Managing patient inquiries after hours

By Emily Margosian, Assistant Editor, May 1, 2022

DermWorld talks to Jennifer Goldwasser, MD, FAAD, from Goldwasser Dermatology in Hartsdale, New York, about how to manage after-hours patient communications while maintaining a good work-life balance.

DermWorld: Tell us about your practice.

Dr. Goldwasser: I think my practice is a bit unusual. I started out solo in 1994, spent time in two group practices, and then reopened as a solo practitioner in 2019. To make it work as a solo practitioner and still provide unhurried care, I do not participate in insurance networks and participate with Medicare as a non-accepting provider. That makes my practice a little different. It’s a community practice, and many of my patients have been with me through these past 28 years. I have longevity with my patients, and I have multi-generational involvement with my patients. It’s a very high-touch practice because people are paying at the time of service. I have to provide patient-centered care, and patients expect to be able to reach me. It’s not what I would call a concierge practice, but it’s similar in that I try to be highly accessible.

Dr. Goldwasser: I use a telehealth platform that allows patients to call, text, fax, email, and securely message me with photos. We still have a landline at the office, of course. If the patient calls the landline, and we’re not there, they are directed to either leave a message, or if their message is urgent, they are directed to both leave a message on my landline voicemail and call the telehealth number — what we call our after-hours number. That number is not my cell phone number, but if they mark their message as urgent, I will get a text message on my cell phone notifying me.

DermWorld: How do you prioritize the urgency of an after-hours request from a patient?

Dr. Goldwasser: I’m essentially leaving that prioritizing up to the patients. Which I think is kind of ideal for them, because — and I’m sure most dermatologists would agree with this — so many calls are not actually urgent, but the patient may perceive that there’s urgency. I feel that I’d rather field a non-urgent call after hours than miss an actual emergency.

DermWorld: Do you bill patients for after-hours communication?

Dr. Goldwasser: That’s highly variable. I don’t charge for a text answer, and I don’t charge for an email answer. However, if somebody is contacting me about something that requires a visit, we are either going to create a virtual visit or an in-person visit. Most of the time, when a patient contacts me by email or text, it’s with just a few finite questions that I’m going to answer.

DermWorld: Do you track patients who are high utilizers of your after-hours number?

Dr. Goldwasser: I have a good memory, and I’ve known most of these people for decades. I know who the misusers are. There are certainly a handful of patients in every practice who think everything is urgent, and we learn who those people are pretty quickly. Often those people have high anxiety, and I call them my ‘nervous nellies.’ That’s the endearing term we use for them in the office so my staff understands that these calls are not malicious or abusive. These calls are because somebody’s suffering, and they may be suffering with anxiety. It’s helpful, in my view, to have continuity of care because we get to know people, and when we understand people and where they’re coming from, it’s much easier to deal with them in a compassionate way.

DermWorld: Medication refills are a common after-hours request. How does your practice handle these types of requests?

Dr. Goldwasser: If a patient calls after hours and marks their message as urgent, if it’s appropriate, I will do everything I can to refill their medicine promptly. However, I try to preempt those calls. They’re very predictable in my experience. For instance, it happens commonly when people have cold sores; they need their anti-viral medication and they’ve run out. They know that if they’re going to treat their cold sore, they need to do it promptly, so they panic. I try to preempt that when I give the initial prescription by giving a quantity that is sufficient, making sure they have refills, and encouraging them to refill their prescription before they have zero pills left. I think that patient education at the point of service is critically important. If we can preempt those emergency calls at the point of service, it’s so much better for everybody.

DermWorld: What prompted you to establish this after-hours communication system?

Dr. Goldwasser: I’ve been doing this a long time and I’ve tried all the different options. When I first started out, doctors still carried pagers. In a way it was good, because I used to have a message on my answering machine that said if this is urgent, you can page Dr. Goldwasser. I think that gave people pause because they understood that when you paged your doctor, it had some significance. When cell phones became available and pagers fell by the wayside, I did leave my personal cell phone number on my outgoing voicemail message. Obviously, it’s not ideal for patients to have your personal number.

When I joined a group practice, there was an answering service. I found that the answering services were almost never ideal. It presents a barrier, and there is a lot of room for problems when you have a third party involved. It introduces a whole new level of human error. When I opened my office in 2019, I decided I didn’t want to use an answering service and started investigating other options. The telehealth platform I use provided me with an ideal option because I can still use my answering machine. We’ve eliminated the expense of an answering service, and we’ve also eliminated that human element of a third-party operator trying to triage what I should and should not be contacted for. I personally feel better with the patient making the decision of whether their problem is urgent or not.

DermWorld: How have patients responded?

Dr. Goldwasser: Generally, people love being able to email, text, fax, call, and urgently call. From a patient standpoint, this is an idyllic situation because most of the time if you’re calling a large group, you’re getting an automated response with a menu system. I think most patients are really fed up with waiting for someone to pick up the phone. It is a bit more challenging for my older patients who aren’t tech savvy. I still have patients who don’t text; I even have some patients who don’t use email. So obviously for them, this is not so great. But those people are fewer and further between as time goes by. Generally, it’s been great for patients. Accessibility is an important thing for patients, because as I explain to my staff all the time, the entire role of a doctor is to be there when the patient perceives a need. Sometimes the perception is off, but I’d rather err on the side of over-responding than under-responding because I feel that routinely diverting patients to urgent care centers or emergency rooms after hours is not ideal for patient care.

DermWorld: How do you maintain a good work-life balance while maintaining prompt communication with patients?

Dr. Goldwasser: I’ll say this: I think that texting offers many advantages over phone calls. They’re faster; they’re less intrusive. There’s less room for ambiguity because everything’s written down. They basically auto-document themselves. You have to document a phone call somehow, but you don’t have to document to text. It’s there. The best thing about it is you don’t have to worry about phone tag. It doesn’t have to happen in real time. I can send a text message to a patient and say, "please reply." Two hours later, they send a reply, and I know the message was received. In many ways, I think texting has improved my work-life balance. For the small minority of patients for whom overuse is a problem, we have to set boundaries. We have to recognize where it’s coming from and protect ourselves a little bit by scheduling a visit with them. That way, they feel like they’ve been heard, and I feel like I’ve been compensated.

The other thing I wanted to communicate, maybe for the younger dermatologists, is that burnout doesn’t happen because of how many hours we spend working. It happens when there’s no meaning to our work. At least for me, when I provide patients with accessibility, I feel like I am rewarded with patient loyalty and gratitude. That, for me, helps to keep the burnout at bay.

Jennifer Goldwasser, MD, FAAD, is in private practice in Hartsdale, New York.

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