Caller satisfaction.

Abstract

To the Editor.—The study by Lee et al1 regarding caller satisfaction with after-hours telephone service is provocative for several reasons despite its limitations. Telephone medicine is an integral part of pediatric practice and pediatric residency training programs. Likewise, practices struggle with the demands placed on them by such calls and have responded in a variety of ways, with most using alternative professionals to triage calls.Lee et al suggest that callers prefer direct pediatrician contact in contrast to experienced nurses. Although seemingly countercultural, it is worth considering. My experience as a practitioner and as a residency director suggests that while pediatricians in practice and in training find telephone medicine an onerous activity (and particularly unique in its volume to pediatrics) they probably quickly key on a patient’s problem. I believe that while populations of patients vary widely, a focused and rapid assessment is considered preferable to a complicated and well-intentioned discussion at 2 am.Unfortunately, this study fails to make the case that I believe is valid. As I have learned over time, faculty generalists are not the experienced practitioners in office care/telephone advice that busy community pediatricians are. Often their core contact with telephone medicine is as a teaching tool for pediatric residents in outpatient settings. Six thousand patients for 16 faculty is really a small number of potential encounters per doctor and, despite other academic duties, reflects only a modicum of attention to this area. The patients in these so-called practices are not a reflection of the diversity of many practices in income and education and thus again do not mirror “real” pediatrics. Finally, I am not sure as to how realistic the use of a “page” operator is who has other duties or a national triage nurse, which is different from the model that practices and managed care groups use.Nonetheless, this study is still powerful. In a highly educated population, for patients to prefer briefer calls, more delays, and some lost calls suggests the magnitude of the effect described would be significantly enhanced in a more general pediatric practice. One additional avenue of research would be to analyze the effect that continuity has on this variable. For those patients with true, personalized continuity, would that element override the question of “who” called back? Future research is desirable to support the author’s valuable conclusion and extend its potential relevance.In Reply.—Dr Bradford makes several valid points that we also addressed in our article. The study setting of an academic pediatric faculty practice that primarily cares for children of well-educated parents is in some ways different from most general pediatric practices. Although approximately half of the faculty have reduced clinical caseloads because of significant administrative responsibilities (division chief and residency director) or research activities, the other half spend 32 hours per week in clinical practice and see numbers of patients comparable to a busy private practice. The practice is otherwise similar to a pediatrics private practice; patients have continuity with their faculty physicians only and receive no care or telephone advice from pediatric residents.We agree that at times some physicians may perceive taking telephone call as an onerous responsibility, especially when taking calls for a large group of physicians. The fact that in the study setting a single physician is on call for all 16 faculty reduces the frequency of being on call but increases the number of calls per day. Many pediatricians in Southern California pay $12/call for a nurse advice service to reduce the number of after-hours calls they receive. This service was arranged by the local chapter of the American Academy of Pediatrics for its members in response to a demand by local pediatricians. It is similar to services provided by children’s hospitals throughout the United States.The page operators at the University of California at Los Angeles (UCLA) act as an answering service for the majority of the faculty. Patients of each clinical service, including pediatrics, are given special numbers to call that are identified to the operators as a patient call and routed to operators who specially handle these calls. In this respect, it is a little different than a traditional after-hours answering service.Before the study, we hypothesized that parents would have a preference for the detailed data-gathering of the nurses and the time they were willing to spend speaking with parents at all hours. We expected higher levels of parental satisfaction based on other reports of satisfaction with nurse advice services that we referenced and were surprised by the magnitude of parental preference for the brief telephone interactions with physicians.