RE: WHAT SHOULD 24/7 ACCESS REALLY MEAN??

[Guest guest]

I would love to discuss what 24/7 access REALLY should mean for us.For me it means I want to be available for hospital care and urgent needs 24/7.  If the ER presents me with a patient at any hour of the day I feel it is my responsibility to be there for that patient (or have coverage with a hospitalist).  If a patient calls me "on their way" to the urgent care  then I will handle their issue on the spot by having them meet me at the office instead OR I will certainly follow up with them the next morning or whatever.  I am available 24/7 for these issues.Obviously (to clarify) I would not expect someone in status asthmaticus to give me a courtesy call on their way to the ED as the ED will call me if I am needed.  Though sometimes it has been my pt calling me the day after admit on to another service that made me aware they were there and I gladly took over their case.  BUT on the way to UC a phone call to me can save them the ED trip. I will often tell them to come right over, fit them in somehow. When we finish our house remodel I will see them at home - all hours for URGENT needs.Personally I am not available 24/7 to discuss acne or other minor issues that obviously can wait till 9-5 hours.  My patients know if they call my office land line (which is in my home) that they will usually get a call back in 2-3 hours if not immediate pick up or within 5 minutes which is often the case.I do NOT think we should be available 24/7 for minor medical questions as some folks will call in the middle of the night with an oh, by the way or I have had constipation for 3 days and what should I do (YES, I got a call like that at 3 am once in a prior dysfunctional setting!!!)I think it is dysfunctional and counterproductive for me to be available at a whim for patients after hours with minor and nonurgent issues.  I think it sets the stage for patients to be LESS ACTIVATED and more dependent and dysfunctional and basically abusive of me/my time/my personal space.  Why would they have to remember all their questions for their office visit if they can just call you on your cell at home at 9 pm with an "Oh by the way I forgot to ask about my brother......"What does 24/7 availability mean to others???  I am very curious....Pamela Good advice generally, but I’m not sure I agree with #3.  I do agree in general terms about keeping people from abusing/misusing your “on call” cell phone.  However, to tell people right on your phone message not to call unless they are on their way to ED/UC could be interpreted to mean you are not providing 24/7 coverage to your patients, which is required by all insurance contracts.  Also, I’d actually ask sort of the opposite: why have them call if they feel like they are bad enough to go to the ED/UC?  In that case, I would NOT want them to waste time calling me but rather go straight there & the staff can call me if indicated.    Just a thought, but that part struck me as being a little too much of a barrier rather than “gentle persuasion” to change behavior.   Re: PRACTICE TRANSFORMATION by ACTIVATING patients  Kathy,  I will attach the handout below.  Regarding your specific issues I would like to make a few comments.   1) If you start giving free advice (telephone medicine) you will never get off the phone and your income will plummet. You will also start to get irritated. You are a professional and you should charge for your services as all professionals do.  A simple answer on the phone will be tempting in cases but folks always seem to have follow up questions and you will set the stage to be doing all your 99212 & 99213s by phone. Your patients will learn that they can call and not come in.--> a counterproductive behavior  (female codependence?)   2) Activated patients come to visits prepared and do not need to make stray phone calls between appointments.  We give them our attention for as long as they need during the office visit and they should be prepared to discuss refills, FU intervals, disease management at that time.  Enforce this.   3) Patients should never ever bother you on your cell phone unless they are on their way to the ED/UC.  If they are worried enough that they will consider disrupting THEIR plans to get in the car and be seen urgently/emergently then I want to know.  Otherwise, if they are not so concerned that they plan NOT to interrupt their plans but can still interrupt YOUR PLANS with an unnecessary phone call then something is wrong with the picture.  ---> Do not train your patients to abuse you. My phone message on my machine says you may notify Dr. Wible on her cell phone at 968-8510 if you are ON YOUR WAY TO THE ED/UC.  Very clear and it is upheld by all patients even my traumatic brain injury patients in the middle of the night when they call in a total panic/frenzy about not being able to find their car keys or their boyfriend walked out on them.  Even with their brain injury and impulse control issues they understand what my cell phone is for. Uphold the sanctity of your personal space.   4) A practice with well trained activated patients will have an office phone that primarily rings for scheduling office visits.   5) Dysfunctional behavior attracts others with dysfunctional behavior.  Clean up your act and set firm boundaries and the patients will be respectful or...they leave and find another kindred dysfunctional soul at ANOTHER office.   You can make your office life whatever you want. You can be supportive, empathetic and firm! Keep a running list of ANYTHING or ANYONE that gets under your skin and problem solve your list weekly. Soon you will have nothing to put on your list!    

[Guest guest]

I would love to discuss what 24/7 access REALLY should mean for us.For me it means I want to be available for hospital care and urgent needs 24/7.  If the ER presents me with a patient at any hour of the day I feel it is my responsibility to be there for that patient (or have coverage with a hospitalist).  If a patient calls me "on their way" to the urgent care  then I will handle their issue on the spot by having them meet me at the office instead OR I will certainly follow up with them the next morning or whatever.  I am available 24/7 for these issues.Obviously (to clarify) I would not expect someone in status asthmaticus to give me a courtesy call on their way to the ED as the ED will call me if I am needed.  Though sometimes it has been my pt calling me the day after admit on to another service that made me aware they were there and I gladly took over their case.  BUT on the way to UC a phone call to me can save them the ED trip. I will often tell them to come right over, fit them in somehow. When we finish our house remodel I will see them at home - all hours for URGENT needs.Personally I am not available 24/7 to discuss acne or other minor issues that obviously can wait till 9-5 hours.  My patients know if they call my office land line (which is in my home) that they will usually get a call back in 2-3 hours if not immediate pick up or within 5 minutes which is often the case.I do NOT think we should be available 24/7 for minor medical questions as some folks will call in the middle of the night with an oh, by the way or I have had constipation for 3 days and what should I do (YES, I got a call like that at 3 am once in a prior dysfunctional setting!!!)I think it is dysfunctional and counterproductive for me to be available at a whim for patients after hours with minor and nonurgent issues.  I think it sets the stage for patients to be LESS ACTIVATED and more dependent and dysfunctional and basically abusive of me/my time/my personal space.  Why would they have to remember all their questions for their office visit if they can just call you on your cell at home at 9 pm with an "Oh by the way I forgot to ask about my brother......"What does 24/7 availability mean to others???  I am very curious....Pamela Good advice generally, but I’m not sure I agree with #3.  I do agree in general terms about keeping people from abusing/misusing your “on call” cell phone.  However, to tell people right on your phone message not to call unless they are on their way to ED/UC could be interpreted to mean you are not providing 24/7 coverage to your patients, which is required by all insurance contracts.  Also, I’d actually ask sort of the opposite: why have them call if they feel like they are bad enough to go to the ED/UC?  In that case, I would NOT want them to waste time calling me but rather go straight there & the staff can call me if indicated.    Just a thought, but that part struck me as being a little too much of a barrier rather than “gentle persuasion” to change behavior.   Re: PRACTICE TRANSFORMATION by ACTIVATING patients  Kathy,  I will attach the handout below.  Regarding your specific issues I would like to make a few comments.   1) If you start giving free advice (telephone medicine) you will never get off the phone and your income will plummet. You will also start to get irritated. You are a professional and you should charge for your services as all professionals do.  A simple answer on the phone will be tempting in cases but folks always seem to have follow up questions and you will set the stage to be doing all your 99212 & 99213s by phone. Your patients will learn that they can call and not come in.--> a counterproductive behavior  (female codependence?)   2) Activated patients come to visits prepared and do not need to make stray phone calls between appointments.  We give them our attention for as long as they need during the office visit and they should be prepared to discuss refills, FU intervals, disease management at that time.  Enforce this.   3) Patients should never ever bother you on your cell phone unless they are on their way to the ED/UC.  If they are worried enough that they will consider disrupting THEIR plans to get in the car and be seen urgently/emergently then I want to know.  Otherwise, if they are not so concerned that they plan NOT to interrupt their plans but can still interrupt YOUR PLANS with an unnecessary phone call then something is wrong with the picture.  ---> Do not train your patients to abuse you. My phone message on my machine says you may notify Dr. Wible on her cell phone at 968-8510 if you are ON YOUR WAY TO THE ED/UC.  Very clear and it is upheld by all patients even my traumatic brain injury patients in the middle of the night when they call in a total panic/frenzy about not being able to find their car keys or their boyfriend walked out on them.  Even with their brain injury and impulse control issues they understand what my cell phone is for. Uphold the sanctity of your personal space.   4) A practice with well trained activated patients will have an office phone that primarily rings for scheduling office visits.   5) Dysfunctional behavior attracts others with dysfunctional behavior.  Clean up your act and set firm boundaries and the patients will be respectful or...they leave and find another kindred dysfunctional soul at ANOTHER office.   You can make your office life whatever you want. You can be supportive, empathetic and firm! Keep a running list of ANYTHING or ANYONE that gets under your skin and problem solve your list weekly. Soon you will have nothing to put on your list!    

[Guest guest]

Oh I agree with your thoughts exactly, I’m

just not sure I would put that message on my answering machine that you do not

want to be called unless they are on their way to ER/UC. Maybe I’m

misinterpreting, but to me that leaves the impression on the surface that you

do not want to be contacted after hours basically at all (I realize that is not

your intentions as per your reply below). I would be afraid medicolegally

that a patient would later say that they had wanted (for example) to call about

their 2 year old with fever & rash but that they were not on their way to

ER/UC & therefore waited (until it was too late). I guess I’m

just thinking of it in a legal sense & because of insurance company

contractual requirements. Some of the company reps actually called my

answering machine after hours during the credentialing process to find out my

after hrs coverage/on call protocol.

DB

Re:

PRACTICE TRANSFORMATION by ACTIVATING patients

Kathy, I will attach the handout below.

Regarding your specific issues I would like to make a few comments.

1) If you start giving free advice (telephone

medicine) you will never get off the phone and your income will plummet. You

will also start to get irritated. You are a professional and you should charge

for your services as all professionals do. A simple answer on the phone

will be tempting in cases but folks always seem to have follow up questions and

you will set the stage to be doing all your 99212 & 99213s by phone. Your

patients will learn that they can call and not come in.--> a

counterproductive behavior (female codependence?)

2) Activated patients come to visits prepared and do

not need to make stray phone calls between appointments. We give them our

attention for as long as they need during the office visit and they should be

prepared to discuss refills, FU intervals, disease management at that

time. Enforce this.

3) Patients should never ever bother you on your cell

phone unless they are on their way to the ED/UC. If they are worried

enough that they will consider disrupting THEIR plans to get in the car and be

seen urgently/emergently then I want to know. Otherwise, if they are not

so concerned that they plan NOT to interrupt their plans but can still

interrupt YOUR PLANS with an unnecessary phone call then something is wrong

with the picture. ---> Do not train your patients to abuse you. My

phone message on my machine says you may notify Dr. Wible on her cell phone at

968-8510 if you are ON YOUR WAY TO THE ED/UC. Very clear and it is upheld

by all patients even my traumatic brain injury patients in the middle of the

night when they call in a total panic/frenzy about not being able to find their

car keys or their boyfriend walked out on them. Even with their brain

injury and impulse control issues they understand what my cell phone is for.

Uphold the sanctity of your personal space.

4) A practice with well trained activated patients

will have an office phone that primarily rings for scheduling office visits.

5) Dysfunctional behavior attracts others with

dysfunctional behavior. Clean up your act and set firm boundaries and the

patients will be respectful or...they leave and find another kindred

dysfunctional soul at ANOTHER office.

You can make your office life whatever you want. You

can be supportive, empathetic and firm!

Keep a running list of ANYTHING or ANYONE that gets

under your skin and problem solve your list weekly. Soon you will have nothing

to put on your list!

[Guest guest]

Oh I agree with your thoughts exactly, I’m

just not sure I would put that message on my answering machine that you do not

want to be called unless they are on their way to ER/UC. Maybe I’m

misinterpreting, but to me that leaves the impression on the surface that you

do not want to be contacted after hours basically at all (I realize that is not

your intentions as per your reply below). I would be afraid medicolegally

that a patient would later say that they had wanted (for example) to call about

their 2 year old with fever & rash but that they were not on their way to

ER/UC & therefore waited (until it was too late). I guess I’m

just thinking of it in a legal sense & because of insurance company

contractual requirements. Some of the company reps actually called my

answering machine after hours during the credentialing process to find out my

after hrs coverage/on call protocol.

DB

Re:

PRACTICE TRANSFORMATION by ACTIVATING patients

Kathy, I will attach the handout below.

Regarding your specific issues I would like to make a few comments.

1) If you start giving free advice (telephone

medicine) you will never get off the phone and your income will plummet. You

will also start to get irritated. You are a professional and you should charge

for your services as all professionals do. A simple answer on the phone

will be tempting in cases but folks always seem to have follow up questions and

you will set the stage to be doing all your 99212 & 99213s by phone. Your

patients will learn that they can call and not come in.--> a

counterproductive behavior (female codependence?)

2) Activated patients come to visits prepared and do

not need to make stray phone calls between appointments. We give them our

attention for as long as they need during the office visit and they should be

prepared to discuss refills, FU intervals, disease management at that

time. Enforce this.

3) Patients should never ever bother you on your cell

phone unless they are on their way to the ED/UC. If they are worried

enough that they will consider disrupting THEIR plans to get in the car and be

seen urgently/emergently then I want to know. Otherwise, if they are not

so concerned that they plan NOT to interrupt their plans but can still

interrupt YOUR PLANS with an unnecessary phone call then something is wrong

with the picture. ---> Do not train your patients to abuse you. My

phone message on my machine says you may notify Dr. Wible on her cell phone at

968-8510 if you are ON YOUR WAY TO THE ED/UC. Very clear and it is upheld

by all patients even my traumatic brain injury patients in the middle of the

night when they call in a total panic/frenzy about not being able to find their

car keys or their boyfriend walked out on them. Even with their brain

injury and impulse control issues they understand what my cell phone is for.

Uphold the sanctity of your personal space.

4) A practice with well trained activated patients

will have an office phone that primarily rings for scheduling office visits.

5) Dysfunctional behavior attracts others with

dysfunctional behavior. Clean up your act and set firm boundaries and the

patients will be respectful or...they leave and find another kindred

dysfunctional soul at ANOTHER office.

You can make your office life whatever you want. You

can be supportive, empathetic and firm!

Keep a running list of ANYTHING or ANYONE that gets

under your skin and problem solve your list weekly. Soon you will have nothing

to put on your list!

[Guest guest]

Pam,

I like your tough love activated patient ideas. I may try to implement some

of them when I am feeling less marshmallow-like.

I had never thought about " on the way to urgent care/ER " as the deciding

factor for whether patients should call or not. It's certainly a logical

place to draw the line.

I would include on your list of appropriate phone calls sick kids with

fevers (usually around 2AM) whose mothers are not quite sure what to do with

them.

Lynn

>

>Reply-To:

>To:

>Subject: Re: WHAT SHOULD 24/7 ACCESS REALLY MEAN??

>Date: Thu, 2 Mar 2006 08:44:49 -0800

>

>I would love to discuss what 24/7 access REALLY should mean for us.

>

>For me it means I want to be available for hospital care and urgent needs

>24/7. If the ER presents me with a patient at any hour of the day I feel

>it is my responsibility to be there for that patient (or have coverage

>with a hospitalist). If a patient calls me " on their way " to the urgent

>care then I will handle their issue on the spot by having them meet me at

>the office instead OR I will certainly follow up with them the next

>morning or whatever. I am available 24/7 for these issues.

>

>Obviously (to clarify) I would not expect someone in status asthmaticus to

>give me a courtesy call on their way to the ED as the ED will call me if I

>am needed. Though sometimes it has been my pt calling me the day after

>admit on to another service that made me aware they were there and I

>gladly took over their case. BUT on the way to UC a phone call to me can

>save them the ED trip. I will often tell them to come right over, fit them

>in somehow. When we finish our house remodel I will see them at home - all

>hours for URGENT needs.

>

>Personally I am not available 24/7 to discuss acne or other minor issues

>that obviously can wait till 9-5 hours. My patients know if they call my

>office land line (which is in my home) that they will usually get a call

>back in 2-3 hours if not immediate pick up or within 5 minutes which is

>often the case.

>

>I do NOT think we should be available 24/7 for minor medical questions as

>some folks will call in the middle of the night with an oh, by the way or

>I have had constipation for 3 days and what should I do (YES, I got a call

>like that at 3 am once in a prior dysfunctional setting!!!)

>

>I think it is dysfunctional and counterproductive for me to be available

>at a whim for patients after hours with minor and nonurgent issues. I

>think it sets the stage for patients to be LESS ACTIVATED and more

>dependent and dysfunctional and basically abusive of me/my time/my

>personal space. Why would they have to remember all their questions for

>their office visit if they can just call you on your cell at home at 9 pm

>with an " Oh by the way I forgot to ask about my brother...... "

>

>What does 24/7 availability mean to others??? I am very curious....

>

>Pamela

>

>

>

>

>

>

>>Good advice generally, but I’m not sure I agree with #3. I do agree in

>>general terms about keeping people from abusing/misusing your “on call”

>>cell phone. However, to tell people right on your phone message not to

>>call unless they are on their way to ED/UC could be interpreted to mean

>>you are not providing 24/7 coverage to your patients, which is required

>>by all insurance contracts. Also, I’d actually ask sort of the opposite:

>>why have them call if they feel like they are bad enough to go to the

>>ED/UC? In that case, I would NOT want them to waste time calling me but

>>rather go straight there & the staff can call me if indicated. Just a

>>thought, but that part struck me as being a little too much of a barrier

>>rather than “gentle persuasion” to change behavior.

>>

>>

>>

>>

>>

>> Re: PRACTICE TRANSFORMATION by ACTIVATING

>>patients

>>

>>

>>Kathy, I will attach the handout below. Regarding your specific issues

>>I would like to make a few comments.

>>

>>

>>1) If you start giving free advice (telephone medicine) you will never

>>get off the phone and your income will plummet. You will also start to

>>get irritated. You are a professional and you should charge for your

>>services as all professionals do. A simple answer on the phone will be

>>tempting in cases but folks always seem to have follow up questions and

>>you will set the stage to be doing all your 99212 & 99213s by phone. Your

>>patients will learn that they can call and not come in.--> a

>>counterproductive behavior (female codependence?)

>>

>>

>>2) Activated patients come to visits prepared and do not need to make

>>stray phone calls between appointments. We give them our attention for

>>as long as they need during the office visit and they should be prepared

>>to discuss refills, FU intervals, disease management at that time.

>>Enforce this.

>>

>>

>>3) Patients should never ever bother you on your cell phone unless they

>>are on their way to the ED/UC. If they are worried enough that they will

>>consider disrupting THEIR plans to get in the car and be seen

>>urgently/emergently then I want to know. Otherwise, if they are not so

>>concerned that they plan NOT to interrupt their plans but can still

>>interrupt YOUR PLANS with an unnecessary phone call then something is

>>wrong with the picture. ---> Do not train your patients to abuse you. My

>>phone message on my machine says you may notify Dr. Wible on her cell

>>phone at 968-8510 if you are ON YOUR WAY TO THE ED/UC. Very clear and it

>>is upheld by all patients even my traumatic brain injury patients in the

>>middle of the night when they call in a total panic/frenzy about not

>>being able to find their car keys or their boyfriend walked out on them.

>>Even with their brain injury and impulse control issues they understand

>>what my cell phone is for. Uphold the sanctity of your personal space.

>>

>>

>>4) A practice with well trained activated patients will have an office

>>phone that primarily rings for scheduling office visits.

>>

>>

>>5) Dysfunctional behavior attracts others with dysfunctional behavior.

>>Clean up your act and set firm boundaries and the patients will be

>>respectful or...they leave and find another kindred dysfunctional soul at

>>ANOTHER office.

>>

>>

>>You can make your office life whatever you want. You can be supportive,

>>empathetic and firm!

>>

>>Keep a running list of ANYTHING or ANYONE that gets under your skin and

>>problem solve your list weekly. Soon you will have nothing to put on your

>>list!

>>

>>

>>

>>

>>

>>

[Guest guest]

Pam,

I like your tough love activated patient ideas. I may try to implement some

of them when I am feeling less marshmallow-like.

I had never thought about " on the way to urgent care/ER " as the deciding

factor for whether patients should call or not. It's certainly a logical

place to draw the line.

I would include on your list of appropriate phone calls sick kids with

fevers (usually around 2AM) whose mothers are not quite sure what to do with

them.

Lynn

>

>Reply-To:

>To:

>Subject: Re: WHAT SHOULD 24/7 ACCESS REALLY MEAN??

>Date: Thu, 2 Mar 2006 08:44:49 -0800

>

>I would love to discuss what 24/7 access REALLY should mean for us.

>

>For me it means I want to be available for hospital care and urgent needs

>24/7. If the ER presents me with a patient at any hour of the day I feel

>it is my responsibility to be there for that patient (or have coverage

>with a hospitalist). If a patient calls me " on their way " to the urgent

>care then I will handle their issue on the spot by having them meet me at

>the office instead OR I will certainly follow up with them the next

>morning or whatever. I am available 24/7 for these issues.

>

>Obviously (to clarify) I would not expect someone in status asthmaticus to

>give me a courtesy call on their way to the ED as the ED will call me if I

>am needed. Though sometimes it has been my pt calling me the day after

>admit on to another service that made me aware they were there and I

>gladly took over their case. BUT on the way to UC a phone call to me can

>save them the ED trip. I will often tell them to come right over, fit them

>in somehow. When we finish our house remodel I will see them at home - all

>hours for URGENT needs.

>

>Personally I am not available 24/7 to discuss acne or other minor issues

>that obviously can wait till 9-5 hours. My patients know if they call my

>office land line (which is in my home) that they will usually get a call

>back in 2-3 hours if not immediate pick up or within 5 minutes which is

>often the case.

>

>I do NOT think we should be available 24/7 for minor medical questions as

>some folks will call in the middle of the night with an oh, by the way or

>I have had constipation for 3 days and what should I do (YES, I got a call

>like that at 3 am once in a prior dysfunctional setting!!!)

>

>I think it is dysfunctional and counterproductive for me to be available

>at a whim for patients after hours with minor and nonurgent issues. I

>think it sets the stage for patients to be LESS ACTIVATED and more

>dependent and dysfunctional and basically abusive of me/my time/my

>personal space. Why would they have to remember all their questions for

>their office visit if they can just call you on your cell at home at 9 pm

>with an " Oh by the way I forgot to ask about my brother...... "

>

>What does 24/7 availability mean to others??? I am very curious....

>

>Pamela

>

>

>

>

>

>

>>Good advice generally, but I’m not sure I agree with #3. I do agree in

>>general terms about keeping people from abusing/misusing your “on call”

>>cell phone. However, to tell people right on your phone message not to

>>call unless they are on their way to ED/UC could be interpreted to mean

>>you are not providing 24/7 coverage to your patients, which is required

>>by all insurance contracts. Also, I’d actually ask sort of the opposite:

>>why have them call if they feel like they are bad enough to go to the

>>ED/UC? In that case, I would NOT want them to waste time calling me but

>>rather go straight there & the staff can call me if indicated. Just a

>>thought, but that part struck me as being a little too much of a barrier

>>rather than “gentle persuasion” to change behavior.

>>

>>

>>

>>

>>

>> Re: PRACTICE TRANSFORMATION by ACTIVATING

>>patients

>>

>>

>>Kathy, I will attach the handout below. Regarding your specific issues

>>I would like to make a few comments.

>>

>>

>>1) If you start giving free advice (telephone medicine) you will never

>>get off the phone and your income will plummet. You will also start to

>>get irritated. You are a professional and you should charge for your

>>services as all professionals do. A simple answer on the phone will be

>>tempting in cases but folks always seem to have follow up questions and

>>you will set the stage to be doing all your 99212 & 99213s by phone. Your

>>patients will learn that they can call and not come in.--> a

>>counterproductive behavior (female codependence?)

>>

>>

>>2) Activated patients come to visits prepared and do not need to make

>>stray phone calls between appointments. We give them our attention for

>>as long as they need during the office visit and they should be prepared

>>to discuss refills, FU intervals, disease management at that time.

>>Enforce this.

>>

>>

>>3) Patients should never ever bother you on your cell phone unless they

>>are on their way to the ED/UC. If they are worried enough that they will

>>consider disrupting THEIR plans to get in the car and be seen

>>urgently/emergently then I want to know. Otherwise, if they are not so

>>concerned that they plan NOT to interrupt their plans but can still

>>interrupt YOUR PLANS with an unnecessary phone call then something is

>>wrong with the picture. ---> Do not train your patients to abuse you. My

>>phone message on my machine says you may notify Dr. Wible on her cell

>>phone at 968-8510 if you are ON YOUR WAY TO THE ED/UC. Very clear and it

>>is upheld by all patients even my traumatic brain injury patients in the

>>middle of the night when they call in a total panic/frenzy about not

>>being able to find their car keys or their boyfriend walked out on them.

>>Even with their brain injury and impulse control issues they understand

>>what my cell phone is for. Uphold the sanctity of your personal space.

>>

>>

>>4) A practice with well trained activated patients will have an office

>>phone that primarily rings for scheduling office visits.

>>

>>

>>5) Dysfunctional behavior attracts others with dysfunctional behavior.

>>Clean up your act and set firm boundaries and the patients will be

>>respectful or...they leave and find another kindred dysfunctional soul at

>>ANOTHER office.

>>

>>

>>You can make your office life whatever you want. You can be supportive,

>>empathetic and firm!

>>

>>Keep a running list of ANYTHING or ANYONE that gets under your skin and

>>problem solve your list weekly. Soon you will have nothing to put on your

>>list!

>>

>>

>>

>>

>>

>>

[Guest guest]

I am available 24/7 as well. What that

means to me is that after I leave the office, I forward the phone to my cell

phone and keep that with me at all times. Although I understand your “tough

love” kind of stance, I don’t necessarily agree with its premise. The

problem is what is urgent or emergent to me may or may not be urgent or

emergent to you and is certainly not clear to a patient with little medical

knowledge. I believe you are right in activating your patients, but I think discouraging

patients from calling when they think they need your services (even if you don’t)

is potentially dangerous. Ex. What if a patient is having diarrhea? They are

encouraged not to call. What if the diarrhea is black and tarry? They still are

encouraged not to call because they probably don’t know the nuances of

treatment algorithms for diarrhea. In my office, I would be mad if they did not

call.

So do I get inundated with calls after hours. No. Why?

I always have same day appointments (so most people know they can get in the

next am) which eliminates many calls. I also get all the work done before I

leave the office, which eliminates even more. Also, those that call after hours

for appointments get a reminder from me that they can schedule an appointment on

my website or call at 8am the next morning (thus

activating them at the time of the error). Those that call for rx refills get told that I don’t

do those except when I am at the office (again activating them when necessary).

Yes, I still have some that abuse the system to some degree, but in general, my

patients are very considerate of my time and very appreciative that I am able

to assist (even if only over the phone) when they are in need.

By the way, I have about 1200 patients

(maybe 1000 active) and average one call on weeknights and probably 3-4 on a

weekend (during the winter). I have had only 3 calls wake me up in the middle

of the night (that I remember) since I opened the office 3 years ago.

Re:

PRACTICE TRANSFORMATION by ACTIVATING patients

Kathy, I will attach the handout below. Regarding your

specific issues I would like to make a few comments.

1) If you start giving free advice (telephone medicine) you will never

get off the phone and your income will plummet. You will also start to get

irritated. You are a professional and you should charge for your services as

all professionals do. A simple answer on the phone will be tempting in

cases but folks always seem to have follow up questions and you will set the

stage to be doing all your 99212 & 99213s by phone. Your patients will

learn that they can call and not come in.--> a counterproductive

behavior (female codependence?)

2) Activated patients come to visits prepared and do not need to make

stray phone calls between appointments. We give them our attention for as

long as they need during the office visit and they should be prepared to

discuss refills, FU intervals, disease management at that time. Enforce

this.

3) Patients should never ever bother you on your cell phone unless they

are on their way to the ED/UC. If they are worried enough that they will

consider disrupting THEIR plans to get in the car and be seen

urgently/emergently then I want to know. Otherwise, if they are not so

concerned that they plan NOT to interrupt their plans but can still interrupt

YOUR PLANS with an unnecessary phone call then something is wrong with the

picture. ---> Do not train your patients to abuse you. My phone

message on my machine says you may notify Dr. Wible on her cell phone at

968-8510 if you are ON YOUR WAY TO THE ED/UC. Very clear and it is upheld

by all patients even my traumatic brain injury patients in the middle of the

night when they call in a total panic/frenzy about not being able to find their

car keys or their boyfriend walked out on them. Even with their brain

injury and impulse control issues they understand what my cell phone is for.

Uphold the sanctity of your personal space.

4) A practice with well trained activated patients will have an office

phone that primarily rings for scheduling office visits.

5) Dysfunctional behavior attracts others with dysfunctional

behavior. Clean up your act and set firm boundaries and the patients will

be respectful or...they leave and find another kindred dysfunctional soul at

ANOTHER office.

You can make your office life whatever you want. You can be supportive,

empathetic and firm!

Keep a running list of ANYTHING or ANYONE that gets under your skin and

problem solve your list weekly. Soon you will have nothing to put on your list!

[Guest guest]

I am available 24/7 as well. What that

means to me is that after I leave the office, I forward the phone to my cell

phone and keep that with me at all times. Although I understand your “tough

love” kind of stance, I don’t necessarily agree with its premise. The

problem is what is urgent or emergent to me may or may not be urgent or

emergent to you and is certainly not clear to a patient with little medical

knowledge. I believe you are right in activating your patients, but I think discouraging

patients from calling when they think they need your services (even if you don’t)

is potentially dangerous. Ex. What if a patient is having diarrhea? They are

encouraged not to call. What if the diarrhea is black and tarry? They still are

encouraged not to call because they probably don’t know the nuances of

treatment algorithms for diarrhea. In my office, I would be mad if they did not

call.

So do I get inundated with calls after hours. No. Why?

I always have same day appointments (so most people know they can get in the

next am) which eliminates many calls. I also get all the work done before I

leave the office, which eliminates even more. Also, those that call after hours

for appointments get a reminder from me that they can schedule an appointment on

my website or call at 8am the next morning (thus

activating them at the time of the error). Those that call for rx refills get told that I don’t

do those except when I am at the office (again activating them when necessary).

Yes, I still have some that abuse the system to some degree, but in general, my

patients are very considerate of my time and very appreciative that I am able

to assist (even if only over the phone) when they are in need.

By the way, I have about 1200 patients

(maybe 1000 active) and average one call on weeknights and probably 3-4 on a

weekend (during the winter). I have had only 3 calls wake me up in the middle

of the night (that I remember) since I opened the office 3 years ago.

Re:

PRACTICE TRANSFORMATION by ACTIVATING patients

Kathy, I will attach the handout below. Regarding your

specific issues I would like to make a few comments.

1) If you start giving free advice (telephone medicine) you will never

get off the phone and your income will plummet. You will also start to get

irritated. You are a professional and you should charge for your services as

all professionals do. A simple answer on the phone will be tempting in

cases but folks always seem to have follow up questions and you will set the

stage to be doing all your 99212 & 99213s by phone. Your patients will

learn that they can call and not come in.--> a counterproductive

behavior (female codependence?)

2) Activated patients come to visits prepared and do not need to make

stray phone calls between appointments. We give them our attention for as

long as they need during the office visit and they should be prepared to

discuss refills, FU intervals, disease management at that time. Enforce

this.

3) Patients should never ever bother you on your cell phone unless they

are on their way to the ED/UC. If they are worried enough that they will

consider disrupting THEIR plans to get in the car and be seen

urgently/emergently then I want to know. Otherwise, if they are not so

concerned that they plan NOT to interrupt their plans but can still interrupt

YOUR PLANS with an unnecessary phone call then something is wrong with the

picture. ---> Do not train your patients to abuse you. My phone

message on my machine says you may notify Dr. Wible on her cell phone at

968-8510 if you are ON YOUR WAY TO THE ED/UC. Very clear and it is upheld

by all patients even my traumatic brain injury patients in the middle of the

night when they call in a total panic/frenzy about not being able to find their

car keys or their boyfriend walked out on them. Even with their brain

injury and impulse control issues they understand what my cell phone is for.

Uphold the sanctity of your personal space.

4) A practice with well trained activated patients will have an office

phone that primarily rings for scheduling office visits.

5) Dysfunctional behavior attracts others with dysfunctional

behavior. Clean up your act and set firm boundaries and the patients will

be respectful or...they leave and find another kindred dysfunctional soul at

ANOTHER office.

You can make your office life whatever you want. You can be supportive,

empathetic and firm!

Keep a running list of ANYTHING or ANYONE that gets under your skin and

problem solve your list weekly. Soon you will have nothing to put on your list!

[Guest guest]

Perfect answer. I agree completely. All

insurances, hospital staff offices, malpractice carriers, probably even the

state medical boards do require that patients have some type of 24/7 access to

yourself or coverage. Yes, I too rarely ever get called after hrs.

I probably have about the same number of pt’s as & I only get

called a few times per month, certainly not every night. I think my

message wording is something like: “this number is to be used for urgent

matters only, those that can not wait until the next business day.”

You must also always give the disclaimer of: “if this is what you

consider a life threatening emergency, call 911 or go to the nearest ER.”

The key to preventing abuse of the after hr’s number is taking care of

everything during the regular visits: spend more time, see fewer total pt’s,

listen, etc. Basically, everything this model of practice seeks to promote.

Re:

PRACTICE TRANSFORMATION by ACTIVATING patients

Kathy, I will attach the handout below.

Regarding your specific issues I would like to make a few comments.

1) If you start giving free advice (telephone

medicine) you will never get off the phone and your income will plummet. You

will also start to get irritated. You are a professional and you should charge

for your services as all professionals do. A simple answer on the phone

will be tempting in cases but folks always seem to have follow up questions and

you will set the stage to be doing all your 99212 & 99213s by phone. Your

patients will learn that they can call and not come in.--> a

counterproductive behavior (female codependence?)

2) Activated patients come to visits prepared and do

not need to make stray phone calls between appointments. We give them our

attention for as long as they need during the office visit and they should be

prepared to discuss refills, FU intervals, disease management at that

time. Enforce this.

3) Patients should never ever bother you on your cell

phone unless they are on their way to the ED/UC. If they are worried

enough that they will consider disrupting THEIR plans to get in the car and be

seen urgently/emergently then I want to know. Otherwise, if they are not

so concerned that they plan NOT to interrupt their plans but can still

interrupt YOUR PLANS with an unnecessary phone call then something is wrong

with the picture. ---> Do not train your patients to abuse you. My

phone message on my machine says you may notify Dr. Wible on her cell phone at

968-8510 if you are ON YOUR WAY TO THE ED/UC. Very clear and it is upheld

by all patients even my traumatic brain injury patients in the middle of the

night when they call in a total panic/frenzy about not being able to find their

car keys or their boyfriend walked out on them. Even with their brain

injury and impulse control issues they understand what my cell phone is for.

Uphold the sanctity of your personal space.

4) A practice with well trained activated patients

will have an office phone that primarily rings for scheduling office visits.

5) Dysfunctional behavior attracts others with

dysfunctional behavior. Clean up your act and set firm boundaries and the

patients will be respectful or...they leave and find another kindred

dysfunctional soul at ANOTHER office.

You can make your office life whatever you want. You

can be supportive, empathetic and firm!

Keep a running list of ANYTHING or ANYONE that gets

under your skin and problem solve your list weekly. Soon you will have nothing

to put on your list!

[Guest guest]

Perfect answer. I agree completely. All

insurances, hospital staff offices, malpractice carriers, probably even the

state medical boards do require that patients have some type of 24/7 access to

yourself or coverage. Yes, I too rarely ever get called after hrs.

I probably have about the same number of pt’s as & I only get

called a few times per month, certainly not every night. I think my

message wording is something like: “this number is to be used for urgent

matters only, those that can not wait until the next business day.”

You must also always give the disclaimer of: “if this is what you

consider a life threatening emergency, call 911 or go to the nearest ER.”

The key to preventing abuse of the after hr’s number is taking care of

everything during the regular visits: spend more time, see fewer total pt’s,

listen, etc. Basically, everything this model of practice seeks to promote.

Re:

PRACTICE TRANSFORMATION by ACTIVATING patients

Kathy, I will attach the handout below.

Regarding your specific issues I would like to make a few comments.

1) If you start giving free advice (telephone

medicine) you will never get off the phone and your income will plummet. You

will also start to get irritated. You are a professional and you should charge

for your services as all professionals do. A simple answer on the phone

will be tempting in cases but folks always seem to have follow up questions and

you will set the stage to be doing all your 99212 & 99213s by phone. Your

patients will learn that they can call and not come in.--> a

counterproductive behavior (female codependence?)

2) Activated patients come to visits prepared and do

not need to make stray phone calls between appointments. We give them our

attention for as long as they need during the office visit and they should be

prepared to discuss refills, FU intervals, disease management at that

time. Enforce this.

3) Patients should never ever bother you on your cell

phone unless they are on their way to the ED/UC. If they are worried

enough that they will consider disrupting THEIR plans to get in the car and be

seen urgently/emergently then I want to know. Otherwise, if they are not

so concerned that they plan NOT to interrupt their plans but can still

interrupt YOUR PLANS with an unnecessary phone call then something is wrong

with the picture. ---> Do not train your patients to abuse you. My

phone message on my machine says you may notify Dr. Wible on her cell phone at

968-8510 if you are ON YOUR WAY TO THE ED/UC. Very clear and it is upheld

by all patients even my traumatic brain injury patients in the middle of the

night when they call in a total panic/frenzy about not being able to find their

car keys or their boyfriend walked out on them. Even with their brain

injury and impulse control issues they understand what my cell phone is for.

Uphold the sanctity of your personal space.

4) A practice with well trained activated patients

will have an office phone that primarily rings for scheduling office visits.

5) Dysfunctional behavior attracts others with

dysfunctional behavior. Clean up your act and set firm boundaries and the

patients will be respectful or...they leave and find another kindred

dysfunctional soul at ANOTHER office.

You can make your office life whatever you want. You

can be supportive, empathetic and firm!

Keep a running list of ANYTHING or ANYONE that gets

under your skin and problem solve your list weekly. Soon you will have nothing

to put on your list!

[Guest guest]

I think you are right, it is dangerous to triage phone calls before you hear the complaints. I use my cell phone after hours  and my patients are never calling for refills  (I don't have too many patients). I noticed that patients on medicaid used to call more, but now I don't accept medicaid anymore. I don't have nursing home patients, so I don't have to listen at 3 AM that Mrs. A fell from her bed or can't go to the bathroom. :)I am available 24/7 as well. What that means to me is that after I leave the office, I forward the phone to my cell phone and keep that with me at all times. Although I understand your “tough love” kind of stance, I don’t necessarily agree with its premise. The problem is what is urgent or emergent to me may or may not be urgent or emergent to you and is certainly not clear to a patient with little medical knowledge. I believe you are right in activating your patients, but I think discouraging patients from calling when they think they need your services (even if you don’t) is potentially dangerous. Ex. What if a patient is having diarrhea? They are encouraged not to call. What if the diarrhea is black and tarry? They still are encouraged not to call because they probably don’t know the nuances of treatment algorithms for diarrhea. In my office, I would be mad if they did not call. So do I get inundated with calls after hours. No. Why? I always have same day appointments (so most people know they can get in the next am) which eliminates many calls. I also get all the work done before I leave the office, which eliminates even more. Also, those that call after hours for appointments get a reminder from me that they can schedule an appointment on my website or call at 8am the next morning (thus activating them at the time of the error). Those that call for rx refills get told that I don’t do those except when I am at the office (again activating them when necessary). Yes, I still have some that abuse the system to some degree, but in general, my patients are very considerate of my time and very appreciative that I am able to assist (even if only over the phone) when they are in need.By the way, I have about 1200 patients (maybe 1000 active) and average one call on weeknights and probably 3-4 on a weekend (during the winter). I have had only 3 calls wake me up in the middle of the night (that I remember) since I opened the office 3 years ago. -----Original Message-----From: [mailto: ] On Behalf Of pamela wibleSent: Thursday, March 02, 2006 11:45 AMTo: Subject: Re: WHAT SHOULD 24/7 ACCESS REALLY MEAN?? I would love to discuss what 24/7 access REALLY should mean for us. For me it means I want to be available for hospital care and urgent needs 24/7.  If the ER presents me with a patient at any hour of the day I feel it is my responsibility to be there for that patient (or have coverage with a hospitalist).  If a patient calls me "on their way" to the urgent care  then I will handle their issue on the spot by having them meet me at the office instead OR I will certainly follow up with them the next morning or whatever.  I am available 24/7 for these issues. Obviously (to clarify) I would not expect someone in status asthmaticus to give me a courtesy call on their way to the ED as the ED will call me if I am needed.  Though sometimes it has been my pt calling me the day after admit on to another service that made me aware they were there and I gladly took over their case.  BUT on the way to UC a phone call to me can save them the ED trip. I will often tell them to come right over, fit them in somehow. When we finish our house remodel I will see them at home - all hours for URGENT needs. Personally I am not available 24/7 to discuss acne or other minor issues that obviously can wait till 9-5 hours.  My patients know if they call my office land line (which is in my home) that they will usually get a call back in 2-3 hours if not immediate pick up or within 5 minutes which is often the case. I do NOT think we should be available 24/7 for minor medical questions as some folks will call in the middle of the night with an oh, by the way or I have had constipation for 3 days and what should I do (YES, I got a call like that at 3 am once in a prior dysfunctional setting!!!) I think it is dysfunctional and counterproductive for me to be available at a whim for patients after hours with minor and nonurgent issues.  I think it sets the stage for patients to be LESS ACTIVATED and more dependent and dysfunctional and basically abusive of me/my time/my personal space.  Why would they have to remember all their questions for their office visit if they can just call you on your cell at home at 9 pm with an "Oh by the way I forgot to ask about my brother......" What does 24/7 availability mean to others???  I am very curious.... Pamela    Good advice generally, but I’m not sure I agree with #3.  I do agree in general terms about keeping people from abusing/misusing your “on call” cell phone.  However, to tell people right on your phone message not to call unless they are on their way to ED/UC could be interpreted to mean you are not providing 24/7 coverage to your patients, which is required by all insurance contracts.  Also, I’d actually ask sort of the opposite: why have them call if they feel like they are bad enough to go to the ED/UC?  In that case, I would NOT want them to waste time calling me but rather go straight there & the staff can call me if indicated.    Just a thought, but that part struck me as being a little too much of a barrier rather than “gentle persuasion” to change behavior.  -----Original Message-----From: [mailto: ] On Behalf Of pamela wibleSent: Wednesday, March 01, 2006 11:33 PMTo: Subject: Re: PRACTICE TRANSFORMATION by ACTIVATING patients Kathy,  I will attach the handout below.  Regarding your specific issues I would like to make a few comments. 1) If you start giving free advice (telephone medicine) you will never get off the phone and your income will plummet. You will also start to get irritated. You are a professional and you should charge for your services as all professionals do.  A simple answer on the phone will be tempting in cases but folks always seem to have follow up questions and you will set the stage to be doing all your 99212 & 99213s by phone. Your patients will learn that they can call and not come in.--> a counterproductive behavior  (female codependence?) 2) Activated patients come to visits prepared and do not need to make stray phone calls between appointments.  We give them our attention for as long as they need during the office visit and they should be prepared to discuss refills, FU intervals, disease management at that time.  Enforce this. 3) Patients should never ever bother you on your cell phone unless they are on their way to the ED/UC.  If they are worried enough that they will consider disrupting THEIR plans to get in the car and be seen urgently/emergently then I want to know.  Otherwise, if they are not so concerned that they plan NOT to interrupt their plans but can still interrupt YOUR PLANS with an unnecessary phone call then something is wrong with the picture.  ---> Do not train your patients to abuse you. My phone message on my machine says you may notify Dr. Wible on her cell phone at 968-8510 if you are ON YOUR WAY TO THE ED/UC.  Very clear and it is upheld by all patients even my traumatic brain injury patients in the middle of the night when they call in a total panic/frenzy about not being able to find their car keys or their boyfriend walked out on them.  Even with their brain injury and impulse control issues they understand what my cell phone is for. Uphold the sanctity of your personal space. 4) A practice with well trained activated patients will have an office phone that primarily rings for scheduling office visits. 5) Dysfunctional behavior attracts others with dysfunctional behavior.  Clean up your act and set firm boundaries and the patients will be respectful or...they leave and find another kindred dysfunctional soul at ANOTHER office. You can make your office life whatever you want. You can be supportive, empathetic and firm!Keep a running list of ANYTHING or ANYONE that gets under your skin and problem solve your list weekly. Soon you will have nothing to put on your list!   

[Guest guest]

I think you are right, it is dangerous to triage phone calls before you hear the complaints. I use my cell phone after hours  and my patients are never calling for refills  (I don't have too many patients). I noticed that patients on medicaid used to call more, but now I don't accept medicaid anymore. I don't have nursing home patients, so I don't have to listen at 3 AM that Mrs. A fell from her bed or can't go to the bathroom. :)I am available 24/7 as well. What that means to me is that after I leave the office, I forward the phone to my cell phone and keep that with me at all times. Although I understand your “tough love” kind of stance, I don’t necessarily agree with its premise. The problem is what is urgent or emergent to me may or may not be urgent or emergent to you and is certainly not clear to a patient with little medical knowledge. I believe you are right in activating your patients, but I think discouraging patients from calling when they think they need your services (even if you don’t) is potentially dangerous. Ex. What if a patient is having diarrhea? They are encouraged not to call. What if the diarrhea is black and tarry? They still are encouraged not to call because they probably don’t know the nuances of treatment algorithms for diarrhea. In my office, I would be mad if they did not call. So do I get inundated with calls after hours. No. Why? I always have same day appointments (so most people know they can get in the next am) which eliminates many calls. I also get all the work done before I leave the office, which eliminates even more. Also, those that call after hours for appointments get a reminder from me that they can schedule an appointment on my website or call at 8am the next morning (thus activating them at the time of the error). Those that call for rx refills get told that I don’t do those except when I am at the office (again activating them when necessary). Yes, I still have some that abuse the system to some degree, but in general, my patients are very considerate of my time and very appreciative that I am able to assist (even if only over the phone) when they are in need.By the way, I have about 1200 patients (maybe 1000 active) and average one call on weeknights and probably 3-4 on a weekend (during the winter). I have had only 3 calls wake me up in the middle of the night (that I remember) since I opened the office 3 years ago. -----Original Message-----From: [mailto: ] On Behalf Of pamela wibleSent: Thursday, March 02, 2006 11:45 AMTo: Subject: Re: WHAT SHOULD 24/7 ACCESS REALLY MEAN?? I would love to discuss what 24/7 access REALLY should mean for us. For me it means I want to be available for hospital care and urgent needs 24/7.  If the ER presents me with a patient at any hour of the day I feel it is my responsibility to be there for that patient (or have coverage with a hospitalist).  If a patient calls me "on their way" to the urgent care  then I will handle their issue on the spot by having them meet me at the office instead OR I will certainly follow up with them the next morning or whatever.  I am available 24/7 for these issues. Obviously (to clarify) I would not expect someone in status asthmaticus to give me a courtesy call on their way to the ED as the ED will call me if I am needed.  Though sometimes it has been my pt calling me the day after admit on to another service that made me aware they were there and I gladly took over their case.  BUT on the way to UC a phone call to me can save them the ED trip. I will often tell them to come right over, fit them in somehow. When we finish our house remodel I will see them at home - all hours for URGENT needs. Personally I am not available 24/7 to discuss acne or other minor issues that obviously can wait till 9-5 hours.  My patients know if they call my office land line (which is in my home) that they will usually get a call back in 2-3 hours if not immediate pick up or within 5 minutes which is often the case. I do NOT think we should be available 24/7 for minor medical questions as some folks will call in the middle of the night with an oh, by the way or I have had constipation for 3 days and what should I do (YES, I got a call like that at 3 am once in a prior dysfunctional setting!!!) I think it is dysfunctional and counterproductive for me to be available at a whim for patients after hours with minor and nonurgent issues.  I think it sets the stage for patients to be LESS ACTIVATED and more dependent and dysfunctional and basically abusive of me/my time/my personal space.  Why would they have to remember all their questions for their office visit if they can just call you on your cell at home at 9 pm with an "Oh by the way I forgot to ask about my brother......" What does 24/7 availability mean to others???  I am very curious.... Pamela    Good advice generally, but I’m not sure I agree with #3.  I do agree in general terms about keeping people from abusing/misusing your “on call” cell phone.  However, to tell people right on your phone message not to call unless they are on their way to ED/UC could be interpreted to mean you are not providing 24/7 coverage to your patients, which is required by all insurance contracts.  Also, I’d actually ask sort of the opposite: why have them call if they feel like they are bad enough to go to the ED/UC?  In that case, I would NOT want them to waste time calling me but rather go straight there & the staff can call me if indicated.    Just a thought, but that part struck me as being a little too much of a barrier rather than “gentle persuasion” to change behavior.  -----Original Message-----From: [mailto: ] On Behalf Of pamela wibleSent: Wednesday, March 01, 2006 11:33 PMTo: Subject: Re: PRACTICE TRANSFORMATION by ACTIVATING patients Kathy,  I will attach the handout below.  Regarding your specific issues I would like to make a few comments. 1) If you start giving free advice (telephone medicine) you will never get off the phone and your income will plummet. You will also start to get irritated. You are a professional and you should charge for your services as all professionals do.  A simple answer on the phone will be tempting in cases but folks always seem to have follow up questions and you will set the stage to be doing all your 99212 & 99213s by phone. Your patients will learn that they can call and not come in.--> a counterproductive behavior  (female codependence?) 2) Activated patients come to visits prepared and do not need to make stray phone calls between appointments.  We give them our attention for as long as they need during the office visit and they should be prepared to discuss refills, FU intervals, disease management at that time.  Enforce this. 3) Patients should never ever bother you on your cell phone unless they are on their way to the ED/UC.  If they are worried enough that they will consider disrupting THEIR plans to get in the car and be seen urgently/emergently then I want to know.  Otherwise, if they are not so concerned that they plan NOT to interrupt their plans but can still interrupt YOUR PLANS with an unnecessary phone call then something is wrong with the picture.  ---> Do not train your patients to abuse you. My phone message on my machine says you may notify Dr. Wible on her cell phone at 968-8510 if you are ON YOUR WAY TO THE ED/UC.  Very clear and it is upheld by all patients even my traumatic brain injury patients in the middle of the night when they call in a total panic/frenzy about not being able to find their car keys or their boyfriend walked out on them.  Even with their brain injury and impulse control issues they understand what my cell phone is for. Uphold the sanctity of your personal space. 4) A practice with well trained activated patients will have an office phone that primarily rings for scheduling office visits. 5) Dysfunctional behavior attracts others with dysfunctional behavior.  Clean up your act and set firm boundaries and the patients will be respectful or...they leave and find another kindred dysfunctional soul at ANOTHER office. You can make your office life whatever you want. You can be supportive, empathetic and firm!Keep a running list of ANYTHING or ANYONE that gets under your skin and problem solve your list weekly. Soon you will have nothing to put on your list!   

[Guest guest]

After hours my office phone goes to voice mail which gives the patient an option to leave a message or to call me on my cell phone for serious medical conditions. At my first visit I tell people that I'm always available but for people to try to respect my time. I currently have over 1200 patients. I rarely get a call after hours maybe once every 2 weeks and maybe 1 call on weekends. The calls I get at night are usually from the interns when one of my patients has been admitted. I agree that even though we don't think that it is an emergency it might be to the patient. I think I have more of a problem with patients leaving me a message when they probably should have called me. By the way at my old office when I shared call and used an answering service I used to get called all the time.Larry Lindeman MDI am available 24/7 as well. What that means to me is that after I leave the office, I forward the phone to my cell phone and keep that with me at all times. Although I understand your “tough love” kind of stance, I don’t necessarily agree with its premise. The problem is what is urgent or emergent to me may or may not be urgent or emergent to you and is certainly not clear to a patient with little medical knowledge. I believe you are right in activating your patients, but I think discouraging patients from calling when they think they need your services (even if you don’t) is potentially dangerous. Ex. What if a patient is having diarrhea? They are encouraged not to call. What if the diarrhea is black and tarry? They still are encouraged not to call because they probably don’t know the nuances of treatment algorithms for diarrhea. In my office, I would be mad if they did not call. So do I get inundated with calls after hours. No. Why? I always have same day appointments (so most people know they can get in the next am) which eliminates many calls. I also get all the work done before I leave the office, which eliminates even more. Also, those that call after hours for appointments get a reminder from me that they can schedule an appointment on my website or call at 8am the next morning (thus activating them at the time of the error). Those that call for rx refills get told that I don’t do those except when I am at the office (again activating them when necessary). Yes, I still have some that abuse the system to some degree, but in general, my patients are very considerate of my time and very appreciative that I am able to assist (even if only over the phone) when they are in need.By the way, I have about 1200 patients (maybe 1000 active) and average one call on weeknights and probably 3-4 on a weekend (during the winter). I have had only 3 calls wake me up in the middle of the night (that I remember) since I opened the office 3 years ago. -----Original Message-----From: [mailto: ] On Behalf Of pamela wibleSent: Thursday, March 02, 2006 11:45 AMTo: Subject: Re: WHAT SHOULD 24/7 ACCESS REALLY MEAN?? I would love to discuss what 24/7 access REALLY should mean for us. For me it means I want to be available for hospital care and urgent needs 24/7.  If the ER presents me with a patient at any hour of the day I feel it is my responsibility to be there for that patient (or have coverage with a hospitalist).  If a patient calls me "on their way" to the urgent care  then I will handle their issue on the spot by having them meet me at the office instead OR I will certainly follow up with them the next morning or whatever.  I am available 24/7 for these issues. Obviously (to clarify) I would not expect someone in status asthmaticus to give me a courtesy call on their way to the ED as the ED will call me if I am needed.  Though sometimes it has been my pt calling me the day after admit on to another service that made me aware they were there and I gladly took over their case.  BUT on the way to UC a phone call to me can save them the ED trip. I will often tell them to come right over, fit them in somehow. When we finish our house remodel I will see them at home - all hours for URGENT needs. Personally I am not available 24/7 to discuss acne or other minor issues that obviously can wait till 9-5 hours.  My patients know if they call my office land line (which is in my home) that they will usually get a call back in 2-3 hours if not immediate pick up or within 5 minutes which is often the case. I do NOT think we should be available 24/7 for minor medical questions as some folks will call in the middle of the night with an oh, by the way or I have had constipation for 3 days and what should I do (YES, I got a call like that at 3 am once in a prior dysfunctional setting!!!) I think it is dysfunctional and counterproductive for me to be available at a whim for patients after hours with minor and nonurgent issues.  I think it sets the stage for patients to be LESS ACTIVATED and more dependent and dysfunctional and basically abusive of me/my time/my personal space.  Why would they have to remember all their questions for their office visit if they can just call you on your cell at home at 9 pm with an "Oh by the way I forgot to ask about my brother......" What does 24/7 availability mean to others???  I am very curious.... Pamela    Good advice generally, but I’m not sure I agree with #3.  I do agree in general terms about keeping people from abusing/misusing your “on call” cell phone.  However, to tell people right on your phone message not to call unless they are on their way to ED/UC could be interpreted to mean you are not providing 24/7 coverage to your patients, which is required by all insurance contracts.  Also, I’d actually ask sort of the opposite: why have them call if they feel like they are bad enough to go to the ED/UC?  In that case, I would NOT want them to waste time calling me but rather go straight there & the staff can call me if indicated.    Just a thought, but that part struck me as being a little too much of a barrier rather than “gentle persuasion” to change behavior.  -----Original Message-----From: [mailto: ] On Behalf Of pamela wibleSent: Wednesday, March 01, 2006 11:33 PMTo: Subject: Re: PRACTICE TRANSFORMATION by ACTIVATING patients Kathy,  I will attach the handout below.  Regarding your specific issues I would like to make a few comments. 1) If you start giving free advice (telephone medicine) you will never get off the phone and your income will plummet. You will also start to get irritated. You are a professional and you should charge for your services as all professionals do.  A simple answer on the phone will be tempting in cases but folks always seem to have follow up questions and you will set the stage to be doing all your 99212 & 99213s by phone. Your patients will learn that they can call and not come in.--> a counterproductive behavior  (female codependence?) 2) Activated patients come to visits prepared and do not need to make stray phone calls between appointments.  We give them our attention for as long as they need during the office visit and they should be prepared to discuss refills, FU intervals, disease management at that time.  Enforce this. 3) Patients should never ever bother you on your cell phone unless they are on their way to the ED/UC.  If they are worried enough that they will consider disrupting THEIR plans to get in the car and be seen urgently/emergently then I want to know.  Otherwise, if they are not so concerned that they plan NOT to interrupt their plans but can still interrupt YOUR PLANS with an unnecessary phone call then something is wrong with the picture.  ---> Do not train your patients to abuse you. My phone message on my machine says you may notify Dr. Wible on her cell phone at 968-8510 if you are ON YOUR WAY TO THE ED/UC.  Very clear and it is upheld by all patients even my traumatic brain injury patients in the middle of the night when they call in a total panic/frenzy about not being able to find their car keys or their boyfriend walked out on them.  Even with their brain injury and impulse control issues they understand what my cell phone is for. Uphold the sanctity of your personal space. 4) A practice with well trained activated patients will have an office phone that primarily rings for scheduling office visits. 5) Dysfunctional behavior attracts others with dysfunctional behavior.  Clean up your act and set firm boundaries and the patients will be respectful or...they leave and find another kindred dysfunctional soul at ANOTHER office. You can make your office life whatever you want. You can be supportive, empathetic and firm!Keep a running list of ANYTHING or ANYONE that gets under your skin and problem solve your list weekly. Soon you will have nothing to put on your list!   

[Guest guest]

After hours my office phone goes to voice mail which gives the patient an option to leave a message or to call me on my cell phone for serious medical conditions. At my first visit I tell people that I'm always available but for people to try to respect my time. I currently have over 1200 patients. I rarely get a call after hours maybe once every 2 weeks and maybe 1 call on weekends. The calls I get at night are usually from the interns when one of my patients has been admitted. I agree that even though we don't think that it is an emergency it might be to the patient. I think I have more of a problem with patients leaving me a message when they probably should have called me. By the way at my old office when I shared call and used an answering service I used to get called all the time.Larry Lindeman MDI am available 24/7 as well. What that means to me is that after I leave the office, I forward the phone to my cell phone and keep that with me at all times. Although I understand your “tough love” kind of stance, I don’t necessarily agree with its premise. The problem is what is urgent or emergent to me may or may not be urgent or emergent to you and is certainly not clear to a patient with little medical knowledge. I believe you are right in activating your patients, but I think discouraging patients from calling when they think they need your services (even if you don’t) is potentially dangerous. Ex. What if a patient is having diarrhea? They are encouraged not to call. What if the diarrhea is black and tarry? They still are encouraged not to call because they probably don’t know the nuances of treatment algorithms for diarrhea. In my office, I would be mad if they did not call. So do I get inundated with calls after hours. No. Why? I always have same day appointments (so most people know they can get in the next am) which eliminates many calls. I also get all the work done before I leave the office, which eliminates even more. Also, those that call after hours for appointments get a reminder from me that they can schedule an appointment on my website or call at 8am the next morning (thus activating them at the time of the error). Those that call for rx refills get told that I don’t do those except when I am at the office (again activating them when necessary). Yes, I still have some that abuse the system to some degree, but in general, my patients are very considerate of my time and very appreciative that I am able to assist (even if only over the phone) when they are in need.By the way, I have about 1200 patients (maybe 1000 active) and average one call on weeknights and probably 3-4 on a weekend (during the winter). I have had only 3 calls wake me up in the middle of the night (that I remember) since I opened the office 3 years ago. -----Original Message-----From: [mailto: ] On Behalf Of pamela wibleSent: Thursday, March 02, 2006 11:45 AMTo: Subject: Re: WHAT SHOULD 24/7 ACCESS REALLY MEAN?? I would love to discuss what 24/7 access REALLY should mean for us. For me it means I want to be available for hospital care and urgent needs 24/7.  If the ER presents me with a patient at any hour of the day I feel it is my responsibility to be there for that patient (or have coverage with a hospitalist).  If a patient calls me "on their way" to the urgent care  then I will handle their issue on the spot by having them meet me at the office instead OR I will certainly follow up with them the next morning or whatever.  I am available 24/7 for these issues. Obviously (to clarify) I would not expect someone in status asthmaticus to give me a courtesy call on their way to the ED as the ED will call me if I am needed.  Though sometimes it has been my pt calling me the day after admit on to another service that made me aware they were there and I gladly took over their case.  BUT on the way to UC a phone call to me can save them the ED trip. I will often tell them to come right over, fit them in somehow. When we finish our house remodel I will see them at home - all hours for URGENT needs. Personally I am not available 24/7 to discuss acne or other minor issues that obviously can wait till 9-5 hours.  My patients know if they call my office land line (which is in my home) that they will usually get a call back in 2-3 hours if not immediate pick up or within 5 minutes which is often the case. I do NOT think we should be available 24/7 for minor medical questions as some folks will call in the middle of the night with an oh, by the way or I have had constipation for 3 days and what should I do (YES, I got a call like that at 3 am once in a prior dysfunctional setting!!!) I think it is dysfunctional and counterproductive for me to be available at a whim for patients after hours with minor and nonurgent issues.  I think it sets the stage for patients to be LESS ACTIVATED and more dependent and dysfunctional and basically abusive of me/my time/my personal space.  Why would they have to remember all their questions for their office visit if they can just call you on your cell at home at 9 pm with an "Oh by the way I forgot to ask about my brother......" What does 24/7 availability mean to others???  I am very curious.... Pamela    Good advice generally, but I’m not sure I agree with #3.  I do agree in general terms about keeping people from abusing/misusing your “on call” cell phone.  However, to tell people right on your phone message not to call unless they are on their way to ED/UC could be interpreted to mean you are not providing 24/7 coverage to your patients, which is required by all insurance contracts.  Also, I’d actually ask sort of the opposite: why have them call if they feel like they are bad enough to go to the ED/UC?  In that case, I would NOT want them to waste time calling me but rather go straight there & the staff can call me if indicated.    Just a thought, but that part struck me as being a little too much of a barrier rather than “gentle persuasion” to change behavior.  -----Original Message-----From: [mailto: ] On Behalf Of pamela wibleSent: Wednesday, March 01, 2006 11:33 PMTo: Subject: Re: PRACTICE TRANSFORMATION by ACTIVATING patients Kathy,  I will attach the handout below.  Regarding your specific issues I would like to make a few comments. 1) If you start giving free advice (telephone medicine) you will never get off the phone and your income will plummet. You will also start to get irritated. You are a professional and you should charge for your services as all professionals do.  A simple answer on the phone will be tempting in cases but folks always seem to have follow up questions and you will set the stage to be doing all your 99212 & 99213s by phone. Your patients will learn that they can call and not come in.--> a counterproductive behavior  (female codependence?) 2) Activated patients come to visits prepared and do not need to make stray phone calls between appointments.  We give them our attention for as long as they need during the office visit and they should be prepared to discuss refills, FU intervals, disease management at that time.  Enforce this. 3) Patients should never ever bother you on your cell phone unless they are on their way to the ED/UC.  If they are worried enough that they will consider disrupting THEIR plans to get in the car and be seen urgently/emergently then I want to know.  Otherwise, if they are not so concerned that they plan NOT to interrupt their plans but can still interrupt YOUR PLANS with an unnecessary phone call then something is wrong with the picture.  ---> Do not train your patients to abuse you. My phone message on my machine says you may notify Dr. Wible on her cell phone at 968-8510 if you are ON YOUR WAY TO THE ED/UC.  Very clear and it is upheld by all patients even my traumatic brain injury patients in the middle of the night when they call in a total panic/frenzy about not being able to find their car keys or their boyfriend walked out on them.  Even with their brain injury and impulse control issues they understand what my cell phone is for. Uphold the sanctity of your personal space. 4) A practice with well trained activated patients will have an office phone that primarily rings for scheduling office visits. 5) Dysfunctional behavior attracts others with dysfunctional behavior.  Clean up your act and set firm boundaries and the patients will be respectful or...they leave and find another kindred dysfunctional soul at ANOTHER office. You can make your office life whatever you want. You can be supportive, empathetic and firm!Keep a running list of ANYTHING or ANYONE that gets under your skin and problem solve your list weekly. Soon you will have nothing to put on your list!   

[Guest guest]

More good points. Unfortunately, you

are right that it does seem like a lot of the after hrs calls are from Medicaid

(I still have some) & nursing home patients (which I don’t do).

I also don’t do inpatient (I use a hospitalist) & that cuts down even

further on the calls.

Re: PRACTICE TRANSFORMATION by ACTIVATING patients

Kathy, I will attach the handout below. Regarding your

specific issues I would like to make a few comments.

1) If you start giving free advice (telephone medicine) you will

never get off the phone and your income will plummet. You will also start to

get irritated. You are a professional and you should charge for your services

as all professionals do. A simple answer on the phone will be tempting in

cases but folks always seem to have follow up questions and you will set the

stage to be doing all your 99212 & 99213s by phone. Your patients will

learn that they can call and not come in.--> a counterproductive

behavior (female codependence?)

2) Activated patients come to visits prepared and do not need to

make stray phone calls between appointments. We give them our attention

for as long as they need during the office visit and they should be prepared to

discuss refills, FU intervals, disease management at that time. Enforce

this.

3) Patients should never ever bother you on your cell phone unless

they are on their way to the ED/UC. If they are worried enough that they

will consider disrupting THEIR plans to get in the car and be seen

urgently/emergently then I want to know. Otherwise, if they are not so

concerned that they plan NOT to interrupt their plans but can still interrupt

YOUR PLANS with an unnecessary phone call then something is wrong with the

picture. ---> Do not train your patients to abuse you. My phone

message on my machine says you may notify Dr. Wible on her cell phone at 968-8510

if you are ON YOUR WAY TO THE ED/UC. Very clear and it is upheld by all

patients even my traumatic brain injury patients in the middle of the night

when they call in a total panic/frenzy about not being able to find their car

keys or their boyfriend walked out on them. Even with their brain injury

and impulse control issues they understand what my cell phone is for. Uphold

the sanctity of your personal space.

4) A practice with well trained activated patients will have an

office phone that primarily rings for scheduling office visits.

5) Dysfunctional behavior attracts others with dysfunctional

behavior. Clean up your act and set firm boundaries and the patients will

be respectful or...they leave and find another kindred dysfunctional soul at

ANOTHER office.

You can make your office life whatever you want. You can be

supportive, empathetic and firm!

Keep a running list of ANYTHING or ANYONE that gets under your

skin and problem solve your list weekly. Soon you will have nothing to put on

your list!

[Guest guest]

More good points. Unfortunately, you

are right that it does seem like a lot of the after hrs calls are from Medicaid

(I still have some) & nursing home patients (which I don’t do).

I also don’t do inpatient (I use a hospitalist) & that cuts down even

further on the calls.

Re: PRACTICE TRANSFORMATION by ACTIVATING patients

Kathy, I will attach the handout below. Regarding your

specific issues I would like to make a few comments.

1) If you start giving free advice (telephone medicine) you will

never get off the phone and your income will plummet. You will also start to

get irritated. You are a professional and you should charge for your services

as all professionals do. A simple answer on the phone will be tempting in

cases but folks always seem to have follow up questions and you will set the

stage to be doing all your 99212 & 99213s by phone. Your patients will

learn that they can call and not come in.--> a counterproductive

behavior (female codependence?)

2) Activated patients come to visits prepared and do not need to

make stray phone calls between appointments. We give them our attention

for as long as they need during the office visit and they should be prepared to

discuss refills, FU intervals, disease management at that time. Enforce

this.

3) Patients should never ever bother you on your cell phone unless

they are on their way to the ED/UC. If they are worried enough that they

will consider disrupting THEIR plans to get in the car and be seen

urgently/emergently then I want to know. Otherwise, if they are not so

concerned that they plan NOT to interrupt their plans but can still interrupt

YOUR PLANS with an unnecessary phone call then something is wrong with the

picture. ---> Do not train your patients to abuse you. My phone

message on my machine says you may notify Dr. Wible on her cell phone at 968-8510

if you are ON YOUR WAY TO THE ED/UC. Very clear and it is upheld by all

patients even my traumatic brain injury patients in the middle of the night

when they call in a total panic/frenzy about not being able to find their car

keys or their boyfriend walked out on them. Even with their brain injury

and impulse control issues they understand what my cell phone is for. Uphold

the sanctity of your personal space.

4) A practice with well trained activated patients will have an

office phone that primarily rings for scheduling office visits.

5) Dysfunctional behavior attracts others with dysfunctional

behavior. Clean up your act and set firm boundaries and the patients will

be respectful or...they leave and find another kindred dysfunctional soul at

ANOTHER office.

You can make your office life whatever you want. You can be

supportive, empathetic and firm!

Keep a running list of ANYTHING or ANYONE that gets under your

skin and problem solve your list weekly. Soon you will have nothing to put on

your list!

[Guest guest]

After being in the same office for eight years I'd say that the frequency

a patient calls often depends on the long term relationship and trust.

There will always be individuals who mis-use a system... use of " gentle

tough love " is likely best for them. But the reasons a person calls after

hours can be quite complex, especially if you compare Medicaid versus

private insurance patients. Many people live very chaotic lives, have

lived in very chaotic families, don't have the means (educational,

financial, social, etc) to get their acts together consistently and have

never had healthy " models " to see how to organize their lives. Plus there

is a portion of our population who work night shifts and have a " reversed "

daily schedule. I would contend that our using " tough love " on such

people will ultimately be of little benefit as we may be perceived as

" another one " who is rude or who can't be trusted (believe me, the

communities of color have a large portion who do not trust doctors due to

a long history of abuses and disrespect).

I do not mean to bring up a new point. But an individual who doesn't act

in a way that we think is appropriate may be dysfunctional (borderline,

etc) OR they may be struggling to keep their lives reasonably orderly. We

should judge each individual and try to help with a respectful, open

manner. Then, if needed, use some tough love, or, consider letting the

person know you understand they are struggling and offer to be a little

flexible.

Regarding the 24/7 coverage, I'd lean toward Brady's description. For

new office I will have ALL calls go directly to voice mail with the

message that 911 should be called for life-threatening problems and that I

can be reached on my cell if the issue is urgent and needs my attention.

I'll see how the patients do... but I'm hopeful since so many of my

patients will have been with me in my old office too and they don't call

often.

I also am asking patients to sign up for RelayHealth to communicate

non-urgent issues at their convenience. That gives me the opportunity to

catch up with issues as I am able.

Tim

> More good points. Unfortunately, you are right that it does seem like a

> lot of the after hrs calls are from Medicaid (I still have some) &

> nursing home patients (which I don't do). I also don't do inpatient (I

> use a

> hospitalist) & that cuts down even further on the calls.

>

>

>

>

>

>

>

> Re: PRACTICE TRANSFORMATION by

> ACTIVATING patients

>

>

>

> Kathy, I will attach the handout below. Regarding your specific issues

> I would like to make a few comments.

>

>

>

> 1) If you start giving free advice (telephone medicine) you will never

> get off the phone and your income will plummet. You will also start to

> get irritated. You are a professional and you should charge for your

> services as all professionals do. A simple answer on the phone will be

> tempting in cases but folks always seem to have follow up questions and

> you will set the stage to be doing all your 99212 & 99213s by phone.

> Your patients will learn that they can call and not come in.--> a

> counterproductive behavior (female codependence?)

>

>

>

> 2) Activated patients come to visits prepared and do not need to make

> stray phone calls between appointments. We give them our attention for

> as long as they need during the office visit and they should be prepared

> to discuss refills, FU intervals, disease management at that time.

> Enforce this.

>

>

>

> 3) Patients should never ever bother you on your cell phone unless they

> are on their way to the ED/UC. If they are worried enough that they

> will consider disrupting THEIR plans to get in the car and be seen

> urgently/emergently then I want to know. Otherwise, if they are not so

> concerned that they plan NOT to interrupt their plans but can still

> interrupt YOUR PLANS with an unnecessary phone call then something is

> wrong with the picture. ---> Do not train your patients to abuse you.

> My phone message on my machine says you may notify Dr. Wible on her cell

> phone at 968-8510 if you are ON YOUR WAY TO THE ED/UC. Very clear and

> it is upheld by all patients even my traumatic brain injury patients in

> the middle of the night when they call in a total panic/frenzy about not

> being able to find their car keys or their boyfriend walked out on them.

> Even with their brain injury and impulse control issues they understand

> what my cell phone is for. Uphold the sanctity of your personal space.

>

>

>

> 4) A practice with well trained activated patients will have an office

> phone that primarily rings for scheduling office visits.

>

>

>

> 5) Dysfunctional behavior attracts others with dysfunctional behavior.

> Clean up your act and set firm boundaries and the patients will be

> respectful or...they leave and find another kindred dysfunctional soul

> at ANOTHER office.

>

>

>

> You can make your office life whatever you want. You can be supportive,

> empathetic and firm!

>

> Keep a running list of ANYTHING or ANYONE that gets under your skin and

> problem solve your list weekly. Soon you will have nothing to put on

> your list!

>

>

>

>

>

>

>

>

[Guest guest]

After being in the same office for eight years I'd say that the frequency

a patient calls often depends on the long term relationship and trust.

There will always be individuals who mis-use a system... use of " gentle

tough love " is likely best for them. But the reasons a person calls after

hours can be quite complex, especially if you compare Medicaid versus

private insurance patients. Many people live very chaotic lives, have

lived in very chaotic families, don't have the means (educational,

financial, social, etc) to get their acts together consistently and have

never had healthy " models " to see how to organize their lives. Plus there

is a portion of our population who work night shifts and have a " reversed "

daily schedule. I would contend that our using " tough love " on such

people will ultimately be of little benefit as we may be perceived as

" another one " who is rude or who can't be trusted (believe me, the

communities of color have a large portion who do not trust doctors due to

a long history of abuses and disrespect).

I do not mean to bring up a new point. But an individual who doesn't act

in a way that we think is appropriate may be dysfunctional (borderline,

etc) OR they may be struggling to keep their lives reasonably orderly. We

should judge each individual and try to help with a respectful, open

manner. Then, if needed, use some tough love, or, consider letting the

person know you understand they are struggling and offer to be a little

flexible.

Regarding the 24/7 coverage, I'd lean toward Brady's description. For

new office I will have ALL calls go directly to voice mail with the

message that 911 should be called for life-threatening problems and that I

can be reached on my cell if the issue is urgent and needs my attention.

I'll see how the patients do... but I'm hopeful since so many of my

patients will have been with me in my old office too and they don't call

often.

I also am asking patients to sign up for RelayHealth to communicate

non-urgent issues at their convenience. That gives me the opportunity to

catch up with issues as I am able.

Tim

> More good points. Unfortunately, you are right that it does seem like a

> lot of the after hrs calls are from Medicaid (I still have some) &

> nursing home patients (which I don't do). I also don't do inpatient (I

> use a

> hospitalist) & that cuts down even further on the calls.

>

>

>

>

>

>

>

> Re: PRACTICE TRANSFORMATION by

> ACTIVATING patients

>

>

>

> Kathy, I will attach the handout below. Regarding your specific issues

> I would like to make a few comments.

>

>

>

> 1) If you start giving free advice (telephone medicine) you will never

> get off the phone and your income will plummet. You will also start to

> get irritated. You are a professional and you should charge for your

> services as all professionals do. A simple answer on the phone will be

> tempting in cases but folks always seem to have follow up questions and

> you will set the stage to be doing all your 99212 & 99213s by phone.

> Your patients will learn that they can call and not come in.--> a

> counterproductive behavior (female codependence?)

>

>

>

> 2) Activated patients come to visits prepared and do not need to make

> stray phone calls between appointments. We give them our attention for

> as long as they need during the office visit and they should be prepared

> to discuss refills, FU intervals, disease management at that time.

> Enforce this.

>

>

>

> 3) Patients should never ever bother you on your cell phone unless they

> are on their way to the ED/UC. If they are worried enough that they

> will consider disrupting THEIR plans to get in the car and be seen

> urgently/emergently then I want to know. Otherwise, if they are not so

> concerned that they plan NOT to interrupt their plans but can still

> interrupt YOUR PLANS with an unnecessary phone call then something is

> wrong with the picture. ---> Do not train your patients to abuse you.

> My phone message on my machine says you may notify Dr. Wible on her cell

> phone at 968-8510 if you are ON YOUR WAY TO THE ED/UC. Very clear and

> it is upheld by all patients even my traumatic brain injury patients in

> the middle of the night when they call in a total panic/frenzy about not

> being able to find their car keys or their boyfriend walked out on them.

> Even with their brain injury and impulse control issues they understand

> what my cell phone is for. Uphold the sanctity of your personal space.

>

>

>

> 4) A practice with well trained activated patients will have an office

> phone that primarily rings for scheduling office visits.

>

>

>

> 5) Dysfunctional behavior attracts others with dysfunctional behavior.

> Clean up your act and set firm boundaries and the patients will be

> respectful or...they leave and find another kindred dysfunctional soul

> at ANOTHER office.

>

>

>

> You can make your office life whatever you want. You can be supportive,

> empathetic and firm!

>

> Keep a running list of ANYTHING or ANYONE that gets under your skin and

> problem solve your list weekly. Soon you will have nothing to put on

> your list!

>

>

>

>

>

>

>

>

[Guest guest]

RE Open access and barriers to care-- my opinion.

1) After having a "traditional" barrier practice out of my control (ie hospital run) for the last 8 years (6 years staff model HMO prior, and 2 years prior in a private 3 person group), with a "call group", etc, and the last 14 months of my own solo practice, I really believe in a "limited barrier" practice.

2) Limited barrier-- I use an answering service (person answers it), pts need to call this number intentionally. If they call the office, they'll get a message to call answering service if they need to talk with me.

3) I was using an EMR at point of care for 40-60% of visits at hospital practice, and since about 1/2 of my pts ended up seeing the PA, I was providing "discontinuity" of care. Admittedly, fair amount of time, this was just plain out out of my control-- I wanted to see the pts, but the "front desk" was offering next appt, and not to me specifically. Plus in my state, the pt has to see the doc every 3rd visit, so a disaster from the start.

Now I use the EMR for every visit, and plan to use it even more as soon as I can. I encourage pts to call if questions-- best source of hx is what pt tells at the visit. I ALWAYS give pts enough med refills to next visit, and guess what! They miss the follow up and call anyway! :-) Some we get into the "here's 30 days and see me within" and then rarely, call in the "2 weeks and you'll need to be here or else."

4) If you get into a power struggle with pts, you need to consider dismissing the pt. You will NOT WIN, so agree that your practice style is different from pt's needs.

You know who the pt is, decide and dismiss if you cannot feel balanced on this. I do it in person, mostly, and hand them a summarized list of my recommendations instead of the "30 day dismissal" issue. Have them sign it, or have a staffer witness the interview.

Some pts just are not appropriate. Drug seekers move from practice to practice-- get old records, or, if asking for narcs, insist on ID, driver's license copy. Last one wouldn't even answer their cell phone after the first visit.

5) Look over the Advanced Open Access articles in Family Practice Management by Murray and Tantua. If you give ready access, and do as much as you can, time permitting, each visit, you'll "catch up" most of the time. And have fewer after hours calls.

6) Decide what you want to do in your practice, and say NO to other things. I decided to continue NOT seeing pts in the hospital. Tough choice in growing a practice, although I was known in the community. But I don't mind being called after hours, and looks like you're being overwhelmed.

Once had a pt ask me results of a BE in a car wash. Now that's a barrier I really don't want to cross over again!! :-)

Matt Levin, MD

Pittsburgh, PA

Re: WHAT SHOULD 24/7 ACCESS REALLY MEAN??

I would love to discuss what 24/7 access REALLY should mean for us.

For me it means I want to be available for hospital care and urgent needs 24/7. If the ER presents me with a patient at any hour of the day I feel it is my responsibility to be there for that patient (or have coverage with a hospitalist). If a patient calls me "on their way" to the urgent care then I will handle their issue on the spot by having them meet me at the office instead OR I will certainly follow up with them the next morning or whatever. I am available 24/7 for these issues.

Obviously (to clarify) I would not expect someone in status asthmaticus to give me a courtesy call on their way to the ED as the ED will call me if I am needed. Though sometimes it has been my pt calling me the day after admit on to another service that made me aware they were there and I gladly took over their case. BUT on the way to UC a phone call to me can save them the ED trip. I will often tell them to come right over, fit them in somehow. When we finish our house remodel I will see them at home - all hours for URGENT needs.

Personally I am not available 24/7 to discuss acne or other minor issues that obviously can wait till 9-5 hours. My patients know if they call my office land line (which is in my home) that they will usually get a call back in 2-3 hours if not immediate pick up or within 5 minutes which is often the case.

I do NOT think we should be available 24/7 for minor medical questions as some folks will call in the middle of the night with an oh, by the way or I have had constipation for 3 days and what should I do (YES, I got a call like that at 3 am once in a prior dysfunctional setting!!!)

I think it is dysfunctional and counterproductive for me to be available at a whim for patients after hours with minor and nonurgent issues. I think it sets the stage for patients to be LESS ACTIVATED and more dependent and dysfunctional and basically abusive of me/my time/my personal space. Why would they have to remember all their questions for their office visit if they can just call you on your cell at home at 9 pm with an "Oh by the way I forgot to ask about my brother......"

What does 24/7 availability mean to others??? I am very curious....

Pamela

Good advice generally, but I’m not sure I agree with #3. I do agree in general terms about keeping people from abusing/misusing your “on call” cell phone. However, to tell people right on your phone message not to call unless they are on their way to ED/UC could be interpreted to mean you are not providing 24/7 coverage to your patients, which is required by all insurance contracts. Also, I’d actually ask sort of the opposite: why have them call if they feel like they are bad enough to go to the ED/UC? In that case, I would NOT want them to waste time calling me but rather go straight there & the staff can call me if indicated. Just a thought, but that part struck me as being a little too much of a barrier rather than “gentle persuasion” to change behavior.

-----Original Message-----From: [mailto: ] On Behalf Of pamela wibleSent: Wednesday, March 01, 2006 11:33 PMTo: Subject: Re: PRACTICE TRANSFORMATION by ACTIVATING patients

Kathy, I will attach the handout below. Regarding your specific issues I would like to make a few comments.

1) If you start giving free advice (telephone medicine) you will never get off the phone and your income will plummet. You will also start to get irritated. You are a professional and you should charge for your services as all professionals do. A simple answer on the phone will be tempting in cases but folks always seem to have follow up questions and you will set the stage to be doing all your 99212 & 99213s by phone. Your patients will learn that they can call and not come in.--> a counterproductive behavior (female codependence?)

2) Activated patients come to visits prepared and do not need to make stray phone calls between appointments. We give them our attention for as long as they need during the office visit and they should be prepared to discuss refills, FU intervals, disease management at that time. Enforce this.

3) Patients should never ever bother you on your cell phone unless they are on their way to the ED/UC. If they are worried enough that they will consider disrupting THEIR plans to get in the car and be seen urgently/emergently then I want to know. Otherwise, if they are not so concerned that they plan NOT to interrupt their plans but can still interrupt YOUR PLANS with an unnecessary phone call then something is wrong with the picture. ---> Do not train your patients to abuse you. My phone message on my machine says you may notify Dr. Wible on her cell phone at 968-8510 if you are ON YOUR WAY TO THE ED/UC. Very clear and it is upheld by all patients even my traumatic brain injury patients in the middle of the night when they call in a total panic/frenzy about not being able to find their car keys or their boyfriend walked out on them. Even with their brain injury and impulse control issues they understand what my cell phone is for. Uphold the sanctity of your personal space.

4) A practice with well trained activated patients will have an office phone that primarily rings for scheduling office visits.

5) Dysfunctional behavior attracts others with dysfunctional behavior. Clean up your act and set firm boundaries and the patients will be respectful or...they leave and find another kindred dysfunctional soul at ANOTHER office.

You can make your office life whatever you want. You can be supportive, empathetic and firm!

Keep a running list of ANYTHING or ANYONE that gets under your skin and problem solve your list weekly. Soon you will have nothing to put on your list!

[Guest guest]

RE Open access and barriers to care-- my opinion.

1) After having a "traditional" barrier practice out of my control (ie hospital run) for the last 8 years (6 years staff model HMO prior, and 2 years prior in a private 3 person group), with a "call group", etc, and the last 14 months of my own solo practice, I really believe in a "limited barrier" practice.

2) Limited barrier-- I use an answering service (person answers it), pts need to call this number intentionally. If they call the office, they'll get a message to call answering service if they need to talk with me.

3) I was using an EMR at point of care for 40-60% of visits at hospital practice, and since about 1/2 of my pts ended up seeing the PA, I was providing "discontinuity" of care. Admittedly, fair amount of time, this was just plain out out of my control-- I wanted to see the pts, but the "front desk" was offering next appt, and not to me specifically. Plus in my state, the pt has to see the doc every 3rd visit, so a disaster from the start.

Now I use the EMR for every visit, and plan to use it even more as soon as I can. I encourage pts to call if questions-- best source of hx is what pt tells at the visit. I ALWAYS give pts enough med refills to next visit, and guess what! They miss the follow up and call anyway! :-) Some we get into the "here's 30 days and see me within" and then rarely, call in the "2 weeks and you'll need to be here or else."

4) If you get into a power struggle with pts, you need to consider dismissing the pt. You will NOT WIN, so agree that your practice style is different from pt's needs.

You know who the pt is, decide and dismiss if you cannot feel balanced on this. I do it in person, mostly, and hand them a summarized list of my recommendations instead of the "30 day dismissal" issue. Have them sign it, or have a staffer witness the interview.

Some pts just are not appropriate. Drug seekers move from practice to practice-- get old records, or, if asking for narcs, insist on ID, driver's license copy. Last one wouldn't even answer their cell phone after the first visit.

5) Look over the Advanced Open Access articles in Family Practice Management by Murray and Tantua. If you give ready access, and do as much as you can, time permitting, each visit, you'll "catch up" most of the time. And have fewer after hours calls.

6) Decide what you want to do in your practice, and say NO to other things. I decided to continue NOT seeing pts in the hospital. Tough choice in growing a practice, although I was known in the community. But I don't mind being called after hours, and looks like you're being overwhelmed.

Once had a pt ask me results of a BE in a car wash. Now that's a barrier I really don't want to cross over again!! :-)

Matt Levin, MD

Pittsburgh, PA

Re: WHAT SHOULD 24/7 ACCESS REALLY MEAN??

I would love to discuss what 24/7 access REALLY should mean for us.

For me it means I want to be available for hospital care and urgent needs 24/7. If the ER presents me with a patient at any hour of the day I feel it is my responsibility to be there for that patient (or have coverage with a hospitalist). If a patient calls me "on their way" to the urgent care then I will handle their issue on the spot by having them meet me at the office instead OR I will certainly follow up with them the next morning or whatever. I am available 24/7 for these issues.

Obviously (to clarify) I would not expect someone in status asthmaticus to give me a courtesy call on their way to the ED as the ED will call me if I am needed. Though sometimes it has been my pt calling me the day after admit on to another service that made me aware they were there and I gladly took over their case. BUT on the way to UC a phone call to me can save them the ED trip. I will often tell them to come right over, fit them in somehow. When we finish our house remodel I will see them at home - all hours for URGENT needs.

Personally I am not available 24/7 to discuss acne or other minor issues that obviously can wait till 9-5 hours. My patients know if they call my office land line (which is in my home) that they will usually get a call back in 2-3 hours if not immediate pick up or within 5 minutes which is often the case.

I do NOT think we should be available 24/7 for minor medical questions as some folks will call in the middle of the night with an oh, by the way or I have had constipation for 3 days and what should I do (YES, I got a call like that at 3 am once in a prior dysfunctional setting!!!)

I think it is dysfunctional and counterproductive for me to be available at a whim for patients after hours with minor and nonurgent issues. I think it sets the stage for patients to be LESS ACTIVATED and more dependent and dysfunctional and basically abusive of me/my time/my personal space. Why would they have to remember all their questions for their office visit if they can just call you on your cell at home at 9 pm with an "Oh by the way I forgot to ask about my brother......"

What does 24/7 availability mean to others??? I am very curious....

Pamela

Good advice generally, but I’m not sure I agree with #3. I do agree in general terms about keeping people from abusing/misusing your “on call” cell phone. However, to tell people right on your phone message not to call unless they are on their way to ED/UC could be interpreted to mean you are not providing 24/7 coverage to your patients, which is required by all insurance contracts. Also, I’d actually ask sort of the opposite: why have them call if they feel like they are bad enough to go to the ED/UC? In that case, I would NOT want them to waste time calling me but rather go straight there & the staff can call me if indicated. Just a thought, but that part struck me as being a little too much of a barrier rather than “gentle persuasion” to change behavior.

-----Original Message-----From: [mailto: ] On Behalf Of pamela wibleSent: Wednesday, March 01, 2006 11:33 PMTo: Subject: Re: PRACTICE TRANSFORMATION by ACTIVATING patients

Kathy, I will attach the handout below. Regarding your specific issues I would like to make a few comments.

1) If you start giving free advice (telephone medicine) you will never get off the phone and your income will plummet. You will also start to get irritated. You are a professional and you should charge for your services as all professionals do. A simple answer on the phone will be tempting in cases but folks always seem to have follow up questions and you will set the stage to be doing all your 99212 & 99213s by phone. Your patients will learn that they can call and not come in.--> a counterproductive behavior (female codependence?)

2) Activated patients come to visits prepared and do not need to make stray phone calls between appointments. We give them our attention for as long as they need during the office visit and they should be prepared to discuss refills, FU intervals, disease management at that time. Enforce this.

3) Patients should never ever bother you on your cell phone unless they are on their way to the ED/UC. If they are worried enough that they will consider disrupting THEIR plans to get in the car and be seen urgently/emergently then I want to know. Otherwise, if they are not so concerned that they plan NOT to interrupt their plans but can still interrupt YOUR PLANS with an unnecessary phone call then something is wrong with the picture. ---> Do not train your patients to abuse you. My phone message on my machine says you may notify Dr. Wible on her cell phone at 968-8510 if you are ON YOUR WAY TO THE ED/UC. Very clear and it is upheld by all patients even my traumatic brain injury patients in the middle of the night when they call in a total panic/frenzy about not being able to find their car keys or their boyfriend walked out on them. Even with their brain injury and impulse control issues they understand what my cell phone is for. Uphold the sanctity of your personal space.

4) A practice with well trained activated patients will have an office phone that primarily rings for scheduling office visits.

5) Dysfunctional behavior attracts others with dysfunctional behavior. Clean up your act and set firm boundaries and the patients will be respectful or...they leave and find another kindred dysfunctional soul at ANOTHER office.

You can make your office life whatever you want. You can be supportive, empathetic and firm!

Keep a running list of ANYTHING or ANYONE that gets under your skin and problem solve your list weekly. Soon you will have nothing to put on your list!

[Guest guest]

Our home phone is listed in the local phonebook and our answering machine, outside of office hours, gives Rian's cell phone number. On the inside of the brochure, that we give to all new patients, is our home phone and Rian's cell phone listed under a short paragraph titled Unfettered Access (thanks to Gordon's idea several years ago). It says that Rian may be reached at that cell 24/7. As I hand patients the brochure and I open it and point that section out, I say to them "Here's how to reach Dr. Mintek outside of our office hours when you have any kind of urgent medical concern....keep an extra brochure in your glove compartment so that when you are traveling you can reach him as well." Patients are simply amazed. No one has offered this kind of access before.

After 23 years of practice and sharing call with a group much of that time we were afraid that in his new practice he'd be bombarded outside clinic hours, but it is amazing. Patients are very respectful of his free time. I think when you show them you are able to be reached easily, it pleases them and your relationship with them strengthens but so does their respect for you and your free time. Patients rarely call him. He maybe averages one call a weekend and we very rarely get calls on weeknights.

However, there HAVE been several occasions (over 2 1/2 yrs) where Rian was VERY glad that a patient DID call him (usually urged to do so by a spouse) - where, for example, a patient was vastly understating an important symptom and also was not planning to go to an ER but did wonder what he thought. In those instances Rian was very glad they called him and glad that he could urge them to be seen in the ER. Some of those situations would have turned out very poorly if they had "toughed it out at home" and also not bothered any physician.

Perhaps the reluctance to "bother" someone is more common in a small midwestern town like ours (ala Garrison Keillor's Minnesota characters who don't like to complain and who understate the illnesses, diseases, and traumas that come their way) When we lived in Philly, I thought people were a lot more aggressive and pushy so maybe everyone's 24/7 policy has to be designed with their regional, cultural style in mind. Still and all, you may want to give a really "unfettered" approach a try. When you are only taking call for yourself and your patients really respect what you are trying to do, you may be surprised at how few bother you in your free time.

a Mintek

office manager

Dowtown Allegan Family Practice

Allegan, Michigan

Re: PRACTICE TRANSFORMATION by> ACTIVATING patients>>>> Kathy, I will attach the handout below. Regarding your specific issues> I would like to make a few comments.>>>> 1) If you start giving free advice (telephone medicine) you will never> get off the phone and your income will plummet. You will also start to> get irritated. You are a professional and you should charge for your> services as all professionals do. A simple answer on the phone will be> tempting in cases but folks always seem to have follow up questions and> you will set the stage to be doing all your 99212 & 99213s by phone.> Your patients will learn that they can call and not come in.--> a> counterproductive behavior (female codependence?)>>>> 2) Activated patients come to visits prepared and do not need to make> stray phone calls between appointments. We give them our attention for> as long as they need during the office visit and they should be prepared> to discuss refills, FU intervals, disease management at that time.> Enforce this.>>>> 3) Patients should never ever bother you on your cell phone unless they> are on their way to the ED/UC. If they are worried enough that they> will consider disrupting THEIR plans to get in the car and be seen> urgently/emergently then I want to know. Otherwise, if they are not so> concerned that they plan NOT to interrupt their plans but can still> interrupt YOUR PLANS with an unnecessary phone call then something is> wrong with the picture. ---> Do not train your patients to abuse you.> My phone message on my machine says you may notify Dr. Wible on her cell> phone at 968-8510 if you are ON YOUR WAY TO THE ED/UC. Very clear and> it is upheld by all patients even my traumatic brain injury patients in> the middle of the night when they call in a total panic/frenzy about not> being able to find their car keys or their boyfriend walked out on them.> Even with their brain injury and impulse control issues they understand> what my cell phone is for. Uphold the sanctity of your personal space.>>>> 4) A practice with well trained activated patients will have an office> phone that primarily rings for scheduling office visits.>>>> 5) Dysfunctional behavior attracts others with dysfunctional behavior.> Clean up your act and set firm boundaries and the patients will be> respectful or...they leave and find another kindred dysfunctional soul> at ANOTHER office.>>>> You can make your office life whatever you want. You can be supportive,> empathetic and firm!>> Keep a running list of ANYTHING or ANYONE that gets under your skin and> problem solve your list weekly. Soon you will have nothing to put on> your list!>>>>>>>>

[Guest guest]

This 24/7 thing is a multiheaded beast. I have often felt like a

prostitute in the middle of the night getting called. They at least

get cash. I discount my price thru insurance, pay my pimp billing

agency a percentage and I am the one doing the work. I also have

a problem with no reimbursement for this service. It is a bundled

service. What bull. Regardless, it also can serve the patient ,

feed patients into the practice to fill the first appt slots in the

am for same day access and limit health care costs rather than have

everybody run to the ER. I am glad most of you have limited phone

calls. I have not been able to limit them as much as I would

like. It is still much better than working for a group. With a

group call system there was no respect for your time. I do

hospital and nursing home stuff. Patients in general are kind. The

staff at facilities are not. I do not have any answers for this.

Do others out their feel like a prostitute at times?

I am not sure what 24/7 realy means either.

Brent

> >

> >

> >

> >

> >

> >

> > Good advice generally, but I'm not sure I agree with #3. I do

agree in

> > general terms about keeping people from abusing/misusing

your " on call "

> > cell phone. However, to tell people right on your phone

message not to

> > call unless they are on their way to ED/UC could be

interpreted to mean

> > you are not providing 24/7 coverage to your patients, which is

required

> > by all insurance contracts. Also, I'd actually ask sort of the

> > opposite: why have them call if they feel like they are bad

enough to go

> > to the ED/UC? In that case, I would NOT want them to waste

time calling

> > me but rather go straight there & the staff can call me if

indicated.

> > Just a thought, but that part struck me as being a little too

much of a

> > barrier rather than " gentle persuasion " to change behavior.

> >

> >

> >

> >

> >

> >

> >

> > Re: PRACTICE TRANSFORMATION by

> > ACTIVATING patients

> >

> >

> >

> > Kathy, I will attach the handout below. Regarding your

specific issues

> > I would like to make a few comments.

> >

> >

> >

> > 1) If you start giving free advice (telephone medicine) you

will never

> > get off the phone and your income will plummet. You will also

start to

> > get irritated. You are a professional and you should charge

for your

> > services as all professionals do. A simple answer on the

phone will be

> > tempting in cases but folks always seem to have follow up

questions and

> > you will set the stage to be doing all your 99212 & 99213s by

phone.

> > Your patients will learn that they can call and not come in.--

> a

> > counterproductive behavior (female codependence?)

> >

> >

> >

> > 2) Activated patients come to visits prepared and do not need

to make

> > stray phone calls between appointments. We give them our

attention for

> > as long as they need during the office visit and they should

be prepared

> > to discuss refills, FU intervals, disease management at that

time.

> > Enforce this.

> >

> >

> >

> > 3) Patients should never ever bother you on your cell phone

unless they

> > are on their way to the ED/UC. If they are worried enough

that they

> > will consider disrupting THEIR plans to get in the car and be

seen

> > urgently/emergently then I want to know. Otherwise, if they

are not so

> > concerned that they plan NOT to interrupt their plans but can

still

> > interrupt YOUR PLANS with an unnecessary phone call then

something is

> > wrong with the picture. ---> Do not train your patients to

abuse you.

> > My phone message on my machine says you may notify Dr. Wible

on her cell

> > phone at 968-8510 if you are ON YOUR WAY TO THE ED/UC. Very

clear and

> > it is upheld by all patients even my traumatic brain injury

patients in

> > the middle of the night when they call in a total panic/frenzy

about not

> > being able to find their car keys or their boyfriend walked

out on them.

> > Even with their brain injury and impulse control issues they

understand

> > what my cell phone is for. Uphold the sanctity of your

personal space.

> >

> >

> >

> > 4) A practice with well trained activated patients will have

an office

> > phone that primarily rings for scheduling office visits.

> >

> >

> >

> > 5) Dysfunctional behavior attracts others with dysfunctional

behavior.

> > Clean up your act and set firm boundaries and the patients

will be

> > respectful or...they leave and find another kindred

dysfunctional soul

> > at ANOTHER office.

> >

> >

> >

> > You can make your office life whatever you want. You can be

supportive,

> > empathetic and firm!

> >

> > Keep a running list of ANYTHING or ANYONE that gets under your

skin and

> > problem solve your list weekly. Soon you will have nothing to

put on

> > your list!

> >

> >

> >

> >

> >

> >

> >

> >

[Guest guest]

I have been very pleasantly surprised by the few phone calls I have received

since going on my own last June. I have received three phone calls after 8 PM

in that time frame and rarely receive more than 1-2 calls on weekends.

I forward my office voicemail to my cell phone for after hours. When patients

call the office after hours, they have the choice of leaving a message for me

to get in the morning or connecting to my cell phone to get directly to me.

I think the reasons my after hours call volume has become so small are

several:

1. Patient population: I only take medicaid for those under 18, I do not

take any nursing home patients, and I do not admit to the hospital.

2. On my after hours policy, I state that after 8 PM,I turn off the

ringer on my cell phone and the message they leave on my voicemail WILL AWAKEN

ME and I will get back to them. (I truly think some patients think we sit up

alert, awaiting patients calls all night.) I think pointing out that I will

have to wake up puts those midnight calls into perspective.

3. Mutual respect policy: I do my very best to see my patients the day

they need to be seen and they then respect my personal/family time.

When I cover for another husband/wife solo team here, I suddenly get quite a

few more calls, almost all from nursing home patients.

I currently have about 900 active patient charts.

Hope this helps.

, M.D.

Durango, CO

On Fri, 03 Mar 2006 04:23:34 -0000

" brenthrabik " wrote:

> This 24/7 thing is a multiheaded beast. I have often felt like a

> prostitute in the middle of the night getting called. They at least

> get cash. I discount my price thru insurance, pay my pimp billing

> agency a percentage and I am the one doing the work. I also have

> a problem with no reimbursement for this service. It is a bundled

> service. What bull. Regardless, it also can serve the patient ,

> feed patients into the practice to fill the first appt slots in the

> am for same day access and limit health care costs rather than have

> everybody run to the ER. I am glad most of you have limited phone

> calls. I have not been able to limit them as much as I would

> like. It is still much better than working for a group. With a

> group call system there was no respect for your time. I do

> hospital and nursing home stuff. Patients in general are kind. The

> staff at facilities are not. I do not have any answers for this.

> Do others out their feel like a prostitute at times?

> I am not sure what 24/7 realy means either.

> Brent

>

> > >

> > >

> > >

> > >

> > >

> > >

> > > Good advice generally, but I'm not sure I agree with #3. I do

> agree in

> > > general terms about keeping people from abusing/misusing

> your " on call "

> > > cell phone. However, to tell people right on your phone

> message not to

> > > call unless they are on their way to ED/UC could be

> interpreted to mean

> > > you are not providing 24/7 coverage to your patients, which is

> required

> > > by all insurance contracts. Also, I'd actually ask sort of the

> > > opposite: why have them call if they feel like they are bad

> enough to go

> > > to the ED/UC? In that case, I would NOT want them to waste

> time calling

> > > me but rather go straight there & the staff can call me if

> indicated.

> > > Just a thought, but that part struck me as being a little too

> much of a

> > > barrier rather than " gentle persuasion " to change behavior.

> > >

> > >

> > >

> > >

> > >

> > >

> > >

> > > Re: PRACTICE TRANSFORMATION by

> > > ACTIVATING patients

> > >

> > >

> > >

> > > Kathy, I will attach the handout below. Regarding your

> specific issues

> > > I would like to make a few comments.

> > >

> > >

> > >

> > > 1) If you start giving free advice (telephone medicine) you

> will never

> > > get off the phone and your income will plummet. You will also

> start to

> > > get irritated. You are a professional and you should charge

> for your

> > > services as all professionals do. A simple answer on the

> phone will be

> > > tempting in cases but folks always seem to have follow up

> questions and

> > > you will set the stage to be doing all your 99212 & 99213s by

> phone.

> > > Your patients will learn that they can call and not come in.--

> > a

> > > counterproductive behavior (female codependence?)

> > >

> > >

> > >

> > > 2) Activated patients come to visits prepared and do not need

> to make

> > > stray phone calls between appointments. We give them our

> attention for

> > > as long as they need during the office visit and they should

> be prepared

> > > to discuss refills, FU intervals, disease management at that

> time.

> > > Enforce this.

> > >

> > >

> > >

> > > 3) Patients should never ever bother you on your cell phone

> unless they

> > > are on their way to the ED/UC. If they are worried enough

> that they

> > > will consider disrupting THEIR plans to get in the car and be

> seen

> > > urgently/emergently then I want to know. Otherwise, if they

> are not so

> > > concerned that they plan NOT to interrupt their plans but can

> still

> > > interrupt YOUR PLANS with an unnecessary phone call then

> something is

> > > wrong with the picture. ---> Do not train your patients to

> abuse you.

> > > My phone message on my machine says you may notify Dr. Wible

> on her cell

> > > phone at 968-8510 if you are ON YOUR WAY TO THE ED/UC. Very

> clear and

> > > it is upheld by all patients even my traumatic brain injury

> patients in

> > > the middle of the night when they call in a total panic/frenzy

> about not

> > > being able to find their car keys or their boyfriend walked

> out on them.

> > > Even with their brain injury and impulse control issues they

> understand

> > > what my cell phone is for. Uphold the sanctity of your

> personal space.

> > >

> > >

> > >

> > > 4) A practice with well trained activated patients will have

> an office

> > > phone that primarily rings for scheduling office visits.

> > >

> > >

> > >

> > > 5) Dysfunctional behavior attracts others with dysfunctional

> behavior.

> > > Clean up your act and set firm boundaries and the patients

> will be

> > > respectful or...they leave and find another kindred

> dysfunctional soul

> > > at ANOTHER office.

> > >

> > >

> > >

> > > You can make your office life whatever you want. You can be

> supportive,

> > > empathetic and firm!

> > >

> > > Keep a running list of ANYTHING or ANYONE that gets under your

> skin and

> > > problem solve your list weekly. Soon you will have nothing to

> put on

> > > your list!

> > >

> > >

> > >

> > >

> > >

> > >

> > >

> > >

[Guest guest]

There is no question the nursing homes & inpatient work is what is getting

you most of your calls. To me, those two arenas are just not worth the

extra income versus unit of time they consume. It's easy to look at those

on the surface & say: " Oh, I can bill for those 6 hospital pt's I see every

AM " , but that fails to take into account all of the extra calls, paperwork

(dictation, non use of EMR, etc), and increased liability (definitely more

likely to get sued on an inpatient vs outpatient). Not to mention all of

the drive time, etc. I was lucky in that in my practice setting I could

choose not to do inpatient and nursing homes, & boy am I ever glad about

that. My life would be infinitely more difficult if I had to do those.

Re: PRACTICE TRANSFORMATION by

> > ACTIVATING patients

> >

> >

> >

> > Kathy, I will attach the handout below. Regarding your

specific issues

> > I would like to make a few comments.

> >

> >

> >

> > 1) If you start giving free advice (telephone medicine) you

will never

> > get off the phone and your income will plummet. You will also

start to

> > get irritated. You are a professional and you should charge

for your

> > services as all professionals do. A simple answer on the

phone will be

> > tempting in cases but folks always seem to have follow up

questions and

> > you will set the stage to be doing all your 99212 & 99213s by

phone.

> > Your patients will learn that they can call and not come in.--

> a

> > counterproductive behavior (female codependence?)

> >

> >

> >

> > 2) Activated patients come to visits prepared and do not need

to make

> > stray phone calls between appointments. We give them our

attention for

> > as long as they need during the office visit and they should

be prepared

> > to discuss refills, FU intervals, disease management at that

time.

> > Enforce this.

> >

> >

> >

> > 3) Patients should never ever bother you on your cell phone

unless they

> > are on their way to the ED/UC. If they are worried enough

that they

> > will consider disrupting THEIR plans to get in the car and be

seen

> > urgently/emergently then I want to know. Otherwise, if they

are not so

> > concerned that they plan NOT to interrupt their plans but can

still

> > interrupt YOUR PLANS with an unnecessary phone call then

something is

> > wrong with the picture. ---> Do not train your patients to

abuse you.

> > My phone message on my machine says you may notify Dr. Wible

on her cell

> > phone at 968-8510 if you are ON YOUR WAY TO THE ED/UC. Very

clear and

> > it is upheld by all patients even my traumatic brain injury

patients in

> > the middle of the night when they call in a total panic/frenzy

about not

> > being able to find their car keys or their boyfriend walked

out on them.

> > Even with their brain injury and impulse control issues they

understand

> > what my cell phone is for. Uphold the sanctity of your

personal space.

> >

> >

> >

> > 4) A practice with well trained activated patients will have

an office

> > phone that primarily rings for scheduling office visits.

> >

> >

> >

> > 5) Dysfunctional behavior attracts others with dysfunctional

behavior.

> > Clean up your act and set firm boundaries and the patients

will be

> > respectful or...they leave and find another kindred

dysfunctional soul

> > at ANOTHER office.

> >

> >

> >

> > You can make your office life whatever you want. You can be

supportive,

> > empathetic and firm!

> >

> > Keep a running list of ANYTHING or ANYONE that gets under your

skin and

> > problem solve your list weekly. Soon you will have nothing to

put on

> > your list!

> >

> >

> >

> >

> >

> >

> >

> >

[Guest guest]

I agree, especially with #4. Your

practice style just will not be a good match for a certain % of patients &

they will need to be dismissed. I see the practice as being like a

garden: you have to grow it & nurture it so that it grows into something

sustainable. You can’t sell out for short term money gains at the

expense of the long term sustainability of the practice. If the schedule

starts to fill up with “trouble patients” and patients that are in

conflict with your practice style, things will progress into chaos, slowly but

surely. I dismiss pt’s fairly readily based on this premise. I

certainly don’t usually do it person though: too much potential for

further conflict & wasting more time in a no-win argument. I just

send the letter (ie, “you have 30 days to find . . . ).

Re:

WHAT SHOULD 24/7 ACCESS REALLY MEAN??

RE Open access and barriers to

care-- my opinion.

1) After having a

" traditional " barrier practice out of my control (ie hospital run)

for the last 8 years (6 years staff model HMO prior, and 2 years prior in a

private 3 person group), with a " call group " , etc, and the last 14

months of my own solo practice, I really believe in a " limited

barrier " practice.

2) Limited barrier-- I use an

answering service (person answers it), pts need to call this number

intentionally. If they call the office, they'll get a message to call

answering service if they need to talk with me.

3) I was using an EMR at point

of care for 40-60% of visits at hospital practice, and since about 1/2 of my

pts ended up seeing the PA, I was providing " discontinuity " of

care. Admittedly, fair amount of time, this was just plain out out of my

control-- I wanted to see the pts, but the " front desk " was offering

next appt, and not to me specifically. Plus in my state, the pt has to

see the doc every 3rd visit, so a disaster from the start.

Now I use the EMR for every visit,

and plan to use it even more as soon as I can. I encourage pts to call if

questions-- best source of hx is what pt tells at the visit. I ALWAYS

give pts enough med refills to next visit, and guess what! They miss the

follow up and call anyway! :-) Some we get into the " here's 30 days

and see me within " and then rarely, call in the " 2 weeks and you'll

need to be here or else. "

4) If you get into a power

struggle with pts, you need to consider dismissing the pt. You will NOT

WIN, so agree that your practice style is different from pt's needs.

You know who the pt is, decide and

dismiss if you cannot feel balanced on this. I do it in person, mostly,

and hand them a summarized list of my recommendations instead of the " 30

day dismissal " issue. Have them sign it, or have a staffer witness

the interview.

Some pts just are not

appropriate. Drug seekers move from practice to practice-- get old

records, or, if asking for narcs, insist on ID, driver's license copy.

Last one wouldn't even answer their cell phone after the first visit.

5) Look over the Advanced Open

Access articles in Family Practice Management by Murray and Tantua. If

you give ready access, and do as much as you can, time permitting, each visit,

you'll " catch up " most of the time. And have fewer after hours

calls.

6) Decide what you want to do

in your practice, and say NO to other things. I decided to continue NOT

seeing pts in the hospital. Tough choice in growing a practice, although

I was known in the community. But I don't mind being called after hours,

and looks like you're being overwhelmed.

Once had a pt ask me results of a BE

in a car wash. Now that's a barrier I really don't want to cross over

again!! :-)

Matt Levin, MD

Pittsburgh, PA

Re:

PRACTICE TRANSFORMATION by ACTIVATING patients

Kathy, I will attach the handout below. Regarding

your specific issues I would like to make a few comments.

1) If you start giving free advice (telephone

medicine) you will never get off the phone and your income will plummet. You

will also start to get irritated. You are a professional and you should charge

for your services as all professionals do. A simple answer on the phone

will be tempting in cases but folks always seem to have follow up questions and

you will set the stage to be doing all your 99212 & 99213s by phone. Your patients

will learn that they can call and not come in.--> a counterproductive

behavior (female codependence?)

2) Activated patients come to visits prepared and do

not need to make stray phone calls between appointments. We give them our

attention for as long as they need during the office visit and they should be

prepared to discuss refills, FU intervals, disease management at that

time. Enforce this.

3) Patients should never ever bother you on your cell

phone unless they are on their way to the ED/UC. If they are worried

enough that they will consider disrupting THEIR plans to get in the car and be

seen urgently/emergently then I want to know. Otherwise, if they are not

so concerned that they plan NOT to interrupt their plans but can still

interrupt YOUR PLANS with an unnecessary phone call then something is wrong

with the picture. ---> Do not train your patients to abuse you. My

phone message on my machine says you may notify Dr. Wible on her cell phone at

968-8510 if you are ON YOUR WAY TO THE ED/UC. Very clear and it is upheld

by all patients even my traumatic brain injury patients in the middle of the

night when they call in a total panic/frenzy about not being able to find their

car keys or their boyfriend walked out on them. Even with their brain injury

and impulse control issues they understand what my cell phone is for. Uphold

the sanctity of your personal space.

4) A practice with well trained activated patients

will have an office phone that primarily rings for scheduling office visits.

5) Dysfunctional behavior attracts others with

dysfunctional behavior. Clean up your act and set firm boundaries and the

patients will be respectful or...they leave and find another kindred

dysfunctional soul at ANOTHER office.

You can make your office life whatever you want. You

can be supportive, empathetic and firm!

Keep a running list of ANYTHING or ANYONE that gets

under your skin and problem solve your list weekly. Soon you will have nothing

to put on your list!