Discussion
In studying after-hours phone calls, we found several systematic barriers between patients and physicians: wrong numbers, messages necessitating a second phone call, and requirements that the patient decide whether the medical complaint was serious enough to initiate contact with the oncall physician. These barriers may negatively affect patient health due to unnecessary delays in evaluation and treatment.
Most patients asked to speak with the physician immediately about important clinical matters: medications, chest pain, contractions, or fever. However, some patients appeared unable to make appropriate triage decisions or persevere long enough to overcome the systematic barriers that prevented them from talking to a physician.
Our physician panel would have wanted to talk to the “no emergency” patients immediately in approximately half the cases. If 10% of 50 million to 100 million after-hours phone calls each year in the United States are not forwarded to the physician because the caller feels the complaint is not emergent, and if half those calls are potentially serious, there may be as many as 2.5 million to 5 million potentially dangerous delays in care each year.
We cannot expect an answering service operator or a parent to know how to triage an infant with a fever when physicians disagree on appropriate disposition.8 New parents with a sick infant, an older patient with chest pain, or a woman having preterm contractions during her first pregnancy might be uncertain as to what constitutes an “emergency.”
Solutions
Several solutions to this problem exist. We made a change in our office and now have all clinical calls forwarded to the on-call physician. No triage decisions are made by the patient or the answering service. This has led to an average increase of only 1 to 2 more patient calls per night. Offices also could become part of a citywide network in which all calls are managed by a trained nursing staff, as the pediatricians have done in Denver, Colorado.5
Interpretations
This study should be interpreted in light of several limitations. First, it was conducted in 1 metropolitan region. It is possible that other regions of the US have different mechanisms or standards for handling after-hours calls. However, given the overwhelming number of offices in our study that required patients to make their own triage decisions, we believe this barrier is likely widespread.
Second, the answering services we surveyed knew we were not patients, and this may have affected their answers. However, even if only 10% of these calls were not forwarded to the physician on call, a significant number of calls might have been unnecessarily delayed and potentially put patients at risk.
The Institute of Medicine’s report on medical errors states: “Errors can be prevented by designing systems that make it hard for people to do the wrong thing and easy for people to do the right thing.”9 Errors in triage by the patient or the answering service may lead to dangerous delays in necessary patient care.
Our future research will focus on identifying adverse outcomes in this study population and prospectively in a practice-based research network. When a patient calls the primary care office after hours, the decisions should be simple and left to those who have the training to make those decisions based on their best medical judgment. We strongly urge all clinicians who use an answering service to examine their policies and procedures for potential sources of medical error.
Acknowledgments
We express our thanks to Tarek Arja, DO, Dan O’Brien, DO, Mark Cucuzzella, MD, and Jacqueline Stern, MD; for agreeing to review nonemergent calls, and Pamela Sullivan for her assistance in preparing the manuscript.