March 25, 2009

Slow Medicine: The Telephone Paradox

When I tell other doctors that my patients have my home phone number, they simply don't believe me. I tell them that calls to my office in the evening and on weekends or holidays get automatically routed to my cellphone or home phone. There is no answering service or triage nurse.

I set this up because the job of the answering service (this is one of the selling points they use for doctors) is to minimize the number of calls they put through. They seem to be measuring their effectiveness by how impenetrable a barrier they are for the patients. When your child is sick, if you want to talk to a doctor—forget the possibility of talking to your doctor—you have to sell the person answering the phone on how desperate your situation is, but not so desperate that they tell you to go to the emergency room. I want to get those calls, and want to know what's going on with your kid.

But my colleagues don't believe it. They tell me that if they let patients call them at home, they would get calls through the night about trivial things. They would suffer and their patients wouldn't benefit. I used to work for a big group practice, and this seemed a reasonable summary of my experience, too. So nobody actually tried it.

Here's what I found. The more I gave out my home number, the fewer calls I got. When I opened my own practice, I could actually program the office phone to direct all the calls automatically. Patients didn't even need my home number, they could get me at home any time. I got almost no calls. In the last 2 years, I have been awakened by phone calls just 6 or 7 times. In each of these cases, I got out of bed, got dressed and either made a housecall then or met the family in the emergency room. So those few calls were well justified.

As I thought more about this paradox, I realized that the general population of doctors had become so convinced of the universality of their experience, that they didn't attempt to repeat my experiment. I think there's an interpretation that isn't so mysterious.

First, in my Slow Medicine practice, everybody knows me. They see the same doctor with every visit and talk to me with every phone call. This leads to a humanization of the doctor as more (and less) than a BMW with a white coat who barely makes eye contact in the five minutes he spends with you, forgetting your name. So I suspect people are more respectful of my private time, the way we all are with our own friends and family. They all know that when they call at night, they won't get an anonymous shift-worker at a call center.

Second, Slow Medicine is all about access to the doctor. Once the parent is convinced they really can get a hold of me anytime, they are more willing to try and handle minor problems on their own. The thinking, I suspect, is that if the child gets worse, they can always call then. That results in perceptive parents carefully observing their sick children. If they get worried, if it gets a little too much for them to feel comfortable with, they can always call me at that time. So parents handle a lot more on their own, I think. In this way, there is another paradox. The fewer calls I get, the more empowered and self-reliant the parents feel. They know I'm there to back them up, so they might be willing to take a few steps on their own.

I believe that the ability to get in touch with your child's personal doctor in a crisis is often very beneficial to the quality and continuity of their care. Besides, if you have confidence in your doctor, and can get your doctor on the phone, then you'll have confidence in the phone advice you get. It's logical that this confidence is itself reassuring, even without actually making the call. This paradox helps me sleep better. And maybe the parents of my patients, too.


  1. Three days ago, we came in for a sick child appointment and since that visit, we've gotten a daily phone call from Dr. Wolffe checking in on Cayden. Tonight Cayden heard his message, smiled and said, "Boy, Dr. Wolffe really wants me to survive. That feels good." Indeed it does.

  2. Our group practice has not had an answering service in 12 years. the doctor on call, is available directly by phone to home or forwarded to cell phone, not a pager. while we have a more traditional pediatric practice, out experience echos your comments...few really unnecessary calls.
    We do have on our messaging, that if the calls are not urgent after hours there may be a charge. the dose of tylenol is on our website and given to parents at each of the shot visits, so something like this would be billed to the patient as an after hours phone charge.


Please let me know what you think. Do you know a child or situation like this?