24 7 access

“I can see you today and am available to you whenever you want and need.”

The medical literature is rich in studies that demonstrate the direct correlation between continuity of care and improved outcomes. Not only does it result in more satisfactory experience of those seeking care, studies have demonstrated reduced hospitalization, improved preventive care measures, and those providing health care express more satisfaction in their work.

So why would we create a system that breaks continuity? When we have failed to create a reasonable balance between work and life we reach for solutions. Quick fix solutions fail to address the systemic flaws and usually have unintended consequences that exacerbate the underlying problem and make the overall situation even worse.

24/7 access in the context of good work-life balance is possible if one understands the systemic issues. Several factors make up the foundation of access, continuity, and efficiency.

Factors that exacerbate the underlying problem:

Sharing call
Supply deficit during regular business hours
Overall supply/demand mismatch

Isn’t this burnout mode?

Not if you manage it right.

24/7 access means that those you serve feel that the typical barriers between them and you have been eliminated. The typical barriers include call groups (which also breaks continuity, leading to less effective and less satisfactory care), answering services. This is based on perceived scarcity. Peter Senge[1] and others discuss the concept they label the Tragedy of the Commons – people demand more of a scarce resource than they truly need. They do this because of the perception (or reality) of scarcity and the personal need to assure access to that resource. We see this in office practice systems: when we make access to clinical care difficult, we make it look like a scarce resource & people demand more – this becomes a vicious cycle. When we eliminate barriers to access we see the virtuous cycle of decreased demand.

24/7 does not mean working beyond your capacity. Burnout is based on working beyond your capacity, not on the attributes of access. In fact, improved access to you results in less unnecessary demand, improves continuity, and improves the work load.

How in the world does total access result in less work?

If you are thinking from the context of a typical practice, this may seem impossible. In typical systems we get used to fractured care, covering for other doctors and getting calls after hours from strangers.

1: Work load for strangers versus those we know:

We try to figure these folks out on the phone, laboriously asking questions to find out what the caller really needs, and try to document it all for the PCP. The work load of a stranger call is very much larger than for a patient you know.

2: Work load based on mutual respect:

When doctors take their own call and convince their patients that “I’m here for you whenever you want and need” the demonstration of respect is matched by patients. The experience of those taking their own call is that patients are extremely respectful.

3: Superb access from 9-5 M-F drives down evening and weekend access. The typical practice has a significant amount of after hours access driven by daytime access problems. Solve the daytime problems and reap the after hours decompression. I can offer all the after hours access in the world and do it easily when the demand is minimal.

What about the patient with the outrageous request at 2AM?

There are exceptions, but they are rare, and the exceptions are dealt with as exceptions. Rather than develop a policy that punishes all by erecting barriers that end up creating more work, work with the exception patient directly.

Take the 7PM call for a prescription refill as an example:

“Mr. S, could you call and leave me a message on my office machine for your refill? I’m sitting down to dinner and don’t have a pen handy.” The implication of having crossed an acceptable threshold is clear in that interaction and will modify the behavior of the majority of those who step outside the boundaries.

For those very rare individuals who continue to step outside the bounds, you should sit down with them and have a frank and honest discussion about the behavior. “Ms. J, you call me on my cell a lot in the evenings and on weekends. While you have important issues to discuss, I have a life outside of work as well. Please contact me during my regular work hours, let’s spend the time to meet your needs, but please reserve your after hours calls to those issues that truly cannot wait.”

When I make myself superbly accessible, patient demand for me increases as they realize they can come to me to fix problems that should be fixed elsewhere in the health care system. Why should I be the one? Am I not then enabling the dysfunctional system?

We do our best to deliver the best care for our patients. As primary care clinicians, our responsibility is to the whole person, and while our historic responsibility ended when they reached the door of the specialist, this is not optimal.

Specialists are good at their specialty. If a specialist acts outside their specialty, they run the risk of error for our patients. Because we treat the whole person it is natural and appropriate that we weigh in on anything that happens for our patients.

This does enable a dysfunctional system, but at the benefit of helping our patients. To get this out of pure enabling, our extra burden is to raise our hands and let the source of dysfunction know. Think about creating at the very least simple mechanisms of notification:

Fax a note to the specialist office:

“Dear Dr. Smith:

We just heard from Mrs. X that she should call us to set up the PT in follow up to the surgery you performed. She was unable to get through to your office to find out where you prefer your total knee patients to go, so she called us. We have arranged her PT. We believe that your choice of PT and guidance is one of the key components of appropriate post operative care. While we are always glad to assist our patients in their care, this work should naturally be done under your guidance. It would be best if your office created a seamless system of entry into PT for your post op knee patients.”

If I ever sent a note like this to a specialist, they would kill me.

I work with many specialist offices in my role with the Institute for Healthcare Improvement and in other improvement initiatives. I hear from surgeons all the time “I would never give my referring docs a hard time – they are the ones who refer! If they are not happy with me, I don’t get the cases I need.” Don’t underestimate your leverage! If they come back at you with heat they may not be the specialist for you and your patient.

If I cover the “whole person” for all their problems with other offices and the mishaps and hurdles in health care, I’ll never reach reasonable balance.

This is obviously a huge burden of work and I don’t mean that as of this moment you should accompany your patient to specialist appointments, follow them into the OR, etc. Judy and I are just exploring the foot hills of this issue in our practice as we struggle with the demand. I truly believe that the whole person responsibility does rest with us, but it is going to be a long time before we can cover more than a fraction.