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Tuesday Mar 22, 2016

Here's My Number, Call Me (Maybe)

Both urban and rural docs in the past shared a different type of accessibility with their patients than most of us do today. Without the communication lines of social media, email and text messaging -- and when the only ways to communicate were in person or via a landline phone -- most rural doctors had their home numbers listed in the phone book. And everyone knew where they lived.  

Even today in small towns and rural areas some of that holds true, as evidenced by stories from our members. But historically it was a much more even playing field. Doctors weren’t isolated from patients but there were far fewer access points. And accessibility, to some degree, affects who chooses family medicine, particularly in rural settings. If you don’t like answering health questions at the grocery store, living and working in a rural community might not be for you.

Often when I am in a group of physicians, I will get a text or a phone call from a patient or a patient’s family member. Without fail, the group will be divided about what is right, wrong, expected, or even should be prohibited, regarding communication with patients(www.wsj.com) outside a face-to-face office visit or a patient portal. Obviously, there are HIPAA issues involved, but the bigger argument among physicians is about handing out a direct access point.

Honestly, whenever I thought the best patient care was going to result from a patient's family having my cell phone number, I gave it. End of life is one of those times when I feel it is important for the family to have 24-hour access to prevent unnecessary anxiety and/or suffering for anyone involved -- patient or family. The hurdle of calling my answering service in a panic or ending up in the ER because someone does not know what to do must be avoided when the patient’s wishes are to die comfortably at home.

Recently I started looking for guidelines to see if there were established ethics or standards for handing out my cell phone number, but I didn’t find much. There are some resources regarding social media, but most essentially say zero social media interaction should occur between patients and doctors(www.fsmb.org), even though the data show patients would be receptive to receiving information from physicians via social media.  

Selfishly, I will often give a family my cell number if it is going to make things easier on me. If I know we need to communicate often, and with quick responses on both my part and theirs, it is much easier for them to contact me directly. And it means we both get the most accurate information with no distortion.

Granted, anyone who has ever worked with me will tell you I am a control freak who wants to be involved with every little decision about my patients. I want subspecialists' consult notes, I want the labs they draw, I want to know how my patients are doing the day after I see them, and I want to know what the ER workup reveals before they ever leave the ER. I'm that doctor that no subspecialist wants to hear is calling for them. I’m a patient advocate above all else, and sometimes that involves asking patients to text me as soon as they complete an imaging test so I can call for the result, or to call me when the home health nurse arrives. Most of those needs occur after normal business hours.  

After-hours care is also a big motivator for me to hand out my cell number. I feel it's much less disruptive for a patient to text me a question I can respond to without having to interrupt a board game with my son. Otherwise I would have to take a call from the answering service and then call the patient back.  

I won’t lie. I have regretted my decision to hand out my number on occasion, but it isn’t the end of the world. Just as patients can overstep boundaries in the office and we have to be professional and maintain an appropriate patient-physician relationship, the same holds true for communication outside the traditional office setting. If I get a text asking about pain or pain meds I reply that they need to call the office and schedule an appointment. If someone starts to text excessively about non-emergent issues I often have office staff call back to address the issues rather than perpetuating the situation, particularly when patients text while I am in the office. But overall, even the negative experiences haven’t changed my perspective. Often we have to step outside the perceived boundaries of our duties and expectations in order to provide the right type of care.  

One night my phone rang at 3 a.m. One of my patients' daughters was distraught and did not know what to do. One of her parents was unstable, and the other could not be left at home. I advised her to send her father to the hospital he had most recently been to where a doctor would be able to review fairly recent health information. I also advised her to have EMS communicate the need to have the triage team call her for a pertinent history over the past couple days. She felt much better, felt OK with the plan. Then I checked back in with both her and the hospital as soon as I got to my office.

I didn't know how she got my number because I hadn’t given it to her, but I honestly didn’t care. I’d helped her and her parents -- all three of them are my patients -- through the night and I felt it was an appropriate call to wake me up.  

A few days later, one of my office staff asked if I was mad at her for giving my cell number out to that family. I explained that I actually didn’t ask the patient who gave it to her and that, no, I was not at all upset. She said, "I was more worried you would be upset with me for not giving it, so I did."  

We could have an entire discussion about payment, reimbursement and the need for billing reform for this type of care, but that is honestly what I’m trying to get away from. So much discussion revolves around the "loss of the family doctor" and the "downfall of the art of medicine," etc. due to electronic health records, time constraints, data collection, quality measures and limiting the time we spend on work after work.

Personally, I want to maintain that traditional, old-school relationship with my patients in spite of the increasingly unreasonable requirements we are faced with. Just as our patients miss that relationship, so do I. Often, a text from a patient makes my day.  

Kimberly Becher, M.D., practices at a rural federally qualified health center in Clay County, W.Va.

Posted at 12:53PM Mar 22, 2016 by Kimberly Becher, M.D.

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