"Just the facts, ma'am." No doubt you've been tempted to use that Dragnet line on patients who can't seem to get to the point. But alas, the strictures of bedside manner and professionalism prevent you from interrogating them like a hard-nosed TV detective. "As much as as I'd like to act like Sgt Joe Friday with some patients, I found there's a better way," explains a veteran Regina solo FP. "Training my non-clinical staff to do some rudimentary pre-interviewing and triaging has really helped me cut to the chase with patients."

Of course, having a nurse screen your patients is the easiest fix, but that's not an economically viable solution for many practices. It makes more sense for many clinics to maximize use of existing staff. Our doc in Regina made sure that anyone who answers a telephone or works in reception (even just to fill in) knows his very basic triage and information gathering procedure.

PLAYING TELEPHONE
Before he decided to draft a new policy on fielding telephone calls, he was thoroughly unhappy with the way things were going. The squeaky wheels always seemed to get the grease in the form of quicker access to his exam room, while sicker, but less pushy patients often had to wait longer. He was scandalized, for example, when a very obviously sick elderly woman who presented with hypoxemia was left waiting while a mewling mamma's boy with shin splints got bumped to the front of the queue.

The proactive doc set about surveying people on how to create a better policy. He was lucky to count some great businessmen among his longtime patients. One let him know that the receptionist was alternately terse and frantic on the telephone, but nice in person. From that he decided that after four rings, calls should be re-routed to the filing clerk in the back office, to take the heat off the receptionist. A couple of other patients told him that the people working at the answering service that picked up his overflow were rude and incompetent. He figured out that he didn't actually get that much overflow, and it was almost all occurring on Mondays. He put in some calls to colleagues and asked if they could recommend any recently-retired receptionists. Someone gave him the number of a woman who was glad to work only Mondays. She ended up being a woman of immense sense and a great teacher to other staffers.

Next the doctor grilled his staff. He asked for their frank opinions on what they thought he could do. Their overwhelming sentiment could be summed up in two words "better communication." The only feedback they ever got was negative. And some of his orders were contradictory: he complained about lag time between patients but told them he wanted patients "primed" and pre-questioned. During this process he learned a great deal about how much of a pressure cooker the front office was. Afterwards he and his staff agreed to work together to draft a clear and consistent protocol, including telephone triage guidelines and a waiting room questionnaire. (For group practices it's essential that all the physicians work together to create a system of telephone answering and patient pre-interviewing that works well for each doctor's style of practice).

TELEPHONE TRIAGE
A receptionist needn't conduct a long interview when he or she gets a patient phone call to get the important stuff on paper. They'll need to take down if it's an emergency and what are the symptoms. They should also be trained to recognize alarming symptoms that may be more urgent or life-threatening than patients themselves might realize — like chest pains and asthma flare-ups. You should give them a list of symptoms and conditions that are serious enough to warrant interrupting you while you're with another patient.

At the same time it's important that these staffers don't overextend themselves. They're not clinicians and should never offer medical advice to patients. If a caller panics, the receptionist's top priority should be to empathize and reassure them that they'll see a doctor shortly. They've done a great job if they've managed to calm a distressed patient and and take down the major symptoms.

A LIVING DOCUMENT
Give your new guidelines a few months of real-world testing and then go back and ask your patients, your staffers and yourself if the system is working well. After making the necessary tweaks you'll be on your way towards having your practice function like a well-oiled machine. What's more, your staffers will be glad you took their concerns into consideration and encouraged teamwork (they may even find that probing patients on the telephone makes their job more interesting and less monotonous). Your patients will be happy because they'll likely see you more quickly and spend more quality time with you once efficiency bottlenecks are cleared. Lastly, your bottom line surely won't suffer any adverse reactions if you see more patients during your regular office hours.

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