Calling the Doctor: 'Is This an Emergency?'

The question is often asked by the answering service when a patient calls a doctor in the middle of the night: Is this an emergency?

Now a new study casts doubt on the widespread practice of screening after-hours calls to physicians. Requiring untrained patients to decide which problems are serious enough to deserve immediate attention and which can wait until morning is unrealistic and potentially dangerous, some experts say. It also may represent a little-recognized source of preventable medical errors, they add. It is estimated that patients annually make 2 million to 5 million calls to doctors' offices at night or on weekends.

"A lot of times patients don't really know if it's an emergency or not," said lead author David Hildebrandt of the University of Minnesota department of family medicine, whose study appears in the current issue of the Journal of the American Board of Family Medicine.

"Does indigestion mean you're having a heart attack, or is it GERD (gastroesophageal reflux disease)?" Hildebrandt asked. "And how would a patient be expected to know?"

Bruce Bagley, director of quality improvement for the 94,000-member American Academy of Family Practice, one of the largest medical specialty groups, agreed. Asking patients to determine if a problem is urgent, he said, is inappropriate: That's the physician's job.

"My pitch is for zero filtering of clinical calls," he said. "A lot of people hesitate to call the doctor to begin with in the middle of the night. It's rare to get a call from a patient in the middle of the night about a cold."

Hildebrandt said his study, and other research he has published on the subject, was prompted by curiosity about what happened to callers who didn't reach the doctor on call at the University of Colorado's family medicine clinic, where he worked at the time. He and his colleagues studied all 2,835 after-hours calls to the Denver clinic logged between April 2000 and March 2001.

Ninety percent of callers were connected to a physician because they told the answering service their problem was an emergency. But among the 10 percent whose calls were not forwarded because they said the matter was not urgent was a man with chest pain radiating down his arm, another who had trouble breathing, and a pregnant woman leaking amniotic fluid - situations that require prompt medical attention because they could be life-threatening.

Using medical records and interviews, the researchers analyzed 119 of the calls that had not been forwarded and found that three patients had been harmed by their failure to reach a doctor and two were at risk of future harm. An additional 31 experienced pain or discomfort due to delayed contact; some saw a doctor the next day for complaints that included untreated fractures or pain from a kidney stone. Six patients sought treatment in an emergency room.

The practice of filtering calls by asking the emergency question is widespread, said Hildebrandt. A minority of large practices, including Kaiser Permanente and the Mayo Clinic, hire nurses to field after-hours calls, but that is more expensive, he noted.

Some practices use both approaches. Karen Hopfl Harris of Washington, whose children are 2 and 5, said she is usually asked the question when she calls her pediatrician after hours and before she reaches a nurse, who may then refer the call to a doctor.

"I know to say yes," said Harris, an environmental and health policy expert and granddaughter of a physician. She estimates she makes such calls twice a year.

"If I bother to call, it means I can't handle the situation, and it's the doctor's responsibility to tell me whether it's an emergency or not," Harris said. She added that she is reluctant to call and runs through a mental checklist trying to decide whether the problem can wait until 7 a.m., when she knows her doctor is available by phone.

Concerns about after-hours calls have long bothered patients and physicians, but for different reasons. Harris said she has waited four or five hours at times for a doctor (not her pediatrician) to call her back, a complaint echoed by other patients.

Doctors have sought ways to protect themselves from unreimbursed after-hours calls that eat up their time and interrupt their sleep, simply to renew prescriptions,cancel appointments or address minor ailments. But many say they want sick patients to be able to reach them.

Steven Schwartz, a family physician in a multi-specialty primary care practice in Montgomery County, Md., said he and his partners decided to jettison their answering service in favor of a computerized telephone system several years ago after "a series of disasters." The last straw, he said, was a mother whose young child had a high fever and had trouble reaching the doctor on duty.

"Most of the time (doctors) never know about the calls that never get through," said Schwartz, who is an associate professor of family medicine at Georgetown University School of Medicine.

The new system, he said, filters out administrative calls that can wait until morning and allows patients to record a message that is automatically forwarded to a physician.

"This way I can hear in the patient's own words what the problem is," Schwartz said.