Why patient follow-up calls might actually deserve your time
It’s 2:30 am, and I am taking a quick break in the call room after a busy start to the night shift in my small town ED. The nurse calls me out to see a 22-year-old male with abdominal pain. The patient has a history of 35 visits to our ED, including eight in this year alone. After an unremarkable work up including a CT scan, the patient is discharged home, moderately unhappy at not having gotten the pain medicine he requested. On his way out, he calls me, the nurses, and the hospital several colorful, unflattering names. Obviously, one of the last things I want to do is call this guy back and talk to him again.
So why am I even considering this?
Several years ago at an ACEP conference, I heard a speaker discuss the benefits of calling patients back the next day. Although I have read that this is the gold standard for patient follow up, I am not aware of any ED providers that actually do it. The idea intrigued me and stuck with me for years, but it always seemed unfeasible.
It’s never been hard to come up with reasons not to call patients back. Personally, I thought it would take too much time. But on a deeper level, I think that part of me was apprehensive about the whole idea. Perhaps I was afraid to hear that they were not doing well. Perhaps I did not want to find someone upset and angry. Or perhaps calling them to check in on them would be seen as an admission of my wrongdoing or insecurity. Still, I thought, if patients were not doing well, would it not be better to talk to them and find out? Have a chance to help them?
Our department already has a very limited follow-up call policy. Certain patients get a phone call from a nurse when they have time. Perhaps two to three call attempts are made a day, but many are unsuccessful due to non-functioning numbers.
As time passed, I found ample reasons to postpone making the calls. I was too busy. I had to study for boards. I always had a good excuse. But two-and-a-half years ago, I decided to give it a try.
I started by calling only select patients back the day after their visit. This lasted for about a month and then progressed to my current practice of calling every discharged patient back after every shift.
At the beginning of my shift I start a list of the patients I have seen, with their room number and diagnosis, to give me a quick reminder of who they are. Just before discharge, I ask for a good phone number. I have learned it is best to get two. Initially, I would make the calls in the afternoon before work, but I have found that I am able to make them at the beginning of my shift. Between seeing patients, looking through records of previous visits, entering orders, and documenting, I make my calls. The calls typically only take one to two minutes each. When I’m not at work, I make the calls from home. I have never had problems with patients abusing my phone number, and in over two years, only once or twice have patients called me back after several days to ask additional questions.
I usually start the calls with, “This is Dr. Jaffe from the ED last night. Is this (Patient Name)? I just wanted to call and check on how you are doing.” This typically results in one of three basic responses: the patient is feeling better, the same, or worse. My experience has been that about three fourths of the patients are better or much better. These are the quickest calls. I ask if they are taking their prescriptions and if they plan on following up as directed. I always ask if they have any questions.
In many cases, they express how much the call means to them. On a daily basis, I hear: “Wow! No one has ever done this before!”, “This really means a lot to me,” or, “I really appreciate you taking the time to do this.”
Honestly, it feels good to hear their genuine appreciation. If they are not better, I ask if they are the same or worse. At this point, using clinical judgment, I advise them to seek follow up either with their primary care doctor or specialist, or I advise them to return to the ED. Documentation of the calls is important, especially for those patients instructed to seek follow-up.
When I had finished my calls, I had a reassuring sense of relief and completion. I would think to myself, “Good, I didn’t miss anything this shift.” I soon started calling all discharged patients back, even the most problematic. Through this practice, I discovered that even the most difficult patients, those that appeared to be drug seeking, angry, or dissatisfied at the time of their visit, were often apologetic and pleasant the next day. It occurred to me that those patients that left unhappy, those that I least wanted to call, were perhaps the most important to call back. If they deteriorated or if something was missed initially, these patients could present a significant liability. Calling them back, in spite of the potential discomfort, gives me a second chance at helping the patient. Often, I am surprised at my success in repairing my relationships with difficult patients.
Initially, I started making the follow up calls in an effort to improve my patient satisfaction scores, and it worked. In fact, my overall scores have improved by about twenty percentile points. Yet as I continue to make these calls, my primary motivation is not to improve my scores, but to feel the appreciation of my patients.
As emergency medicine physicians, we see patient after patient and do our best to assess and treat them appropriately. We diagnose problems and prescribe treatments the best we can based on the information we have. Honestly, at times, I feel like I am forcing a square peg into a round hole. I’ll think: Was my diagnosis correct? Did the treatment work? Did my patient get better? Did they get worse? These are questions all EPs certainly ponder on a daily basis.
After many years of practicing emergency medicine, I have gotten somewhat used to these questions. But have we not all felt that blow to the gut when a colleague or staff member asks, “Remember that patient you saw the other day?” We often assume the worst, thinking to ourselves, “Oh shit, what happened? What did I miss?”
Following up does not remove the possibility of a bad outcome or the worry of one, but I do believe it significantly reduces both. I believe that patient after patient, shift after shift, and year after year, these doubts and vulnerabilities add up. Yet each time I finish making my calls, I get a sense of relief, the reassured feeling of knowing that I didn’t miss anything serious, that my patients are all okay. The ones that are not, I know that I have done all I can by instructing them to return to the ED. While I have heard the argument that making follow up calls can contribute to burnout, in my experience, the opposite is true! Making these calls actually counteracts burnout.
The effect of calling patients back has motivated me to continue this practice after each shift.
I am now expanding to call more people back; patients seen by the mid-levels, those that I pick up at change of shift, and those that are transferred out. When time allows, I even check in personally on some admitted patients. I also use the follow-up call as an opportunity to confirm that any questionable X-ray reading I have made is consistent with the radiology reading.
Patient feedback as a result of these calls helps me to gradually improve and refine my clinical practice. On occasion, I will talk to a patient the next day and they will need an antiemetic, something for pain, an antibiotic, or a work excuse that they did not get initially. I will help them as I am able, often obviating the need for another ED visit.
Knowing that I will talk to the patient the next day has helped me to better anticipate their needs. Generally, after a patient leaves the ER, we have little information regarding their outcome unless they get worse and return. Feedback is important in any learning situation, and I have discovered that these follow ups create an opportunity to gain valuable feedback on which practices work well and which may need to change.
After two-and-a-half years, I still look forward to completing my list of calls and the peace of mind that comes with it. These calls have become an indispensable part of my practice.
This brings us back to the twenty-two year old male who stormed out the night before. I call him and he answers. To my surprise, he is actually doing better and apologizes for his behavior. At his next ED visit, he now tells the nurse, “Dr. Jaffe is great—he even called me up at home the next day to see how I was doing.”
With the current focus on moving patients through the ED quickly, taking the time to connect with my patients and show them that I care has been a powerful choice. I have found this to be one of the few opportunities where mere minutes per patient can make a meaningful difference in creating a positive patient experience.
Try it for a month, and see if you and your patients don’t feel better.
My Callback Routine
- At the beginning of my shift I start a list of the patients I have seen, with their room number and diagnosis, to give me a quick reminder of who they are.
- Just before discharge, I ask for a good phone number. I have learned it is best to get two.
- I make the calls at the beginning of a shift, between seeing patients, looking through records of previous visits, entering orders, and documenting. When I’m not at work, I make the calls from home.
- The calls typically take one to two minutes each.