Your on-call doctor probably didn't receive training in telephone medicine

Physicians spend a lot of time counseling patients on the phone. Often, these conversations occur at night with patients we have never met before. When I am on-call in the evenings or on the weekends, these are some typical phone calls I receive from patients I have never met.

I have a very bad stomach ache for the last hour.
I started having rectal bleeding an hour ago.
My wife tells me that my eyes are yellow.
My chest is hurting. It feels different from my usual heartburn.

How do we manage patients with issues like those above? We get hundreds of calls like this every year. Do we send every patient to the emergency room just to play it safe? Do we tell them to hang in there and to call their regular doctor when office hours open? How can we be sure that a simple stomach ache isn’t the first warning of appendicitis or some other severe abdominal condition?

Phone medicine relies on an entirely different skill set than physicians use in the office or in the hospital. Consider these obstacles:

We often don’t know the patient. The doctor who does know him may readily recognize that the complaint is benign.
On a phone call, we cannot read body language to gauge a patient’s level of distress. Seasoned physicians get a gestalt feeling about a patient’s intensity of illness from simple observation.
There is no opportunity to perform a physical examination.
Prior medical records may not be available, although many electronic medical record systems to do permit remote access.

During my three years of internal medicine training and my two years of gastroenterology fellowship, I received not a whit of training in phone medicine. This was a gaping oversight in medical education considering how important these skills are to practicing physicians. I use them every day. I confess that during my first several months on the job, there were many anxious moments for me as I fielded phone calls from anxious and sick patients. It would have been easier had my educators given me a few pointers.

Understandably, patients who are calling physicians off hours are not aware of the handicaps that these doctors face. Patients often seem to feel that even on a phone call, we somehow have our full toolboxes available and can make diagnoses or prescribe treatments. Consider the following scenarios: