Published in the November 2003 issue of Today’s Hospitalist
A family physician in rural Georgia sees a toddler with an unusual rash or a teenager with an uncommon set of symptoms. There is no one in the office to grab for a curbside consult. Time spent on the telephone or at the computer asking for advice, seeking a subspecialist and arranging a hospital admission, is time away from a waiting room full of other patients who need help. What is she going to do?
Enter “Doctor Direct,” a free telephone service set up more than 10 years ago by Scottish Rite Pediatric and Adolescent Consultants (SRPAC), the hospitalist group at Children’s Healthcare of Atlanta.
Any pediatrician, family practitioner, emergency room physician or supervised MLP in Georgia taking care of a child can call a toll-free number any time of the day or night, and the call will be answered by one of SRPAC’s seven hospitalists. There are no messages to leave or secretaries to navigate.
“You won’t find this anywhere else,” says Richard D. Kenney, MD, a founding member of the group. “There is no operator intervention. One doctor gets another doctor … directly. You call me, you get me. Sometimes that’s a real shock to doctors who call us for the first time.”
Less shocking is what a successful marketing mechanism Doctor Direct has been for the hospitalist group. Most of the calls come from office-based or emergency room physicians asking the SRPAC doctors to admit one of their patients. Another significant number are calls from primary care physicians asking the SRPAC general pediatricians either to recommend a subspecialist or to arrange a subspecialty referral directly so the office-based physician does not have to spend time doing it.
About 20% are calls asking the hospitalists for advice about a patient’s diagnosis or treatment or for reassurance that what they have done is correct.
“When we were thinking about putting this in place years ago,” Dr. Kenney explains, “we thought about how doctors interact. They either catch someone in the hall, or they have a close colleague they call and ask them what they think. Or they are troubled by a diagnosis or a finding.”
“Most primary care offices work on volume,” he adds. “If a doctor has to spend a lot of time on the phone trying to arrange a transfer or a referral and is hassled by everybody, he’s not going to call again.”
In 1992, when the SRPAC hospitalists were just getting their practice off the ground, they realized that they had a lot of work to do just to get pediatricians and family physicians across Georgia to realize they existed. Their hospital-Children’s Healthcare of Atlanta at Scottish Rite–was known for subspecialty care, not general pediatric care.
Before 1992, Dr. Kenney recalls, nonstaff physicians could not admit patients “efficiently, easily and welcomingly.” The latter point, he adds, was probably most critical in the minds of physicians in the community.
So Dr. Kenney and his colleagues, who are employed by the hospital system, went door to door, visiting about 1,400 physician offices around the state. As part of those visits, Dr. Kenney would explain that the doctors would carry a cell phone 24/7 to take calls from any physician who cares for children.
From January through October of this year, Doctor Direct has averaged a little more than 200 calls a month. (The phone rings significantly more often during the winter months than in the summer.) Hospitalists carry cards they use to log each call as it comes in, so staff can analyze how the service is being used. \
Although most calls are for an admission or a referral, the curbside consult aspect of Doctor Direct remains an indispensable part of the service.
“These are office-based doctors usually who use us as a second opinion,” Dr. Kenney explains. “A lot is reassurance. They say, ‘I want to make sure I’m not missing anything.’ Or they say, ‘I want to make sure you don’t think I should do something more.’ Most of the time, they are doing fine. We give them professional support.”
Because the phone service has been getting busier and busier with each passing year, SRPAC has had to institute a few changes. On some of the busiest days during the winter, the hospitalist answering the Doctor Direct cell phone was so busy answering calls that she barely had time to take care of her own admissions.
As a result, the SRPAC physicians just this year split the day in two shifts. And if the call volume is too much, the SRPAC physician charged with answering the phone that day has the option of passing it to a colleague.
And because the 800 number became known to pharmacies, nonphysician staff and even parents as a good way to reach a physician directly, other changes have been made. This year, after what Dr. Kenney describes as “a lot of soulsearching,” the group decided to triage the calls.
Callers now hear a message instructing physicians authorized to call Doctor Direct to “push 1.” Other callers are told to follow a series of prompts. Physicians who push 1 then reach the doctor with the phone, while all others are directed to various office and nursing staff.
The result, Dr. Kenney says, is many fewer calls from pharmacists–and no complaints from physicians.
Dr. Kenney says the Doctor Direct service’s main benefit is helping physicians in outlying offices navigate what can be a formidable subspecialty-oriented health care system. The hospitalists, in many ways, act as a broker, getting patients admitted easily or seen by subspecialists quickly.
“We help them get past office roadblocks,” he explains. “And it has paid off big in terms of referrals and admissions.”