The last call

 

It’s 7:30 on a Tuesday evening, and you will be on call until 8 o’clock the next morning. You have already been in the office 9 hours. Usual start time is 8 a.m., but that extra hour at home is a perk you have earned by being on call tonight.

A quick glance at the schedule screen suggests that if nothing ugly crops up, you will finish seeing your last patient and be out the door and on your way home by 8:15 p.m. The phone has been quiet for the last half hour, but as you are making your quickstep transition between exam rooms, the nurse tells you that the receptionist has received a call from a very anxious mother who has just discovered that her 6-year-old has a fever of 103° F. The child didn’t eat any dinner and is now complaining that he has a sore throat. The mother is worried because the child had a couple of febrile seizures when he was a toddler, and she has heard of several cases of strep in his class at school.

Depending on the health care resources, geography, and weather in your community, you could respond to this scenario in any one of a dozen ways, each of which has its drawbacks. You could tell the nurse, whom we will assume will take a more detailed history, to suggest to this mother that if she is very concerned, she should take the child to emergency room. This response could quadruple the cost to the family and possibly entail a 90-minute drive over snow-covered roads. The ED trip will likely mean the child won’t get to bed until midnight or later. It also might result in a midnight call from an inexperienced and nervous ED physician asking for your reassurance or even with a plea that you come to see what turns out to be a mildly ill child.

On the other hand, you could ask the nurse to reassure the mother that a febrile seizure at age 6 is very unlikely and encourage the mother to call you if she continues to be concerned. The problem here hinges on the experience and skills of the nurse. Even if your office has a well-vetted portfolio of clinical algorithms, you may be relying on a nurse with whom you aren’t familiar. Or maybe your past experience makes you uncomfortable with this particular nurse. She or he may have missed some obvious red flags in the past or may be so unskillful at reassurance that it is very likely that you will be getting a 2 a.m. call from this worried parent.

Another option could be to suggest that after reassuring the mother, the nurse offer her a first of the morning appointment tomorrow. There are several problems with this strategy, and I have always discouraged our office staff from making these next morning appointments for sick children. The offer of the appointment seldom reassures the very anxious parents nor does it prevent the middle of the night calls. More importantly, our experience, and I suspect yours, is that half of those newly sick children with fevers will be better by the next morning or their parents ended up going to the emergency room. This will leave you with a wasted appointment slot that you would really like to have available when the phones heat up in the morning. A more efficient strategy is to promise parents that if the child is still sick in the morning, you can guarantee them a timely appointment.

Finally, there are two responses that worked best for me. The first is to have the nurse ask the parents how long it will take them to get to the office. Add 15 minutes to their estimate, and if you can accept that estimated time of arrival, have the nurse tell that family to hustle on in. Send the staff home unless they want the overtime, and see the patient yourself.

The second response is to get on the phone yourself and talk directly to the mother. You were probably going to end up speaking with her in the middle of the night anyway, so you might as well invest the time now in taking your own history. Even if your own version of reassurance fails to prevent a 2 a.m. call, at least you will have some frame of reference when you need to make one of those dangerous middle of the night clinical decisions. A quiet night may depend on how you manage that last call of the day.
 

 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.” Email him at [email protected].

 

It’s 7:30 on a Tuesday evening, and you will be on call until 8 o’clock the next morning. You have already been in the office 9 hours. Usual start time is 8 a.m., but that extra hour at home is a perk you have earned by being on call tonight.

A quick glance at the schedule screen suggests that if nothing ugly crops up, you will finish seeing your last patient and be out the door and on your way home by 8:15 p.m. The phone has been quiet for the last half hour, but as you are making your quickstep transition between exam rooms, the nurse tells you that the receptionist has received a call from a very anxious mother who has just discovered that her 6-year-old has a fever of 103° F. The child didn’t eat any dinner and is now complaining that he has a sore throat. The mother is worried because the child had a couple of febrile seizures when he was a toddler, and she has heard of several cases of strep in his class at school.

Depending on the health care resources, geography, and weather in your community, you could respond to this scenario in any one of a dozen ways, each of which has its drawbacks. You could tell the nurse, whom we will assume will take a more detailed history, to suggest to this mother that if she is very concerned, she should take the child to emergency room. This response could quadruple the cost to the family and possibly entail a 90-minute drive over snow-covered roads. The ED trip will likely mean the child won’t get to bed until midnight or later. It also might result in a midnight call from an inexperienced and nervous ED physician asking for your reassurance or even with a plea that you come to see what turns out to be a mildly ill child.

On the other hand, you could ask the nurse to reassure the mother that a febrile seizure at age 6 is very unlikely and encourage the mother to call you if she continues to be concerned. The problem here hinges on the experience and skills of the nurse. Even if your office has a well-vetted portfolio of clinical algorithms, you may be relying on a nurse with whom you aren’t familiar. Or maybe your past experience makes you uncomfortable with this particular nurse. She or he may have missed some obvious red flags in the past or may be so unskillful at reassurance that it is very likely that you will be getting a 2 a.m. call from this worried parent.

Another option could be to suggest that after reassuring the mother, the nurse offer her a first of the morning appointment tomorrow. There are several problems with this strategy, and I have always discouraged our office staff from making these next morning appointments for sick children. The offer of the appointment seldom reassures the very anxious parents nor does it prevent the middle of the night calls. More importantly, our experience, and I suspect yours, is that half of those newly sick children with fevers will be better by the next morning or their parents ended up going to the emergency room. This will leave you with a wasted appointment slot that you would really like to have available when the phones heat up in the morning. A more efficient strategy is to promise parents that if the child is still sick in the morning, you can guarantee them a timely appointment.

Finally, there are two responses that worked best for me. The first is to have the nurse ask the parents how long it will take them to get to the office. Add 15 minutes to their estimate, and if you can accept that estimated time of arrival, have the nurse tell that family to hustle on in. Send the staff home unless they want the overtime, and see the patient yourself.

The second response is to get on the phone yourself and talk directly to the mother. You were probably going to end up speaking with her in the middle of the night anyway, so you might as well invest the time now in taking your own history. Even if your own version of reassurance fails to prevent a 2 a.m. call, at least you will have some frame of reference when you need to make one of those dangerous middle of the night clinical decisions. A quiet night may depend on how you manage that last call of the day.
 

 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.” Email him at [email protected].

 

It’s 7:30 on a Tuesday evening, and you will be on call until 8 o’clock the next morning. You have already been in the office 9 hours. Usual start time is 8 a.m., but that extra hour at home is a perk you have earned by being on call tonight.

A quick glance at the schedule screen suggests that if nothing ugly crops up, you will finish seeing your last patient and be out the door and on your way home by 8:15 p.m. The phone has been quiet for the last half hour, but as you are making your quickstep transition between exam rooms, the nurse tells you that the receptionist has received a call from a very anxious mother who has just discovered that her 6-year-old has a fever of 103° F. The child didn’t eat any dinner and is now complaining that he has a sore throat. The mother is worried because the child had a couple of febrile seizures when he was a toddler, and she has heard of several cases of strep in his class at school.

Depending on the health care resources, geography, and weather in your community, you could respond to this scenario in any one of a dozen ways, each of which has its drawbacks. You could tell the nurse, whom we will assume will take a more detailed history, to suggest to this mother that if she is very concerned, she should take the child to emergency room. This response could quadruple the cost to the family and possibly entail a 90-minute drive over snow-covered roads. The ED trip will likely mean the child won’t get to bed until midnight or later. It also might result in a midnight call from an inexperienced and nervous ED physician asking for your reassurance or even with a plea that you come to see what turns out to be a mildly ill child.

On the other hand, you could ask the nurse to reassure the mother that a febrile seizure at age 6 is very unlikely and encourage the mother to call you if she continues to be concerned. The problem here hinges on the experience and skills of the nurse. Even if your office has a well-vetted portfolio of clinical algorithms, you may be relying on a nurse with whom you aren’t familiar. Or maybe your past experience makes you uncomfortable with this particular nurse. She or he may have missed some obvious red flags in the past or may be so unskillful at reassurance that it is very likely that you will be getting a 2 a.m. call from this worried parent.

Another option could be to suggest that after reassuring the mother, the nurse offer her a first of the morning appointment tomorrow. There are several problems with this strategy, and I have always discouraged our office staff from making these next morning appointments for sick children. The offer of the appointment seldom reassures the very anxious parents nor does it prevent the middle of the night calls. More importantly, our experience, and I suspect yours, is that half of those newly sick children with fevers will be better by the next morning or their parents ended up going to the emergency room. This will leave you with a wasted appointment slot that you would really like to have available when the phones heat up in the morning. A more efficient strategy is to promise parents that if the child is still sick in the morning, you can guarantee them a timely appointment.

Finally, there are two responses that worked best for me. The first is to have the nurse ask the parents how long it will take them to get to the office. Add 15 minutes to their estimate, and if you can accept that estimated time of arrival, have the nurse tell that family to hustle on in. Send the staff home unless they want the overtime, and see the patient yourself.

The second response is to get on the phone yourself and talk directly to the mother. You were probably going to end up speaking with her in the middle of the night anyway, so you might as well invest the time now in taking your own history. Even if your own version of reassurance fails to prevent a 2 a.m. call, at least you will have some frame of reference when you need to make one of those dangerous middle of the night clinical decisions. A quiet night may depend on how you manage that last call of the day.
 

 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.” Email him at [email protected].