to letting the fever do its job!

Uncontrollable pain.

If you've used standard pain relievers and your child is still hurting, we cannot do anything by phone that will improve the situation. A careful exam might find a treatable cause of pain.

Most rashes.

Though these don't necessarily need to be seen emergently unless there are other concerns, rashes cannot be evaluated on the phone and a physical exam is needed.

If your child is otherwise well appearing, treat the symptoms of the rash.

If he's otherwise sick and you're concerned, then he should be seen.

Chronic problems.

If your child has been dealing with anything for more than a few days, it might help to schedule a visit with your usual provider. This is especially true if it relates to a chronic condition, such as asthma, constipation, or other issue.

Many parents deal with a problem for months (or years) but have NEVER been in to discuss it specifically. They might mention it at another visit as an aside, but we never really talk about it in depth and give it the attention it deserves.

Diagnosis vs information.

If you want a diagnosis, we need to see your child.  We cannot tell if the ear is infected or if your child has Strep based on symptoms alone.

If you want advice of what to do with symptoms, we can generally give advice. Remember that the websites above can be helpful with this type of information too!

Behavior problems.

These are best discussed with your usual provider, not an on-call provider who doesn't know your child. Most of these build up over time and are not emergent issues.

If it is an emergent issue, such as a child is in physical danger due to his actions or if a child is threatening another person, call 911.

If your child is suicidal, call the suicide hotline at 1-800-273-8255.

Injuries.

If your child has a significant injury, they often require prompt evaluation. Call 911 before calling your doctor's office if your child is seriously injured.

Lacerations must be repaired as soon as possible, so don't wait until office hours the next day if there's a gaping wound!

Minor bumps and bruises can be handled at home, but if you're not sure, give us a call to discuss what happened.

Help me help you!

Let me know what else you need to know to be an educated caller.

I'd be happy to answer questions about when to call, what to ask, and what to expect.

If I left any questions unanswered, please ask!