Family Medicine: After Hours and Night Call

The cell phone chimes at the end of the work day.  It's a call from my office (where I am still seeing my last patient, or, rarely, just finished seeing the last patient of the day).  I look at the number, stop the ring and call back or answer the phone, which I already know will be our night answering system, aka our voice messaging system for after hours calls.  When the machine answers and I enter a numeric code, I get a recording noting how many new messages are waiting.  I press another time to hear the new message.  "This is your test page", I hear from the staff member still working at the check out desk in the front of the office.

I walk to the front of the office and tell that person, "I got the test page."  Every day, we have to know that our night call system is working before we leave so our patients who call after hours with problems can "leave a message for the doctor on call", as directed by our recording.  Yes, folks, your Family Doctor is available 24/7 to respond to your urgent or emergency situations.

When a patient leaves a message, the system automatically pages our doctor on call immediately, who receives a call on their cell phone just like the test page, giving them the opportunity to listen to the message immediately or when they finish their current task.  The doctor on call listens to the patient's message and phone number and returns the call.  Our machine records the patient's phone number, also, so we can listen to the recorded number via voice recording of the system immediately at the end of the patient's recorded message.  This is useful if the patient recording wasn't clear, due to the patient's illness (hoarseness, weakness, crying baby, barking dog, etc.).  Also, it's helpful for people who forget to leave their phone number or hang up without leaving a number.  Usually the person who hangs up without leaving a message actually had a need that the physician can respond to but the patient had second thoughts about bothering the physician.  I almost always call the hang ups, knowing it's always been a patient of ours who is calling.  Wrong numbers must be hearing  the recording and hang up before the paging system is activated.

What do people call about?  Someone is sick, miserable, having a reaction to medication, having no response to medication for intense symptoms, pain, acute stress reaction, clarifying whether to go to an emergency room (or urgent care).  If we advise going to an emergency room, we call the emergency room to let them know about our patient and whether we wish to be called back once a diagnosis and treatment plan is established.  We help the patient, the ER staff and ourselves by calling since we know our schedule for follow up possibilities and we know our patient and their family.  We may apprise the ER staff- usually I speak with a physician- about the past medical and personal history of the patient to provide the physician with a better starting point for understanding our patient and their situation.

I want them to sense that my patient is a unique and interesting person with a doctor who cares.  ("Please love my patient, you wonderful ER doc, you won't regret it.  I will make your work easier by willingly seeing the patient in follow up at which time I will edify the work done in the ER and the people who did it.")  We also let them know who will be admitting the patient should the need arise (we have most people admitted to a hospitalist group that we know fairly well, since we stopped admitting about two years ago.  This is worthy of another post since a new hospital just opened right next door to our office.  I love going to hospitals and caring for my own patients and want to start admitting again, BUT there are considerations about increasing complexity in all of our endeavors that may preclude admitting my own patients.  More later on this subject.).

We also let the ER doctor know whether the patient has already seen a sub-specialist in an area of concern for the current episode (if they may be having a heart problem and they have a cardiologist, we want the ER to relate to the same cardiologist and not accidentally consult another cardiology group- continuity is important).  I also let them know that if the patient is admitted, I want to speak with the admitting physician so I can give more background about my patient.  This type of personal communication helps everyone, increases "quality" and decreases the potential for disasters.

Sick babies are especially important  to us at night.  Parents can be very stressed with a sick child, so we are committed to hearing their story and connecting to the stress as well as the sickness.  The first child (what I call the "training child") generates more stress than later ones, so we add comments of validation and    reassurance when speaking with parents about the "training child".  A friendly comment to "call back if you aren't comfortable with how the child is doing or your pulse rate is over 100."  The parent, who is also our patient -one of the beautiful aspects of Family Medicine- often feels better knowing that it's ok to call back (Yes, we're in this together).

As a Family Physician, I (or my cross coverage-someone from my own practice) am available 24/7.  I get surprised when I see an ad on TV or a billboard promoting Ask a Nurse type night call companies and think, "Why ask a nurse when you can ask your own personal Family Physician?"  There must be physician groups with less availability at night than ours, or less curiosity or more stress.  I could see a patient use of Nurse on- call companies for when the patient doesn't get along with the doctor on cross-coverage call or doesn't agree with their advice.  The nurse may be very comforting for them.

This post was inspired by the calls I received in the last 12 hours while I've been on call.  We're very close to the Ohio flu season, so night call will get even more interesting.  What have your experiences been with after hours and night call medical interactions?