Managing Your Practice
Advisory No. 7

Telephone Advice Programs - the Benefits and Risks

• Proceed with caution
• Pros and cons of telephone advice programs
• Create a telephone advice guide
• Reduce your liability risks
• Selected bibliography
• Sample telephone advice guidelines
• Get_advice_from_MIEC

"This is Nancy Grant, Bobby's mother. He's had a fever and runny nose for two days. We're leaving on vacation tomorrow. Can Dr. Smith give Bobby something for his cold?"

"Hi, Fred Watson calling. The medicine Dr. Jones gave me after my surgery yesterday is making me nauseous. What should I do?"

"I'm in my sixth month of pregnancy and I've been spotting a lot lately. Is that normal?"

"I hate to bother the doctor, but I've had a tight feeling in my chest all night. Should I go to the hospital?"

These questions are typical of the inquiries many medical offices receive daily from patients who seek advice, treatment recommendations, prescriptions or reassurance from their doctor. The volume of calls tends to increase in bad weather periods, especially during the "cold and flu season," when people are less willing to venture outdoors. Requests for telephone advice have increased as more patients are enrolled in managed care plans that discourage-age unnecessary office visits or won't pay for visits to an emergency department that, retrospectively, the plan deems were not emergencies. For some patients, the expense of an office visit is an incentive to want to resolve medical problems with a phone call.

Proceed with caution

Some doctors welcome and encourage phone calls in lieu of a visit, but others find they are unable to handle the growing number of calls, or worry about malpractice liability if they are sued for misdiagnosing a condition reported by phone. Giving medical advice on the telephone may be a convenience for patients, but in some cases it can be risky without the benefit of a physical exam. Many doctors contend that the art of practicing medicine often entails skilled observation. Sometimes a doctor can see that a patient is sick before an exam or tests prove it. Physicians must use good judgment in deciding if they can diagnose and give treatment advice without observing the patient directly.

Physicians who dispense telephone advice find it helps to reduce unnecessary visits for minor problems that respond to first aid or basic care, such as taking aspirin, elevating feet, stay-staying in bed, or trying an over-the-counter medication. Phone advice supporters also believe that giving phone advice improves patient relations. They note that some patients are unhappy if, after an office visit, they believe the doctor could have given them advice about their minor problem just as easily over the phone.

Clinics and high-volume practices such as pediatric offices are among those that favor formal telephone advice programs staffed by a trained nurse who can screen (triage) calls and make judgments about which of them require the doctor's prompt attention. While useful, telephone triage also has some limitations. Concerns of triage nurses include deciding how serious a patient's symptoms are, and how to elicit enough meaningful information from ill patients to make a decision for action. As some people who are sick enough to be seen by a physician are hope-hopeful a phone call will save them a trip to the doctor, advice nurses must err on the side of caution and advise patients to come in to be seen and evaluated if there is any question about the seriousness of their complaints.

Pros and cons of phone advice

Proponents say phone advice programs offer these benefits:

• Minor illnesses can be managed without the expense of an office visit.
• Often the patient is experiencing a recurrent problem that can be treated with medication that worked well in the past.
• Costs of office visits are reduced, a plus in capitated managed care plans.
• A doctor's willingness to manage minor problems by phone promotes good will.

Some of the liability risks of dispensing advice by telephone:

• A physician is not able to personally assess the patient's appearance, severity of symptoms, body language or other factors he or she usually takes into account while doing a physical exam.
• Patients ­ or others calling on their behalf - may be unreliable historians, or inaccurately assess the severity or location of physical complaints; lay people often incorrectly describe or minimize symptoms, a potentially serious omission in conditions such as an impending heart attack. 
• Unclearly-worded questions may elicit misleading responses. One example: in a settled misdiagnosed meningitis malpractice case, ----the doctor had asked a patient's mother who called for advice if her child "has a fever." The mother responded in the negative. The doctor later learned that the mother did not have a thermometer, but she had assumed the child was afebrile because his forehead did not seem warm to her touch. Given the child's other reported symptoms, the doctor had to concede, it would have been important to know the patient's actual temperature.
• Increased volume of phone calls may strain the phone system or staff, although adding a phone line and encouraging patients to limit non-emergency calls to specific times can alleviate these burdens.

Create a phone advice guide

A first step to help nurses (or other trained staff) to effectively answer patient questions with physician-approved responses is to prepare a Telephone Advice Guide. The Guide should contain general information for all staff who answer telephones. Include instructions on the proper way to: (a) answer calls; (b) transfer calls; (c) politely put patients on hold; (d) manage difficult callers; (e) overcome language barriers; (f) document messages in each patient's chart. Emphasize the importance of telephone courtesy. Policyholders may incorporate MIEC's Guidelines for Telephone Etiquette Managing Your Practice, [Advisory Number 10] into their Guide. 

The Guide should contain clear instructions for staff who are authorized to dispense advice. Include an alphabetized list of the most frequently-asked-about medical subjects, followed by a list of frequently-reported chief complaints and symptoms. 

For each medical condition or major complaint protocol, the physician should decide what findings or symptoms require that: (1) the patient be seen immediately; (2) the patient be seen within a specific time; (3) the patient be given advice for treatment at home; or (4) the call be referred at once to the doctor. Each protocol should list questions the doctor wants the nurse to ask callers, such as the onset and duration of symptoms, vital signs, medication use, and other information the physicians would want to know. Based on the caller's responses to the initial questions, the nurse determines which advice protocol to follow. The protocols should indicate under what circumstances the nurse may make an independent judgment or alter the advice in the protocol. Use clear, concise language for the advice protocols. When writing the text, consider the possibility that the protocols may be introduced as evidence in a malpractice claim against the physician. (See the bibliography below and sample phone advice guidelines on page 4.)

Policyholders can submit a draft of their telephone advice guide to MIEC's Loss Prevention Department for a complimentary review and comments.

Reduce liability risks

These additional steps can minimize the liability risks for physicians who dispense medical advice by telephone:

• Permit only physicians, nurses or qualified staff to handle telephone advice calls.
• Tell patients in writing how to use this service. Give examples of the types of complaints the doctor and staff usually can handle by phone and those that are likely to require an office visit.
• Advise patients each time they call about the limitations of dispensing medical advice by phone; tell patients how soon they should call back if their condition does not improve or if it worsens.
• Give callers ample time to explain their problem; avoid leading questions that can result in less-than-accurate responses. For example, rather than ask, "Have you had this pain for a long time?" ask, "How long have you had this pain?" Instead of "Do you have any chest pain?" ask, "Exactly where are you having pain?" Ask callers to describe the type, duration and severity of their symptoms.
• Physicians and aides who dispense phone advice should avoid using medical terms or acronyms; lay people may not know that common words (e.g., "void") can have a separate, medical meaning.
• When in doubt about a caller's accuracy or reliability, encourage an office visit; pay attention to your professional instincts.
• Carefully evaluate a patient's contention that the current problem is identical to a complaint the doctor treated earlier.
• Physicians should be aware of the risks of prescribing medication by phone for a new complaint; a wrong diagnosis can result in an ineffective or harmful prescription. Close follow-up is advisable.
• Document all phone advice calls. Use the caller's words, when possible. Document calls in each patient's chart, rather than in a phone log. This makes the information accessible to the doctor when the chart is in hand, and avoids potential oversights. (MIEC's phone message form can be reproduced or adapted.) Physicians who permit staff to handle advice calls should frequently review their documentation to ensure that phone advice guidelines are being followed, appropriate advice was dispensed and, in individual cases, that the physician was properly informed.

Selected Bibliography

Bartlett, E. Managing Your Telephone Risks, Journal of Healthcare Risk Management, American Society of Healthcare Risk Management, Summer 1995.

Borzo, G. Dialing for Doctors, American Medical News, January 15, 1996.

Protocols help staff give appropriate advice, ED Management, Jan 1994.

Schmitt, B. Pediatric Telephone Advice, Little, Brown, 1995.

Scott, MP and Packard, KP, Telephone Assessment with Protocol for Nursing Practice, W.B. Saunders, 1990.

Sweeney, D. Why your staff needs a manual for handling phone calls, Medical Economics, July 10, 1995.

Telephone advice lines: Worth the risk? ED Management, April 1996.

See also: Baldwin, G. For the physician, press 1, American Medical News, May 4, 1998. (regarding commercial phone advice services)

Get advice from MIEC

Sample Abdominal Pain Telephone Advice Guidelines for Pediatric Office*

If child has abdominal pain, but caller answers "no" to the above questions, advise caller to watch child for 3-4 hours. If pain continues or child shows any other sign of illness, call back. If caller resists advice to bring child to office, alert the doctor.

Sample Head Injury/ Blow to the Head Telephone Advice Guidelines for Pediatric Office*

If child has had blow to head, but has no symptoms, advise caller to watch child closely for 3-4 hours. If child shows any sign of illness, call back. If caller resists advice to bring child to office, alert the doctor.

* These are one physician's suggestions. Each physician should develop his or her own questions and advice guidelines.