I am a new hospitalist in my first real job. We work a typical 7-on 7-off fashion.
We have a sort of secretary (I mean no disrespect I don’t know her exact title), who helps us with signing home health orders, orders for DME, oxygen, etc, but often we will get messages during our service weeks or even during our off weeks requesting us to call back a patient or family member for “questions”–these are for patients/families that have already been discharged from the hospital.
I was curious to ask how I should handle this and how others approach this.
I don’t want to be rude or unapproachable but I feel that these are inappropriate for a few reasons:
Sometimes I hate this crap and I don’t know who I’m supposed to talk to. Patient D/C for clot with rx for eliquis to my pharmacy at 7pm. I don’t see the rx till next morning. Not covered, ins wants something else. Call hospital - doctor now off service and f/u appointment not for another week. Nobody willing to help me get a med switched. Next dose due in 3 hours. Ok great…
What is your best recommendation in this scenario? Sometimes the current doctor on duty will approve an order for me after a brief review of the patient EHR but I find that kind of strange as they were not involved in the care of the patient at all and I’m sure they’re just doing it out of kindness. Ideally med access is confirmed prior to discharge but I end up in this scenario more often than you’d think. Any recommendations?
As a pcp I feel like they need to follow up with an outpatient physician unless there is truly an emergency question regarding discharge instructions. It is usual you even have a number to be reached. If you’re getting messages with implication of needing to respond on your off week then you’re essentially on call which is inappropriate.
At my hospital, these calls always end up getting forwarded to the nurses station for some reason. Our hospitalists are very hesitant to answer questions or talk with pts after d/c because the majority of questions involve asking for them to either diagnose something new over the phone or to call in more medications. When patients call with questions after d/c it seems like 99% of the time the correct answer is “follow up with your PCP or if this is a medical emergency dial 911”. I’m guessing that if a doc does chat with d/c’d pts they would have to go back into the pt’s chart and document the conversation- which can be a huge pain depending on which EMR is used.
Key is prevention. Send prescriptions early in the day. Make sure important Meds such as Eliquis are covered. Make sure patients can pick up their prescriptions the day of discharge. Go over discharge instructions yourself with the patients and make sure they understand what you’re talking about. Talk to their adult children if they’re older… etc
I get calls from pharmacists on the same day and clarify things occasionally which are easy to fix.
I very rarely get calls from patients (once every couple of months) asking to clarify things.
If I was coming on to service and I get a call from a patient who was discharged the previous day by the previous hospitalist I try to help clarify things by quickly going over their chart without talking to them directly. I never send prescriptions for patients I didn’t personally see as it’s a liability. I’ve never had a serious situation where I had to notify the previous hospitalist. Most of these things can be fixed by following up with PCP.
One time I got a call from a different family members that wasn’t there at time of discharge asking to clarify discharge medications that I refused to take for the simple fact that I already went over this with the patient and with one of his sons. I have a strict rule that things get explained once to the family per day and I will never go over the same things with multiple family members on the same day, who has time for that seeing 15-20 patients a day? Talk to each other.
If it matters at all, I have the highest hcahps scores in my group so maybe I’m doing something right at time discharge.
I’m also a 7on/7off hospitalist. Likewise, I get occasional inquiries on my off weeks. Most can wait until I come back on service ie home health orders, DME, etc. But occasionally, there are time urgent issues that can’t wait and the patient doesn’t have a PCP. In that case, I do take the time to answer them. It’s not a frequent occurance and it improves patient care, rather than turfing the issue to one of my colleagues who doesn’t know the patient. I just chalk up to being part of the job.
If they’re discharged it’s their PCPs issue. If it’s a high impact issue (important rx didn’t go through, critical lab result drawn while admitted) I’ll take care of it as my professional responsibility. If it is a simple easy fix I’ll do it as a courtesy if I have time. I don’t usually do forms other than DME - I signed FMLA stuff once in a unique circumstance.
Answering questions? Probably not, no. Too busy & no longer my responsibility. I do very thorough DC counseling & detailed instructions they can refer to.
If I’m on my off week I am totally unavailable. I don’t check email or work calls unless scheduled via text (I usually work nights so my phone is DND mode while the sun is up).
Re: liability - definitely a potential issue though likely way overblown as long as you are reasonable
Documenting depends on EMR - I can chart a telephone encounter in epic
Time - 100%, don’t have the time
Billing - also agree, minimize the unpaid work you do. AFAIK can’t use the f/u call codes within 1 week of a F2F encounter.
We give patients our hospitalist office phone number and they can leave messages on our voicemail. It gets checked 2 or 3 times a week. … I usually don’t call back.
I will respond to questions related to the hospitalization, but anything else needs to go to the primary care doctor. I will not discuss their ongoing symptoms at all, but refer them to their PCP or recommend they come back to the ED if they need to be re-evaluated.
Hmm I’m a hospitalist and we really don’t have a number to call back. If the patient was just discharged (like that day), usually what happens is they call the nurses station and they page us (still on station), and then it’s usually something related to the dc instructions or meds, which is fine. I don’t know that I’ve ever answered questions/pages on my time off, but I have called patients with results that appear after their hospitalization - and document it. When we give dc instructions, we give them the number to call their PCP with any issues. I’m curious how they are getting your number - is the secretary forwarding the messages to you? I would talk to your colleagues and see what they are doing. In general, if the questions are related to dc instructions/meds, totally appropriate and reasonable for you to call patients back but if related to a new complaint or worsening symptoms should be referred to the pcp or Ed as appropriate. Maybe if they could at least triage if it is related to the discharge/hospitalization that would help filter out some of these calls.
As an inpatient nurse, sometimes we’ll have discharged patients call the floor and ask questions. Once we had a patient discharged on dofetilide and eliquis and somehow the wife thought the eliquis coupon card pack actually contained eliquis pills, and I don’t know what she thought about the dofetilide, but they didn’t pick up either one from pharmacy and she called our floor at like 2200 asking what she should do because it was hours past both meds being due.
We had another call about an incision soaking through dressings multiple days post op.
I felt a bit sketched out by those so just gave them the number for the cardiologist or CT surgery offices so they could reach the on call.
I trained in the 80s before industrialized medicine, 12 hour shifts, 7 on/7 off so take me with a grain of salt.
Patients need to know which MD holds the baton of responsibility. But you don’t want to be that guy once the patient has been discharged. So…
Make sure the patient has a f/u appt w PCP/other treating MD prior to d/c. Once there’s an appt, that guy is on the hook.
If no PCP, make appt with a practice taking new patients. But a new MD isn’t on the hook until a face-to-face with the patient so meanwhile…
Have someone screen calls like you’re doing. Ideally, a clinical person rather than a secretary but times are tough. The triage person should tell patients to go to the ER if they feel they’re having an emergency that can’t wait. Otherwise, wait. Or if the issue is a simple Rx transfer or signature for DME, do that.
This is a good question. I am a hospitalist at a county hospital and a lot of the patients are unfunded and simply can’t follow up with a primary care doctor due to financial reasons or otherwise. We have a physician liaison for our group that takes calls for us, and if something comes up he will run it by us. A lot of times, I will simply call the patient back, or redo a prescription, or something simple along these lines because our liaison screens calls that we simply can’t handle once outside the hospital (for example, if they say they are now having chest pain at home and asking what to do, our liaison will instruct them to return to ER etc). I think patients typically really appreciate it if you do go the extra step and help out with a prescription that wasn’t approved or a quick question about something and it honestly doesn’t take up too much time in the end because they are usually simple. I just try to act as I would want to be treated in these circumstances, but mind you, again, my patient population is probably different than yours, so that changes things I am sure.
not everything fits into a perfect box. whether you have an ethical obligation to return calls/pages on discharged patients depends on your system, patient population, and setting. just ask your colleagues what they do and decide for yourself
my personal feeling is that you don’t want to return these calls/pages and are looking for ways to justify it, but none of the concerns you listed seem particularly valid to me
We don’t have an “answering service” but we do have a secretary who fields our calls during the day and follows up with us if we’re on and sometimes when we’re not.
The way it’s worked at both of the hospitals I’ve worked at is they don’t get any number besides the hospital operator… that would be my first step. Figure out how they’re getting your personal number and fix that. We did have an issue a few months ago in which the resident workroom number got inadvertently added to ALL the discharge summaries and it was a disaster.
Then it goes to the nursing station, where they can usually triage. If they do get through to a doctor it’s just whoever’s on inpatient, they wouldn’t call us directly. I would personally only take action if it’s regarding a discharge prescription I/my group provided. Otherwise see PCP or come back to the ED.
My group also does proactive call backs for specific situations, like if a blood culture is pending at discharge and pops positive.
How are these calls even getting to you? We answer them on the unit and redirect to clinic (+/- rec the on call option if after hours) or EMS/ED for emergency. Occasionally I have to troubleshoot (i.e. contacting a pharmacy to re-order verbally), but you should not be getting calls on your time off!
I think that’s a big part of my irritation too, this expectation to provide medical advice outside of my working hours without pay.
Just to be clear, this is not how I feel when I’m on service. If someone needs urgent/emergent care and it’s 6:01 PM, this is not my attitude. This is specifically for days that I am completely off schedule.