How do things like crisis calls and refills work when you are outpatient?

[nighthawk2551]

So my university residency program has a clinic where 3rd and 4th years practice. Medication refill calls and crisis calls are taken 24/7, however, after 5pm this phone service is run by the second years on call. We have talked about getting rid of this, but the underlying push-back we get is that the clinic is supposedly required to provide these services (e.g. 24/7 phone access). For one, I find it hard to believe that every clinic, and theoretically every private practice provider would need to provide 24/7 access for patients to call in. Is this true? My second question, is how is this handled in most non-residency affiliated clinics? One person in the group on call on a rotating schedule? Just provide info for crisis lines? No med refills after a certain time? How would this work for a single provider running their own private practice?

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[Merely]

It works by them calling and you having an automated message saying to go to the emergency department if needed. The scripts are filled during business hours. No need to be on call 24/7 that's just crazy..

 

[MedMan80]

Our resident/fellow clinic is also staffed by pager 24/7, I've read here that for PP the standard of care is having an after hours number for emergencies. Don't know what the legal requirements are though.

 

[nighthawk2551]

for PP the standard of care is having an after hours number for emergencies. Don't know what the legal requirements are though.

What does that mean though? A PP provider always needs to have their phone on them for crisis calls? I've heard this is often just verbal instructions to go to the ED or call a crisis line, which seems like something patients should already know (and be told in every clinic visit).

 

[Bartelby]

I have heard different things. For academic medical centers having overnight coverage as you describe is typical. Some PP psychiatrists give out their cell phone number to every patient, some have nothing but a voice message, some do pooled call coverage, some hire services to provide overnight coverage. There are a wide variety of solutions. Personally I think just a voicemail is questionable coverage, but I don't know of anyone getting in trouble for that (which doesn't mean it hasn't happened!).

 

[FlowRate]

It works by them calling and you having an automated message saying to go to the emergency department if needed. The scripts are filled during business hours. No need to be on call 24/7 that's just crazy..

There are plenty of posts on this forum, including in the psychiatry sub, as well as opinion pieces written by supposed experts, that claim you need to be available for pts 24/7. I don't know nearly enough about this to have an informed opinion in terms of legal risk of not being available. According to some old posts, it's partially based on standard of care in your area.

As for our residency program, one of our duties while on call is to take the odd outpatient page. Typically 1-2 per night in the evening, usually requesting a med refill.

 

[Merely]

There are plenty of posts on this forum, including in the psychiatry sub, as well as opinion pieces written by supposed experts, that claim you need to be available for pts 24/7. I don't know nearly enough about this to have an informed opinion in terms of legal risk of not being available. According to some old posts, it's partially based on standard of care in your area.

As for our residency program, one of our duties while on call is to take the odd outpatient page. Typically 1-2 per night in the evening, usually requesting a med refill.

Is the pcp available for his patients 24/7?

 

[FlowRate]

Is the pcp available for his patients 24/7?

Not necessarily direct cell access but presumably available via call center/triage.

 

[Armadillos]

Is the pcp available for his patients 24/7?

All mine have always been. There is a reason “take two aspirin and call me in the morning” is a common stereotype of what a doctor tells you when they aren’t worried.

 

[NickNaylor]

Our resident clinic does not gave 24/7 staff available - phone calls are managed by the front staff during normal business hours, after which they can leave a message. Patients do not have direct access to the residents unless the resident gives them direct contact information (I have no idea what would possess someone to do that, but some of my colleagues did) or if they utilize MyChart since we use Epic.

 

[Merely]

All mine have always been. There is a reason “take two aspirin and call me in the morning” is a common stereotype of what a doctor tells you when they aren’t worried.

You think that a family care doctor is available 24/7 for his patients so that if they have an issue at 8 pm they call him instead of going to the ER? What fantasy land are you from? If you have any issue whatsoever after hours you either go to the urgicare or the emergency department I have never seen a family doctor give their cell number to patients so they could call him at night..they are not paid nearly enough for that..and neither are you

 

[clausewitz2]

You think that a family care doctor is available 24/7 for his patients so that if they have an issue at 8 pm they call him instead of going to the ER? What fantasy land are you from? If you have any issue whatsoever after hours you either go to the urgicare or the emergency department I have never seen a family doctor give their cell number to patients so they could call him at night..they are not paid nearly enough for that..and neither are you

Very practice dependent. Some big group practices of my personal acquaintance definitely have someone on call for after hours/weekend issues. No, they're usually not seeing people in the office or anything like that at 3 AM on a Saturday but they might well be refilling a vital med or helping someone figure out if they need to go to the ED.

 

[FlowRate]

You think that a family care doctor is available 24/7 for his patients so that if they have an issue at 8 pm they call him instead of going to the ER? What fantasy land are you from? If you have any issue whatsoever after hours you either go to the urgicare or the emergency department I have never seen a family doctor give their cell number to patients so they could call him at night..they are not paid nearly enough for that..and neither are you

Outpatient positions take call for a reason, no?

Here's an old thread on the subject.

And here's an interesting, newer article.

 

[Armadillos]

You think that a family care doctor is available 24/7 for his patients so that if they have an issue at 8 pm they call him instead of going to the ER? What fantasy land are you from? If you have any issue whatsoever after hours you either go to the urgicare or the emergency department I have never seen a family doctor give their cell number to patients so they could call him at night..they are not paid nearly enough for that..and neither are you

Should have clarified I meant a doc in the practice, not necessarily your particular doc. We called my sisters FP practice at 2am for a asthma attack and the doc on call didn’t think it was bad enough to warrant an ER trip so managed at home and saw him in the morning.

 

[24blue8]

I havent seen a program that requires this. This sounds like concierge medicine or something.

Is someone else triaging this or any patient who calls after hours gets through to a resident??

I wouldn't feel comfortable doing this. Every time I'm on call I might be responsible for filling every other residents outpatient panel controlled substance scripts just because that's when the patient found time to call and ask? Patients think everything is an emergency. Someone realizing they're out of Ritalin at 10p isn't my emergency. The ED is different because I'm actually seeing and assessing the patient. Random blind fills over the phone at the patients convenience would stress me out.

Patients should take some responsibility in their care.

Edited to add: my program has an after hour triage service and attendings are on call. But med refills are not forwarded to them.

 

[birchswing]

Answering service flow chart:

"Is this a true medical emergency?"

No—>GET OFF THE PHONE; WE GOTTA KEEP THE LINES CLEAR FOR EMERGENCIES!

Yes—>GET OFF THE PHONE; YOU GOTTA CALL 911; THIS ISN'T FOR EMERGENCIES!

 

[Armadillos]

I havent seen a program that requires this. This sounds like concierge medicine or something.

Is someone else triaging this or any patient who calls after hours gets through to a resident??

I wouldn't feel comfortable doing this. Every time I'm on call I might be responsible for filling every other residents outpatient panel controlled substance scripts just because that's when the patient found time to call and ask? Patients think everything is an emergency. Someone realizing they're out of Ritalin at 10p isn't my emergency. The ED is different because I'm actually seeing and assessing the patient. Random blind fills over the phone at the patients convenience would stress me out.

Patients should take some responsibility in their care.

Edited to add: my program has an after hour triage service and attendings are on call. But med refills are not forwarded to them.

Just because you get a Med refill request at 10pm doesn’t mean your under any obligation to refill it unless there is a clinical reason something can’t wait till tomorrow.

 

[Ironspy]

Just because you get a Med refill request at 10pm doesn’t mean your under any obligation to refill it unless there is a clinical reason something can’t wait till tomorrow.

Our resident outpatient after hours service directs patients to call our psych ED which is staffed by residents and attendings 24/7. The psych ED doesn't refill meds but can direct patients to follow up during business hours or present for an admission ED evaluation. No one leaves our psych ED with a prescription. period. There's no psych med that needs to be emergently filled at 2 am and there are few (any?) pharmacies open at that time. Benzos are the only potentially fatal withdrawal and if someone is concerned about a benzo withdrawal they need to present for in person evaluation.

 

[FlowRate]

Just because you get a Med refill request at 10pm doesn’t mean your under any obligation to refill it unless there is a clinical reason something can’t wait till tomorrow.

Exactly. Most of our med refill calls end in "call your doctor in the morning."

BUT there are some that pretty much amount to some variation on "your doctor (always attendings) forgot to X", whether that's Rx the med at all or Rx the appropriate dose/amount which they otherwise documented in their note.

 

[nighthawk2551]

Answering service flow chart:

"Is this a true medical emergency?"

No—>GET OFF THE PHONE; WE GOTTA KEEP THE LINES CLEAR FOR EMERGENCIES!

Yes—>GET OFF THE PHONE; YOU GOTTA CALL 911; THIS ISN'T FOR EMERGENCIES!

This is the rationale our residents used when trying to get rid of the service. Calls are either a waste of time (ID patient just wanting to talk to someone) or a waste of time (situation is actually an emergency and they should be calling EMS/going to the hospital).

 

[MedMan80]

Its hard to do as a trainee, I've been called out for not giving a few day supply of a medication (not controlled) and was told, "maybe you should've given a few days". Again it depends on the practice mode, PP cash only, sure you can get a 10, 30 day refill as long as you're established in the clinic. CHMC/indigent clinic, 3 months since last appointment?, then no soup for you!

 

[ryerica22]

Its hard to do as a trainee, I've been called out for not giving a few day supply of a medication (not controlled) and was told, "maybe you should've given a few days". Again it depends on the practice mode, PP cash only, sure you can get a 10, 30 day refill as long as you're established in the clinic. CHMC/indigent clinic, 3 months since last appointment?, then no soup for you!

Why do you have different standards for the CHMC/indigent? Do you know how hard it can be for some of these patients to get to see you?

We had a receptionist take calls from 8-5PM. After 5PM, you can leave a message. if its an emergency, you go to the ER as per the recording.

 

[MedMan80]

Why do you have different standards for the CHMC/indigent? Do you know how hard it can be for some of these patients to get to see you?

We had a receptionist take calls from 8-5PM. After 5PM, you can leave a message. if its an emergency, you go to the ER as per the recording.

It's that patients have different standards/expectations, i think having some sort of answering service is minimum and anymore than that is for convenience sake that the patients pay for (cash PP)