Pediatric Resident Training in Telephone Management: A Survey of Training Programs in the United States

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Pediatric

Resident

Training

in Telephone

Management:

A Survey

of Training

Programs

in

the United

States

Pamela

Runge

Wood,

MD

From the Department of Pediatrics, The University of Texas Health Science Center at San Antonio

ABSTRACT. Although practicing pediatricians spend a major portion of each day in the management of acute

illness via telephone, information concerning

instruc-tional programs in telephone management is scanty. A

34-item questionnaire was mailed to the 242 program

directors of US training programs to obtain information

on how telephone calls are handled in pediatric training programs and how pediatric house officers are trained in telephone management. Fifty-five percent of programs

have a formalized system for handling telephone calls.

One half of programs have a policy on who can answer

telephone calls; 1 1% stated that only physicians are

per-mitted to handle calls. Residents handle an average of 19 calls per day (39% of the total calls received). Only 51%

of programs document any telephone calls and only 19%

document all calls. Despite the volume of calls handled

by pediatric residents, only 45% of training programs

offer specific training in telephone management. The

most common instructional method is lecturing. Less

than one third of programs have a review system or periodically audit telephone calls. Programs that offer resident training in telephone management are signifi-cantly more likely to have a system for handling calls, to document calls, and to have a review system. Pediatrics 1986;77:822-825; telephone, resident, education.

Practicing pediatricians spend an estimated 27%

of total practice time’ and 6% to 12.5% of office

time2’3 in the management of acute illness via the

telephone. Pediatric house officers and practicing

pediatricians often fail to obtain important

histor-ical information by telephone,47 and this

made-Received for publication June 3, 1985; accepted Sept 6, 1985.

Presented in part, at the annual meeting of the American Pedi-atric Society/Society for Pediatric Research/Ambulatory

Pedi-atric Association, Washington, DC, May 9, 1985.

Reprint requests to (P.R.W.) Department of Pediatrics,

Univer-sity of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, TX 78284.

American Academy of Pediatrics.

quate telephone management may adversely affect

patient care.8

Information concerning instructional programs

in telephone management is scanty.9’2 Little

infor-mation is available on how telephone calls from

patients and parents are handled in pediatric

train-ing programs.’3 The purpose of this study was to

obtain information on how telephone calls are

han-died in pediatric training programs and how

pedi-atnic residents are trained in telephone

manage-ment.

METHODS

A 34-item questionnaire was mailed to the 242

program directors of accredited US pediatric

resi-dency training programs.’4 The questionnaire asked

how telephone calls are handled in each institution,

whether and how telephone calls are documented

and/or periodically reviewed, what role house

offi-cers play in answering telephone calls from patients

and their parents, and whether and how residents

are trained in the telephone management of

pedi-atnic problems. Two months following the original

mailing, a second questionnaire was sent to

nonre-sponders.

Information about the number of residents and

total outpatient visits per year for nonrespondent

programs was obtained from the 1983/1984

Direc-tory of Residency Training Programs.’4 Data anal-ysis was performed using the Statistical Package

for the Social Services (SPSS) on a DEC

System-2060 computer. Continuous variables were analyzed

using two-tailed Student’s t test and the

Mann-Whitney U test where appropriate. Categorical

van-iables were analyzed using

x2,

Fisher exact test, and

Wilcoxan signed ranks. Pearson’s correlation

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Handled by Different

Total Calls

Handled (%)

ARTICLES 823

RESULTS

Characteristics of the Training Programs

Of the programs surveyed, 151 (62%) responded.

Institutions received a mean of 52.2 (± 66.6 SD) calls per day with a range of one to 500 calls pen day. Nonresponding institutions differed from re-sponding institutions only in the fact that they had

fewer different hospital on clinic sites (mean = 1.5

± 0.8v 2.2 ± 1.8;P< .001).

Organizational Aspects

Fifty-five percent of programs stated that they

had a system for handling telephone calls from

patients. The most commonly used systems were

(1) a nurse handled telephone calls (21%) or (2) a physician was assigned to answer telephone calls (15%). Some other type of system was used by 19%

of programs. Several factors were associated with

an increased likelihood of having a system for

han-dung calls. Programs with a higher mean number

of phone calls per day, programs that provide house

staff training in telephone management, and pro-grams that document or formally review telephone

calls were significantly more likely to have a formal

system.

Although only one half of programs had a

for-malized system for dealing with all calls from

pa-tients, 78% of programs had a system for dealing

with calls about poisonings. Eighty-five percent of

programs stated that residents answer calls about poisonings or ingestions. Sixty-three percent of programs had poison control centers.

In most programs, a variety of personnel were

involved in handling calls (Table 1). Ofthe training

programs, 50% stated that they had a policy on who

can answer telephone calls. Only trained nursing

staff and physicians were permitted to answer calls

in 29% of programs; 11% of programs permitted

only physicians to handle calls from patients. An

additional 10% of programs placed other

nestnic-tions on who can answer calls.

Role of the Pediatric Resident

Pediatric residents answered telephone calls in

almost all of the training programs (96%). The

TABLE 1. Telephone Calls

Health Providers

Health Care Provider

Pediatric house officers 39

RNs 32

Faculty members 17

LVNs 5

Secretary only 4

Other 3

majority of programs involved pediatric residents

at all levels in this task, whereas 16% of programs

permitted only second and third year residents to

answer calls. Pediatric residents handled an average

of 19 calls per day (39% of total calls received). Residents answered calls in a variety of different

hospital areas including the emergency room,

walk-in clwalk-inics, pediatric wards, and continuity clinics.

Most programs (91%) placed no restrictions on the type of calls that were handled by residents. Calls

were restricted to those from continuity clinic

pa-tients only in 4% of programs.

Training programs used a variety of different

methods of referring calls to pediatric residents.

The majority of programs (53%) stated that calls

were handled by any available resident. A specific

resident was assigned to answer all calls during a

given time period in 21% of programs, and 19%

referred calls directly to the patient’s continuity

clinic physician or to a backup resident if necessary.

A variety of resources were used by pediatric

residents to assist them in answering calls from patients. Faculty consultation occurred in 79% of programs and was ranked as significantly more

important than any other resource. The second

most frequently mentioned resource was reference

books, such as pediatric textbooks (42% of

pro-grams). Written guidelines or protocols were most

commonly used for patients with specific illnesses

such as diabetes or seizure disorder (53%). Many

programs (25%) mentioned other resources

includ-ing the resident’s own knowledge and consultation with other residents.

House Staft Training in Telephone Management

Although pediatric residents answered telephone

calls in almost all of the training programs, only 45% of programs offered some sort of training for residents in telephone management of pediatric

problems. The most common instructional methods

were formal lectures (30% of all programs),

confer-ences (27%), and simulated patients (11%). A few

programs had developed elaborate systems for

pro-viding feedback to residents, such as individual

review or direct listening by faculty members (5%)

or audiotaping of calls for later review (3%). Many

programs made use of several different

instruc-tional methods. Most programs offering training

(74%) provided this training to residents at all

levels; 15% offered training only to residents at the

PL1 level. An average of 11 (± 40 SD) hours were

spent training residents in telephone management

in those programs that provided any training.

Pro-grams that offered specific training in telephone

management were much more likely to have a

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TABLE 2. Factors Associated With Telephone Management Training

Program Characteristics

.

Training Offered

(%)

No Training

Offered (%)

P Value

Have system for han- 69 42 .002

dling calls

Have policy on who can 67 37 .0005

answer calls

Documents calls 66 40 .002

Have review system 48 17 .0001

mal system for dealing with telephone calls, to have

a policy on who can answer telephone calls, to

document calls, and to have some sort of review

system (Table 2). The presence ofa specific

instruc-tional program was not related to the number of outpatient visits, the number of phone calls ne-ceived, or the number of residents.

Although less than half of programs offered spe-cific training in telephone management, 64% of programs provided some sort of training in com-munication on in interviewing techniques. An

av-enage of 18 (± 46 SD) hours was spent in this

activity. Lectures were the most frequently used instructional technique (44% of programs), fol-lowed by conferences (38%), videotaping (29%), simulated patients (13%), and other methods such

as direct observation and case discussions (20%). Less than one third of training programs (29%) had a review system on conducted periodic audits

of telephone calls. Review was usually conducted by faculty members.

Medical-Legal Aspects

Fifty-one percent of programs stated that they

documented some telephone calls and less than one

half of these documented all calls. Calls were more likely to be documented when advice was given or

if they involved an ingestion or poisoning. The most common methods of documentation were placing a note in the patient’s chart (57%), completing a standardized recording form (43%), recording in-formation in a logbook (26%), and audiotaping calls (4%).

DISCUSSION

Pediatric residents are actively involved in

tele-phone management of pediatric illness and can

expect to continue to spend a substantial portion

of their practice time in this activity. In addition,

their failure to obtain important historical infor-mation has been well-documented.4’5’78” Physician

performance may affect patient outcome in three

areas: health, satisfaction, and use of health

serv-ices. Preliminary data suggest that patients whose

calls are handled by residents, attending physicians,

and other emergency room personnel experience

greater morbidity than patients whose calls are

handled by trained health assistants using

proto-cols.8 In addition, maternal satisfaction correlates with physician interview skills.7 Caplan et al15 found that physicians are able to recognize only 16.6% of dissatisfied callers and that dissatisfied callers are much more likely to seek care in an emergency room. Residents caring for unfamiliar patients may fail to recognize parental expectations

and may have difficulty assessing the family’s

abil-ity to provide accurate historical information and to comply with recommendations.

Although both pediatric residents and practicing

pediatricians are responsible for handling a large number of calls from families, less than half of residency programs offer any specific training in

telephone management. When training is offered,

it often takes the form of formal lectures, which may not be the most effective technique for

devel-oping a specific set of performance skills. However,

informal training may occur to a greater extent than appreciated in that “faculty consultation” is

ranked as the most important resource for residents

in helping them to handle telephone calls.

Imme-diate feedback by faculty members may provide “on

the spot” instruction which is more difficult to quantitate.

A few programs have been successful in

imple-menting a more structured system for involving

residents in the handling of telephone calls. In one

training program, residents on call receive calls from pediatric group practice patients.’3 Such a

system offers residents a training experience that

is similar to that which they may encounter in

practice, facilitates documentation of calls, and

cre-ates the opportunity for faculty members to review calls and provide feedback to residents.

Most programs offer some type of training in

communication or interviewing techniques. It is not

known whether these techniques can be applied to

the specific situation of telephone encounters, when

the physician’s performance may be impaired by the lack of nonverbal cues and by an inability to

see or examine the sick child.

Information on the efficacy of various instruc-tional techniques is scanty. Most reports deal with the training of medical students and nonphysician

personnel.’#{176}”6”7 In one study, pediatric resident

performance, as measured by the percentage of standard questions asked of “parent simulators,” was unimproved following a single discussion

ses-sion.’1 In contrast, Evens and Curtis’2 describe a

program for family practice residents in which

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ARTICLES 825

simulators to teach telephone communication

skills. However, the method used to measure

pen-formance is not clearly described.

Despite recent concern about the potential

ha-bility issues surrounding the handling of telephone

encounters with patients,18’19 only one half of

pro-grams document calls, and less than one third of

programs have any sort of review system. However,

calls about poisonings or ingestions are handled in

a more systematic manner, which may reflect both

the proliferation of regional poison control centers

and concern about the potential legal implications

of handling these calls. In contrast to the lack of

documentation and review of phone calls, Hems et

al2#{176}found that 78% of pediatric residency programs

audit selected medical records. Inadequate

docu-mentation of telephone encounters severely limits

our ability to monitor resident performance and

may also render institutions more vulnerable to

litigation.

Because physician performance is not optimal

and performance affects patient outcome, greater

emphasis should be placed on training residents in

telephone management and on evaluating resident

performance. As a first step, training programs

must take a more active role in documenting

tele-phone encounters and in systematically reviewing

resident performance. Future studies should focus

on the development and evaluation of effective

teaching strategies in this important area.

SUMMARY

Although institutions responsible for training

pe-diatnic residents receive an average of 52 calls per

day concerning ill children, only 55% of training

programs have a formalized system for handling

calls and only one half have a policy on who is

permitted to handle calls. Similarly, only 51 % of

programs document any calls and only 19%

docu-ment all calls. Pediatric residents are responsible

for handling almost 40% of the total calls received.

Despite the volume of calls handled by pediatric

residents, only 45% of training programs offer

spe-cific training in this area and less than one third of

programs periodically audit calls. Programs that

offer resident training in telephone management

are significantly more likely to have a system for

handling calls, to document calls, and to have a

review system. The most commonly used

instruc-tional method, formal lectures, may not be the most

effective technique for improving performance

skills.

The development and evaluation of effective

teaching programs in telephone management has

been minimal despite the amount of time that

pe-diatnicians spend in this activity and the potential

effects of physician performance on patient

out-come. For both educational and medical-legal

rea-sons, residency training programs should attempt

to document telephone encounters and

systemati-cahly review resident performance. Institutions can

then identify potential problem areas and monitor

the effectiveness of teaching programs.

ACKNOWLEDGMENTS

This study was supported in part by an institutional research grant as part of the National Institutes of Health, Biomedical Research Support grant program.

Mr John Schoolfield performed the data analysis. The

manuscript was prepared by Ms Ann Harris.

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1986;77;822

Pediatrics

Pamela Runge Wood

Programs in the United States