The telephone is an essential tool in modern psychiatric practice, but there are potential liability risks associated with its use. Risk management strategies can be used to prevent and minimize these risks. The best risk management is always to promote effective, satisfying communication between patients and psychiatrists regardless of the means of communication.
Experience has shown that patient dissatisfaction and frustration may be the deciding factor in a patient’s decision to sue or file an administrative complaint. Long waits on "hold"; exasperating encounters with answering machines, answering services, or telephone menus; and other barriers that prevent patients from speaking with a human being have the potential to intensify existing dissatisfaction and frustration. Even if formal action is never taken, these types of experiences may cause some patients to seek care elsewhere.
• Do not let problem telephone practices work against the telephone’s inherent advantages and convenience.
Take the time to establish and maintain effective and user-friendly telephone policies and procedures. Consider the following risk management strategies to reduce the likelihood of patients’ irritation when communicating with you and your practice by telephone.
• Office staff should have specific instructions and training about handling calls.
Make sure that office staff know how to treat callers courteously and professionally, how to minimize the time callers spend on hold, and the types of calls that should be directed to you (or another clinician) immediately.
• Your answering service should meet the same high-quality service requirements that you expect of your office staff in handling and triaging calls.
Periodically call in to the answering service to find out how the operators respond to and manage calls.
• Periodically assess your telephone system and protocols.
• If you use an automated telephone system, review and approve of the messages placed on the answering machine.
Occasionally dial into your office, listen to the recording, and evaluate how it sounds to patients. Is it sending the intended message—both explicitly and implicitly?
• Avoid lengthy and confusing telephone menus.
Telephone menus that are long and complicated may confuse and frustrate patients. Listen to the menu and evaluate it. For example, how would a patient in crisis or an impaired patient perceive the menu choices? Consider having others evaluate your menu and give feedback.
• Answering machines are subject to malfunction, power failures, and so on. Check the operation of your system regularly and have a back-up plan.
• Avoid directions that require a patient to hang up and call another number.
Unfortunately, this is sometimes the only option available for calling an emergency number or for contacting a covering physician. In that case, make sure that the instructions are as clear and simple as possible.
• If at all possible, give callers the option to talk to a live person or to receive a prompt return call.
• Provide information about how often messages are checked and when callers can expect a response.
For example, if a patient calls on Friday afternoon, can the patient expect a call back that day or will he or she need to wait until Monday? This type of information allows patients to make decisions about what alternative actions they may need to take.
• Make sure patients can access after-hours coverage, when necessary.
You can use either a mechanical answering system or an answering service. A mechanical system can instruct callers about how to contact the covering psychiatrist or automatically page him or her when messages are left. Any system in which you have to check messages every few hours around the clock is unrealistic and, probably, unsatisfactory.
Section 1-AA of the APA’s "Opinions of the Ethics Committee on the Principles of Medical Ethics, With Annotations Especially Applicable to Psychiatry" (2001 ed.) provides the following:
Question: One of our members is concerned that psychiatrists in this area do not routinely check in with their answering machines after hours, leave no number where they may be reached, or leave a message for patients to contact the local emergency room in case of emergency.
Answer: Is this member’s concern about the ethics of these psychiatrists warranted? Yes. Ethical psychiatrists are obliged to render competent care to their patients. That competent care would include either being available for emergencies at all times or making appropriate arrangements. Certainly, a message telling patients to call an emergency room is not adequate coverage. Even in rather stable practices, including analytic practices with relatively stable patients, emergencies do arise. Care must be taken that, if and when such emergencies do arise, the patient is not abandoned (September 1993).
• Carefully consider what information/directions will be provided for patients who have an emergency.
It seems obvious, but with an automated system, it is important to provide instructions that are as clear and straightforward as possible for patients who are in crisis or experiencing an emergency situation.
• Carefully consider how patients with an urgent, but not an emergency, situation should be directed.
Sometimes a patient may be unsure about whether his or her particular situation constitutes an emergency and, thus, may be hesitant to go to a hospital emergency department or call 911. This may cause a delay in necessary treatment. In contrast, patients who do not have an urgent or emergency situation sometimes misuse the emergency contact procedure because they want immediate access to the psychiatrist. These types of problems can be reduced, although never eliminated, through patient education. Include information about what to do in an emergency in written information or office brochures for patients. Some practices include emergency procedures in the "Consent to Treatment" forms signed by patients. A discussion about what to do if the patient is experiencing a crisis or an emergency should be part of the ongoing communication between the patient and psychiatrist. Re-evaluate your answering system if patients continue to misuse emergency numbers and procedures when there is no emergency. They could be telling you they are frustrated in their attempts to reach you through regular telephone calls to your office, answering service, or automated answering system. ▪
Ms. Melonas is vice president of risk management for Professional Risk Management Services Inc., the manager of the Psychiatrists’ Program, the APA-endorsed professional liability insurance program.