Telephone Calls
Telephone calls are problematic because the caller and the physician often have different expectations. Some patients call physicians day or night about every minor medical question that comes to mind. Many patients call physicians after office hours only when they believe that they have a serious problem. From the physician’s perspective, most calls involve minor problems. This creates a sense of complacency that may lead physicians to mishandle telephone calls by underestimating the severity of the patient’s condition.
From a medical perspective, new patients and new problems should not be evaluated over the telephone. If the patient has a medical complaint, the only question would be whether an ambulance should be sent to pick up the patient or whether the patient can find transportation to a medical care facility. Patient and physician resources make this an unreasonable ideal. In many situations patients must be evaluated without a hands- on examination. This should not blind physicians to the medical and legal hazards implicit in such indirect evaluations.
A physician who listens to the patient’s complaints assumes the duty to make a triage decision about the patient’s condition: recommending treatment, no treatment, or that the patient see a physician in person. Physicians have an ethical duty to see that patients with emergent conditions get proper treatment. For persons who do not have a preexisting relationship with the physician, this duty can be fulfilled by sending the patient to a properly equipped emergency room. If the physician becomes more involved, such as by calling the ambulance, he or she must carry out these actions correctly—perhaps by calling the emergency room later and inquiring after the patient.
A physician who listens to a patient’s complaints and then recommends no treatment is implicitly telling the patient that he or she does not need immediate medical services. Usually the physician does intend for the patient to assume that he or she does not need further medical care. Occasionally, however, the physician does not want to treat the patient personally; he or she does not intend to imply that the patient does not need medical care. Once a physician has listened to the patient’s complaints, he or she has assumed a limited duty to that patient. It is this limited duty that creates the inference that not prescribing treatment is the same as telling the patient that he or she does not need treatment. A physician who does not want to accept responsibility for the patient must pass the patient on to another physician. This must be done expeditiously to avoid responsibility for determining that the patient is not in need of immediate care.
Prescribing medication is an exercise of independent medical judgment and creates a physician–patient relationship. It does not matter whether the physician recommends a prescription drug or an over-the-counter medication. Recommending aspirin is just as much as an exercise of judgment as prescribing digitalis. Telling the patient to “take two aspirin and call the office in the morning” assumes that the physician has ruled out the presence of any serious conditions that would require prompt attention. Recommending treatment over the telephone is best reserved for patients with whom the physician already has a relationship. If the physician has not seen the patient before, he or she does not have the necessary context to judge the patient’s condition. Is a headache due to a cold or out-of-control blood pressure? When dealing with existing patients, the physician must ensure that he or she has enough information to evaluate the patient’s condition properly. If the physician has not seen the patient recently enough to remember him or her accurately and does not have the patient’s chart available, the patient should be seen or referred to an emergency room.
All telephone conversations that involve medical decision making should be documented. If the call concerns an existing patient, the record of the call should be added to the patient’s chart. If the call involves a person that the physician accepts as a new patient, a preliminary record should be opened for that patient. If the call involves a person whom the physician refers to another medical care provider, including an emergency room, a referral record should be created. These records have two purposes. For existing patients, recording telephone calls is necessary to ensure that the patient’s medical chart is complete. For persons who are not patients, the record of the call prevents later misunderstandings about what the physician told the patient. The record should contain the time and date of the call, the identity of the caller, how he or she came to call the physician (name out of the telephone book, for example), the nature of the complaint, exactly what the physician told the person, and where the patient was referred.