In the era of managed care, the impetus is on primary care providers to manage more complex cases with fewer subspecialist referrals.1-3 An accessible, accurate, and convenient source of medical information is crucial to the success of this endeavor.4,5 Practitioners often prefer to discuss patients with colleagues, but the availability of colleagues is often a limiting factor.6 The telephone is a viable and increasingly utilized avenue for physician consultation.7,8 The purpose of this study is to determine the number, source, and content of outpatient calls received by 2 pediatric infectious disease practitioners through a direct telephone access line connection from the community. Methods The physician access line (PAL) was instituted at Children's National Medical Center, Washington, DC (CNMC) beginning July 7, 1997, for the purpose of facilitating community physician access to medical specialists at CNMC and ultimately improving patient care. By dialing a designated number, community physicians are directly connected to the requested CNMC physician through a dedicated telephone line with an identified operator Monday through Friday, 8:30 AM to 5:00 PM. The call is directly transferred to the pager of the requested subspecialist. The calls are monitored to assure that the subspecialist responds within 15 minutes. All PAL calls received by 2 infectious disease attending physicians (B.A.J., W.J.R.) who were rotating on the outpatient service were prospectively documented by the physicians in a composition notebook. The investigators began timing calls received during January and February 1998. Comparison of the median length of calls among physician categories was evaluated using the Mann-Whitney U test. Calls made to the infectious disease service during evenings, nights, and weekends were answered by the inpatient infectious disease attending physician on call and were not included in the study. This study was approved by the institutional review board of CNMC. Results The 2 infectious disease physicians received 320 outpatient calls during a 7-month period. The number of calls was distributed among the months as follows: July 1997 (62 calls), August 1997 (59 calls), September 1997 (38 calls), October 1997 (32 calls), December 1997 (43 calls), January 1998 (53 calls), and February 1998 (33 calls). All calls were answered within 15 minutes. The majority of calls (191/320 or 60%) originated from community physicians in practice. Physicians based at outside hospitals made 84 (26%) of 320 calls, CNMC physicians placed 26 (8%) of 320 calls, nurse practitioners made 2% of the calls, and health department physicians (1%), other physicians (1%), home-care personnel (1%), and parents (1%) comprised the remaining callers. Community physicians in practice called for the following reasons: to discuss a patient in their practice (86/191 or 45%), refer a patient to clinic (46/191 or 24%), discuss a patient seen by the infectious disease department (30/191 or 16%), discuss a patient hospitalized at another institution (9/191 or 5%), or for other reasons (20/191 or 10%). There were 75 timed calls: 42 in January 1998 and 33 in February 1998. The investigators spent 3.8 hours answering calls in January and 3.3 hours in February. The median length of calls from community physicians in practice was 5 minutes (range, 1-20 minutes) compared with 6.3 minutes (range, 1.9-10.2 minutes) for hospital-based physicians (P = .89). Calls from community physicians resulted in referrals 79 (25%) of 320 calls. Calls from community physicians resulting in referrals did not differ in length from calls from community physicians placed for other purposes (P = .35). Community physicians placed 86 calls to discuss a patient in their practice. These calls embraced 34 topics in the following categories: systemic infections (21 questions); gastrointestinal (10 questions); respiratory tract (9 questions); nervous system (5 questions) including meningitis, Bell palsy, and rabies; genitourinary (4 questions) including pyelonephritis and vaginitis; and miscellaneous (37 questions). The miscellaneous category included questions regarding bacteremia (6 questions), soft tissue infections (6 questions), fever (5 questions), immunizations (5 questions), recurrent infections (4 questions), osteomyelitis (2 questions), pharyngitis (2 questions), and others. Specific diseases that generated the largest number of questions were Lyme disease (7 questions), herpes simplex infection (6 questions), and tuberculosis (5 questions). Hospital-based physicians placed 26% of the calls to discuss a patient seen by the infectious diseases department (65/84 or 77%), request a consultation for a hospitalized patient (17/84 or 20%), or for other reasons (2/84 or 3%). Comment In the era of managed care, the PAL may enhance community physicians' management of patients with more complex illnesses. The PAL allows a practitioner to obtain timely feedback from a specialist while the patient is in the office. The majority of telephone calls to pediatric infectious disease subspecialists emphasize case management. Kleiman9 reviewed 105 calls directed to a pediatric infectious disease subspecialist in 1986 and noted that all but 1 focused on patient management. Our results demonstrate that infectious disease subspecialists remain an important resource for community physicians in practice. The infectious disease subspecialist also plays a significant role in the management of patients hospitalized at outside institutions. The questions from physicians in practice reflected a wide variety of topics. Input from infectious disease physicians was sought regarding the management of many common diagnoses and not just for esoteric cases or emerging infections. Physicians at CNMC used the PAL to contact colleagues. This hindered the operators' ability to handle outside calls and a memorandum was subsequently issued to CNMC faculty to discourage their internal use of the PAL. Two parent calls were received through the PAL. One parent had a PhD, identified herself as "Doctor" and was routed through the PAL by the operator; a second parent deliberately manipulated the system to reach the physician. Our department prefers that parent calls be channeled through their primary care provider. The PAL may facilitate patient management and physician education by providing a convenient access to case-oriented input from specialists. The questions raised by physicians through the PAL reflect relevant issues of concern for community physicians and provide potential topics for continuing medical education programs. The PAL is not designed to replace formal infectious disease consultation. In a few cases, however, the information provided by the infectious disease consultant may have adequately addressed the practitioner's concerns and eliminated the need for formal consultation. The investigators believe that this happened in a minority of cases. The investigators did not notice a decline in the number of referrals nor in the number of patients seen in clinic following the introduction of the PAL. The question arises as to whether physicians should be reimbursed for their time spent answering PAL calls, and if so, who should pay for these calls. The PAL was not designed to generate revenue. The PAL was designed as a goodwill service to the community to enhance community physicians' access to subspecialists to improve patient care. This service should enhance the public image of the institution in the community. It may also enhance physician allegiance in the community for future referral, thus benefiting the institution that provides the service. Subspecialists can document their time answering PAL calls and submit this to the medical center's administration to provide additional evidence of their value to the institution. An important reason not to bill for this service is that billing establishes a physician-patient relationship with the infectious disease consultant and opens the door to medicolegal liability. The medicolegal liability of the telephone infectious disease consultant remains an open question. Validity of information provided by the consultant is limited by the quality of data provided by the caller. There is also no assurance that the caller comprehends or correctly records the consultant's advice. A malpractice case in Michigan prompted review of whether 2 physicians' providing informal consultation to a colleague may be construed as the consultants' having a professional relationship with the patient in question and being liable for their advice.10 In this one particular instance of curbside consultation involving an obstetrics case, the court noted that the patient had not employed the consultants and the consultants had not known, spoken with, or examined the patient. The court further noted that the consultants' opinions were directed to their colleague and not to the patient, and were recommendations that the patient's primary physician could accept or reject. On this basis, the court ruled that the consultants had no physician-patient relationship with the patient and would not be held liable for their advice. The author of this opinion pointed out the limitations of applying the rulings of 1 court to activities in other states, but concluded that " . . . it does appear . . . that curbside consultations are useful, desirable, and generally legally safe."10 In the era of managed care, the PAL may allow community physicians to manage patients with more complex illnesses with fewer subspecialist referrals. The PAL was designed as a goodwill service to facilitate community physician access to medical specialists, and to ultimately improve patient care. The PAL was not designed to replace formal infectious disease consultation. References 1. AMA Council on Ethical and Judicial Affairs, Ethical issues in managed care. JAMA. 1995;273330- 335Google ScholarCrossref 2. Kassirer JP Access to specialty care. N Engl J Med. 1994;3311151- 1152Google ScholarCrossref 3. Cartland JDCYudkowsky BK Barriers to pediatric referral in managed care systems. Pediatrics. 1992;89183- 192Google Scholar 4. Keating NLZaslavsky AMAyanian JZ Physicians' experiences and beliefs regarding informal consultation. JAMA. 1998;280900- 904Google ScholarCrossref 5. Pollack S A role for academic medical centers in the era of managed care: immediate, interactive, free information. Acad Med. 1998;73357- 359Google ScholarCrossref 6. Connelly DPRich ECCurley SP et al. Knowldege resource preferences of family physicians. J Fam Pract. 1990;30353- 359Google Scholar 7. Holt NCrawford MA Medical information service via telephone. Ann N Y Acad Sci. 1992;670155- 162Google ScholarCrossref 8. Manian FAMcKinsey DS A prospective study of 2,092 "curbside" questions asked of two infectious disease consultants in private practice in the midwest. Clin Infect Dis. 1996;22303- 307Google ScholarCrossref 9. Kleiman MB The infectious disease consultant and the telephone consultation. Pediatr Infect Dis J. 1986;551- 53Google ScholarCrossref 10. Landwirth J Legal liability for curb side consultations. Infect Dis Child. 1991;421Google Scholar
Archives of Pediatrics & Adolescent Medicine – American Medical Association
Published: Nov 1, 2000
Keywords: telephone,infectious disease consultation,communicable diseases
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