The Telephone Paradox -- Follow Up

When I wrote the post called The Telephone Paradox, I thought it would be interesting to my readers. Mostly, I think, these are parents and parents of patients of mine. I know that at least a few other doctors read some of the pieces. Since I'm a member of a private listserv focusing on telemedicine through the American Academy of Pediatrics, I let the administrator know about the post in case it would be of interest to colleagues.

In that post, I noted my experience in giving my patients open, unlimited access to calling me any time, at home, on weekends, or at night. I found that the number of phone calls I received actually went down, and the ones I did get were all appropriate and important.

I was not prepared for what happened.

Some responses were flatly doubtful. Many doctors commented that they absolutely knew that my observations were in error, and that I must have a very unusual practice if all kinds of wacky people weren't calling me through the night for foolish reasons. They didn't quite say that I made it all up, but they clearly thought that was a possibility. The most hostile comment came from someone who worked at a for-profit call center. She claimed that waking up doctors in the middle of the night was extremely dangerous because they were likely to make hazardous errors in judgment. She said that people with genuinely sick children would not call when they should because they'd be intimidated by the fact the doctor himself would be answering the phone.

But there were a surprising number of comments noting similar experiences to mine. Typically doctors from small practices, they, too, thought they were the only ones with this experience. These doctors said that they rarely, if ever, were bothered unnecessarily. Patients were respectful of their time and sleep, and they were glad to get the calls they did get.

I redoubled my efforts to search the medical literature. This has never been studied. So while I can discuss my personal experience, and others their experiences, I have nothing to report as supported by statistics.

What I believe is that I have stumbled upon a great example of conventional wisdom. Everybody, including the most exalted experts, believes the world is flat. They are so sure of it that they don't want to send out an expedition to the edge to find out for sure. Why bother when they already know the truth. Yet I, in my little boat, have sailed to where the edge was supposed to be and it's not there at all. So I found out there is a whole industry of for-profit call centers, with people who make a living working in them and managing them. Their purpose is to relieve doctors of the burden of patient calls, a burden that is strongly supported by conventional wisdom.

I made a decision to try and avoid alienating my colleagues (at least for this--I've got some whoppers in the pipeline), and didn't argue with any of them. I had my say in the post, and I thought it was a good idea to let others comment as they might. It gradually became clear that there are no data supporting anything that was said. The person who claimed that patients would be intimidated by calling the doctor had a particularly difficult task if she were ever asked to prove that somehow the medical care of a patient would be improved with less communication with their own doctor. Though I have no data either, at least I have my own genuine experience, and others have had the same experience. Those that have not had this experience have never tried giving out their home phone number, so they believe their experience confirms the conventional wisdom. Since they've never tried it any other way, I don't think it really does.

My readers and my patients know that I question dogma about, well, everything. At least my patients can call me.

Please see my post on Swine Flu.

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.