The Child Not Seen

It was Natalie Saunders’ (not her real name) first visit to our practice. As usual I asked her why she had chosen our office. She replied that the practice she had been going to "wouldn’t see my son. I called several times, and I was always transferred to a nurse who would ask me a whole bunch of questions, some of which made me wonder if she had been listening to my answers. She would tell me that everything sounded okay, but to call if his symptoms persisted. When I would call back it was the same runaround."

I asked her if she had ever told the nurse that she wanted her son to see the doctor. She wasn’t sure that she had. And, knowing just a little about the pediatricians in that practice several towns away, I’m sure that had she been more assertive they would have seen her son promptly.

Unfortunately, I have heard similar stories from other parents, friends, and family members scattered across the country. And, even more unfortunately, I have had a few parents tell me that it has happened in our office

After listening to the history of her son’s complaint and examining him, it was clear that his symptoms hadn’t required an office visit. However, it also was apparent that the face-to-face encounter had allowed her to close that chapter and move on.

Many doctor’s offices are struggling to meet the demands of the population they serve. Sometimes it is the result of a shortage of providers. Sometimes it is because a practice has become too popular for its own good. Occasionally, "too-busy-to-see-you" situations are temporary, such as during an influenza or respiratory syncytial virus (RSV) outbreak. However, there are times when deflecting patients is a reflection of disorganization and lack of communication within an office. As in Natalie Saunders’ case, I’ll bet if someone had told the doctor the story, he or she would have said, "Sure, I don’t think we need to see him, but have him come on in."

But, the person on the front line, be it a nurse or a receptionist, may have incorrectly perceived that the doctors were too busy to squeeze in a patient whose symptoms didn’t require a face-to-face encounter. Sometimes this is a genuine desire to protect a dangerously stressed physician. Occasionally, triage personnel have developed a pride in their ability to deflect calls and view every scheduled office visit as a failure. Armed with a lengthy algorithm, a nurse or receptionist can wear down even the most persistent parent.

One of the worst culprits is an unrealistically crafted appointment book or computer screen. If applied correctly, the concept of "open-access booking" might have solved Natalie’s problem. It may be that every triage algorithm should begin, "I sense you are concerned. Do you want to come in and see the doctor?" The time saved answering repeat calls and employing tedious deflecting strategies usually compensates for that invested in seeing the patient.

I fear that some physicians have avoided open-access booking because they have developed a habit of scheduling follow-up visits in situations where a phone call would have been at least as effective. Parents appreciate phone calls even if it is from an assistant, but they don’t appreciate taking time off from work and sitting in a waiting room for an appointment that they realize has little or no value.

Second, a schedule that is too heavily weighted toward health maintenance visits doesn’t leave enough room for same-day calls. Does an 8-year-old with a spotless health record really need annual checkups? If the physician has time. Maybe. But, if the trade-off is a front office deflecting calls from the worried well, not to mention the seriously ill who might slip through the cracks in a triage algorithm, it’s a bad deal. The notion that a pediatrician can’t or doesn’t do some targeted anticipatory guidance and health promotion at an acute sick visit is bogus.

Twenty years ago when we had only 3 pediatricians for the same population base that is now served by 12, the office staff was too busy to deflect calls for an appointment. If you called, you got seen.

Dr. William G. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him. 

It was Natalie Saunders’ (not her real name) first visit to our practice. As usual I asked her why she had chosen our office. She replied that the practice she had been going to "wouldn’t see my son. I called several times, and I was always transferred to a nurse who would ask me a whole bunch of questions, some of which made me wonder if she had been listening to my answers. She would tell me that everything sounded okay, but to call if his symptoms persisted. When I would call back it was the same runaround."

I asked her if she had ever told the nurse that she wanted her son to see the doctor. She wasn’t sure that she had. And, knowing just a little about the pediatricians in that practice several towns away, I’m sure that had she been more assertive they would have seen her son promptly.

Unfortunately, I have heard similar stories from other parents, friends, and family members scattered across the country. And, even more unfortunately, I have had a few parents tell me that it has happened in our office

After listening to the history of her son’s complaint and examining him, it was clear that his symptoms hadn’t required an office visit. However, it also was apparent that the face-to-face encounter had allowed her to close that chapter and move on.

Many doctor’s offices are struggling to meet the demands of the population they serve. Sometimes it is the result of a shortage of providers. Sometimes it is because a practice has become too popular for its own good. Occasionally, "too-busy-to-see-you" situations are temporary, such as during an influenza or respiratory syncytial virus (RSV) outbreak. However, there are times when deflecting patients is a reflection of disorganization and lack of communication within an office. As in Natalie Saunders’ case, I’ll bet if someone had told the doctor the story, he or she would have said, "Sure, I don’t think we need to see him, but have him come on in."

But, the person on the front line, be it a nurse or a receptionist, may have incorrectly perceived that the doctors were too busy to squeeze in a patient whose symptoms didn’t require a face-to-face encounter. Sometimes this is a genuine desire to protect a dangerously stressed physician. Occasionally, triage personnel have developed a pride in their ability to deflect calls and view every scheduled office visit as a failure. Armed with a lengthy algorithm, a nurse or receptionist can wear down even the most persistent parent.

One of the worst culprits is an unrealistically crafted appointment book or computer screen. If applied correctly, the concept of "open-access booking" might have solved Natalie’s problem. It may be that every triage algorithm should begin, "I sense you are concerned. Do you want to come in and see the doctor?" The time saved answering repeat calls and employing tedious deflecting strategies usually compensates for that invested in seeing the patient.

I fear that some physicians have avoided open-access booking because they have developed a habit of scheduling follow-up visits in situations where a phone call would have been at least as effective. Parents appreciate phone calls even if it is from an assistant, but they don’t appreciate taking time off from work and sitting in a waiting room for an appointment that they realize has little or no value.

Second, a schedule that is too heavily weighted toward health maintenance visits doesn’t leave enough room for same-day calls. Does an 8-year-old with a spotless health record really need annual checkups? If the physician has time. Maybe. But, if the trade-off is a front office deflecting calls from the worried well, not to mention the seriously ill who might slip through the cracks in a triage algorithm, it’s a bad deal. The notion that a pediatrician can’t or doesn’t do some targeted anticipatory guidance and health promotion at an acute sick visit is bogus.

Twenty years ago when we had only 3 pediatricians for the same population base that is now served by 12, the office staff was too busy to deflect calls for an appointment. If you called, you got seen.

Dr. William G. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him. 

It was Natalie Saunders’ (not her real name) first visit to our practice. As usual I asked her why she had chosen our office. She replied that the practice she had been going to "wouldn’t see my son. I called several times, and I was always transferred to a nurse who would ask me a whole bunch of questions, some of which made me wonder if she had been listening to my answers. She would tell me that everything sounded okay, but to call if his symptoms persisted. When I would call back it was the same runaround."

I asked her if she had ever told the nurse that she wanted her son to see the doctor. She wasn’t sure that she had. And, knowing just a little about the pediatricians in that practice several towns away, I’m sure that had she been more assertive they would have seen her son promptly.

Unfortunately, I have heard similar stories from other parents, friends, and family members scattered across the country. And, even more unfortunately, I have had a few parents tell me that it has happened in our office

After listening to the history of her son’s complaint and examining him, it was clear that his symptoms hadn’t required an office visit. However, it also was apparent that the face-to-face encounter had allowed her to close that chapter and move on.

Many doctor’s offices are struggling to meet the demands of the population they serve. Sometimes it is the result of a shortage of providers. Sometimes it is because a practice has become too popular for its own good. Occasionally, "too-busy-to-see-you" situations are temporary, such as during an influenza or respiratory syncytial virus (RSV) outbreak. However, there are times when deflecting patients is a reflection of disorganization and lack of communication within an office. As in Natalie Saunders’ case, I’ll bet if someone had told the doctor the story, he or she would have said, "Sure, I don’t think we need to see him, but have him come on in."

But, the person on the front line, be it a nurse or a receptionist, may have incorrectly perceived that the doctors were too busy to squeeze in a patient whose symptoms didn’t require a face-to-face encounter. Sometimes this is a genuine desire to protect a dangerously stressed physician. Occasionally, triage personnel have developed a pride in their ability to deflect calls and view every scheduled office visit as a failure. Armed with a lengthy algorithm, a nurse or receptionist can wear down even the most persistent parent.

One of the worst culprits is an unrealistically crafted appointment book or computer screen. If applied correctly, the concept of "open-access booking" might have solved Natalie’s problem. It may be that every triage algorithm should begin, "I sense you are concerned. Do you want to come in and see the doctor?" The time saved answering repeat calls and employing tedious deflecting strategies usually compensates for that invested in seeing the patient.

I fear that some physicians have avoided open-access booking because they have developed a habit of scheduling follow-up visits in situations where a phone call would have been at least as effective. Parents appreciate phone calls even if it is from an assistant, but they don’t appreciate taking time off from work and sitting in a waiting room for an appointment that they realize has little or no value.

Second, a schedule that is too heavily weighted toward health maintenance visits doesn’t leave enough room for same-day calls. Does an 8-year-old with a spotless health record really need annual checkups? If the physician has time. Maybe. But, if the trade-off is a front office deflecting calls from the worried well, not to mention the seriously ill who might slip through the cracks in a triage algorithm, it’s a bad deal. The notion that a pediatrician can’t or doesn’t do some targeted anticipatory guidance and health promotion at an acute sick visit is bogus.

Twenty years ago when we had only 3 pediatricians for the same population base that is now served by 12, the office staff was too busy to deflect calls for an appointment. If you called, you got seen.

Dr. William G. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him.