Wednesday, November 21, 2007

Let's play telephone

Ah, remember the silly games of childhood and how much fun this one was? With my little sister and friends, our 'telephone' conversation revolved around invitations for tea parties, dares, or the everlasting teasing about the boys who stole our pencils or chased us during recess.

I've recently discovered another game of 'telephone' . It's got a different name: telephone triage for oncology patients. While the sound quality I've experienced is undeniably better than that of a tin can, the kiddie game of 'telephone' is much more fun, I can guarantee you.

Telephone triage is more daunting for various reasons, like oh, say...liability. I don't even want to google telenursing and liability..As far as I'm concerned, at this point the less I know, the better. There's the issue of language barriers, such as that Chinese-speaking lady who speaks a little bit of English and refuses to use an interpreter so conversations are reduced to near comedy rivaling that of the movie 'Lost in Translation'.

One of my personal favorites is the patient with a talent for revisionism... like how when Mr. Jackson reports a fever of 101.7 F. He had chemotherapy a week ago and his latest labs indicate he is borderline neutropenic... so of course he's advised to immediately go to the hospital. Mr Jackson decides to make his story more interesting: "Oh, but I didn't really have a fever that high...the other thermometer said it was only 99 degrees, and that first one I used is broken..It's kind of a funny story, would you believe my dog ate it? Actually, I'm just really worried about my dog. Yeah, he's a dumb dog but he doesn't look to good right now."

Okay, okay. So their excuses are not quite that outrageous. But sometimes they're pretty darn close. Patients will sometimes do an awful heck of a lot to avoid actually following your advice once they call to ask for it and decide they're not fond of your instructions.

Meet the face of telehealth nursing, a rapidly growing facet of medical care: 25% of encounters between primary care physicians and patients involve its use. According to my trusty telephone triage for oncology nurses book, for every visit to the oncologist an average of 4 phone calls are made. For every physician who never incurs a malpractice lawsuit versus every physician who has been faced with a lawsuit, one study found an interesting correlation: the non-malpractice docs spent an average of 3.3 more minutes with patients and employed the use of a telephone triage nurse. (I would love to quote the study authors here, but unfortunately my book remains at my office cubby).

For some reason this little factoid about how extra physician time spent with patients really intrigued me and I resolved to try and be as open as I could in my conversations with patients...and to take my time. Keeping this idea in the forefront of my brain has already been extremely helpful, case in point...

(For the sake of the hallowed HIPAA, identifying characteristics have been thoughtfully removed)

Telephone Nurse calls to check up on Mr. Romano's pain per request of Dr. Chemo...Mr. R was recently prescribed additional oxycodone for increased mid-abdominal pain. He has early-stage hepatocellular cancer and underwent chemotherapy about a week ago.

TN: Hi Mr Romano, this is TN and I wanted to see how you're doing today. Dr. Chemo mentioned that you were having some problems with pain, and I wanted to see how your new medication was working for you.

Mr. R, rushed: Oh, very good, thank you. The medicine is working better, I no longer have that stabbing pain in my belly. I've had much less pain. Things are very good for me at the moment.

TN: I'm glad to hear that.

Mr. R, background noises: Hey, you know...I've even felt good enough to go back to work. This is my first time back in a while.

TN: Oh, that's great. What kind of work do you do?

Mr. R: Actually, I'm an aeronautical engineer and we're on a tight deadline today...(more muffled noises) I'm actually walking to the production warehouse right now. (stifled groan in background)

TN: I'm glad to hear that your pain has improved. I understand that you're busy, but I just have a few more questions. Are you still having regular BMs? Because the oxycodone can be constipating, plus you had chemo last week.

Mr. R: Oh yeah, I know...but I'm doing ok with that. Been regular so far, taking the stool softeners.

TN: Well, great! How have you been feeling overall since your chemotherapy?

Mr. R: Well, you know, pretty good. No nausea, appetite's been ok. I still got some hair (laughs). Mostly I'm just glad to be back at work.

TN: I'm glad to hear it sounds like things are going well for you. Before I get off the phone with you, do you have any questions for me or is there anything you're concerned about?"

Mr. R: My pain is actually gone....but you know, I have some pain in both legs. They're kinda tender, and it feels like my bones...are cracking...when I walk.

TN thinks to herself, oh we go, this is potentially a big problem.

*** END SCRIPT ***

Ok, just for the fun of it to revive the spirit of the telephone game, let's all take a guess at what is going on here, is it:

a) arthritis
b) dvt
c) he just doesn't like to walk
d) new bone lesions

Well, if you picked B you are absolutely correct. Mr R was assessed a bit more to find that he had no acute DVT symptoms and was advised to report to his large urban medical center PCP no later than tomorrow morning. (The conversation took place late in the business day) Lo and behold, unfortunately for Mr. R bilateral non-0cclusive DVTs were diagnosed.

Mr R was rushed while he was on the phone and even with the additional questions his potentially serious symptom was not mentioned. He was distracted, quite probably stressed by his work life and his discomfort...he was even currently performing the exact activity that was causing him distress.

For whatever reason(s) Mr. R did not relate to TN that he was having a serious new pain until the very end of the conversation. In the real conversation that took place, the initial mention of leg pain was much more subtle than that in the above script. Ah, the infinite wisdom of the open-ended question, courtesy of Nursing Communication 101.

With a few extra questions and an invitation for the sharing of concerns, the truth came out.

Just 3.3 extra minutes. A valid proposition to calculate.


Anonymous said...

Dude, I love talking on the phone...

I do customer service on the phone and I totally love messing with the peeps at the other end...

You should be like: Yo, Mr. R, go run outside for a while then smoke a J... that'll make you feel better ... :)

cool blog, btw, peace!

raecatherine said...

hey, do you mind identifying who you are mr anonymous? thanks for the funny comment. =) I think I'd go crazy if I did customer-service in a more traditional sense.

Jaime said...

I'll admit it, I was a telemarketer in high school at one point in my life, peddling newspaper subscriptions. The job didn't last long. It was without a doubt one of the worst experiences of my life lol.

Jen said...

Rae, I had to laugh when I read the "dog ate my thermometer" conversation...I have patients like that who say "Oh, but I'm not really that sick." Then, I have to say, "Well, it's YOUR body, but MY official recommendations is that you get YOUR body to the hospital!!" :)