The Way I See It

Call is a waste of time

For primary care physicians, being at the mercy of a pager is not only annoying, but accomplishes little, the author asserts.

By John Egerton, MD
FP/Friendswood, TX

I wouldn't be heartbroken if I never again had to answer the telephone in the middle of the night or hear that hideous beeping from my pager. I'll bet I'm not the only doctor who doesn't enjoy being on call.

Nobody expects to be treated within minutes of a phone call during a normal working day—not for a minor medical complaint, anyway. But somehow, after 6 pm on Friday, everything becomes an emergency.

On a recent Friday evening, I was paged while at a business meeting. The message read that the caller had had a sore throat for two days—something that could wait until the meeting was over. During the next hour, the same caller had me paged four more times. When I did get in touch with her, I suggested that she try to show a little more patience. "But I need a prescription," she replied.

The same weekend, another young woman called because she'd been stung by a wasp the day before. She left her pager number. I left my answering service number on her pager. It took several calls between the patient and the service to get a number at which I could reach her. When I called, I got an answering machine. The woman soon paged me once more, to say that she was sorry she missed me, but could I call her back right away? She was about to go out again.

The episode cost me time, a per-page fee, and probably several minutes of my life, because it increased my chance of succumbing to one of the stress-related illnesses I try to teach my patients to avoid.

Early Sunday morning, a different caller paged me because her son had had a rash since the previous day. Ten minutes later, the pager beeped with an addendum: The mother was really worried!

Later that day, I was paged by a woman who had a stuffy nose and thought she might get sick.

"Is this really an emergency?" I asked her.

"Certainly!" she said. "I'm a teacher, and I have to go to work tomorrow."

I remember the days before pagers, when being on call meant being unable to leave the telephone. Somehow, calls did seem to be more urgent then. Today, our mobility isn't as restricted, but that makes less serious calls seem even more intrusive.

Would it harm anyone if we didn't so diligently take call for hospital patients? Since I'm a primary care doctor, most of my hospital work now is social. Any patient who's really ill—and they're the only ones who get admitted these days—is under a specialist's care. It would be irresponsible for a primary care doctor to claim specialists' expertise in all the skills needed to care for hospitalized patients. But we have to be on call, anyway—and if we don't respond within 20 minutes, we're in big trouble.

Marcus Welby's image also lives on in the land of the pager. We primary care doctors are still supposed to dash around performing medical miracles—ready to get in up to the elbows in someone's ruptured abdominal aneurysm, deal with that suicidal teenager, check on those metabolic crises cooking in the ICU, and deliver a baby or two on the way home. We're sacrificing our coronary arteries to provide care that, compared to a specialist's, is second-rate! No wonder malpractice lawyers love us.

As for emergencies—real ones—those should be treated in the emergency room. Our area has an abundance of such facilities. But patients don't want to go unless I give them permission.

Sometimes, getting that permission wastes precious time. A teenage boy cut himself badly with a chain saw one day. Instead of going straight to the ER, his parents called me. I was already on the phone when the page came through. While they waited for me to return their call, the parents watched their son bleed. Fortunately, he survived.

One 42-year-old patient wasn't so lucky. He collapsed when he was playing tennis. His wife spent precious minutes trying to reach me before she called an ambulance. The patient died. Perhaps the extra minutes could have saved his life.

I also regularly get calls from patients who just want to tell me they're on the way to the hospital. And I get plenty from airheads: One wants antibiotics because he's catching a cold; another wants an appointment Monday morning and figures he'll get in earlier if he calls on a Sunday night.

It's not just patients making silly calls. I frequently get pages from the hospital staff asking whether it's okay to resume home meds for Ms. Jones or to follow the surgeon's recommendation to discharge Mrs. Smith, or even whether they could give Mr. Brown some acetaminophen.

Many calls from the ER are also less than urgent. Often they're just requests for authorization to treat a patient or notifications of an admission—bureaucratic requirements, no more. Sure, an admitting physician is needed, and if the patient has several ongoing problems rather than one primary diagnosis, it makes sense for the primary care doctor to fill out the forms. But usually paperwork is all that's necessary. I don't want to be on call for that.

I wonder at the rationale of being on call at all as a primary care doctor. On a typical weekend, I could be a hundred miles away from a telephone, and nobody would suffer. I could hire an extern to do my hands-on hospital work and a nurse to give telephone advice, and no one would even know I'm not around.

Call is unpleasant, it interrupts whatever I'm doing, it raises my blood pressure, and it wrecks my mood. It costs me money for an answering service, a paging service, and time for which I could find better use. And I don't earn a dime for a weekend on call: we don't charge patients for the time.

Being on call doesn't even make me feel useful. Instead, I feel used, because most people's weekend calls are matters of convenience, not medical urgency.

Thanks to call duty—and caller ID—at least one unstable person now knows my home phone number: a woman who returned from Las Vegas late on a Saturday night to find that her 17-year-old son's cough hadn't responded to the over-the-counter medicines he'd taken for a week. She wanted a prescription. I told her I couldn't suggest anything better than what he'd already tried, and that the boy should see his doctor on Monday. A few seconds later, the phone rang again. It was the same woman, angrily demanding that I write a prescription for her son—or else she'd report me to the hospital!

So next time the pager sounds, I'll realize that I don't have to drop everything to answer it. It shouldn't rule my life. In fact, while I'm writing this, the thing is beeping away. Let it wait.

On the other hand, it might be the hospital, or maybe a real emergency. I'd better check.

 

John Egerton. Call is a waste of time. Medical Economics 2000;9:91.