Ambulatory Obstetrical Care

The telephone call is a major means by which obstetrician/gynecologists provide care to their patients,1-3 and telephone calls account for approximately 20% (Fig. 1) of all encounters between obstetrician/gynecologists and their patients.2 Of these patient encounters, 70% of the calls are managed by the telephone alone.4 With a greater emphasis on ambulatory services by managed care plans to reduce health care costs5-7 and the shift in reimbursement from fee for service to capitation, the telephone will play an even greater role in patient care.FIG. 1: 2). Fam Pract, family practice; Ob/Gyn, obstetrics/gynecology; Int Med, internal medicine; Peds, pediatrics.The contemporary practice of obstetrics/gynecology has witnessed a shift to ambulatory women's health care services. During the past several years, and as reflected in this symposium, management of diabetes8; outpatient preterm labor detection9; follow-up care of patients with placenta previa,10 preeclampsia,11 or pyelonephritis12; and ambulatory surgical procedures, such as hysteroscopy13 and laparoscopy,14 have become a major component of outpatient care. For these reasons, the telephone will be used with increased frequency during the next several years. Unfortunately, this shift from inpatient to outpatient services comes at a time when telephone medicine is not considered reimbursable and is considered a component of a physician's fee for service. One study has shown these calls last on average of 4.3 minutes, and few calls are considered urgent.2 For example, if an obstetrician/gynecologist handles 10 calls per day, he or she will not receive reimbursement for approximately 45 minutes of work. Although 90% of these calls are from regular patients,2 calls from patients unknown to the physician last even longer and frequently require some form of physician intervention.2 For the practicing obstetricians/gynecologists in the study (Fig. 2), the primary focus of the patient's telephone complaint varied, but most were related to an obstetric or gynecologic problem.2 Although these telephone contacts resulted in primarily (Fig. 3) advice and directions, more than half required an office visit or a medical referral.2 On closer scrutiny, patients who called between 11:00 PM and 7:00 AM had an emergent or serious problem more than 70% of the time.15FIG. 2: The patient's primary problem area when contacting her obstetrician/gynecologist (used with permission from reference 2). CIRC, circulatory; RESP, respiratory; GI, gastrointestinal; OB/GYN, obstetrical or gynecologic.FIG. 3: The physician's action in response to a patient's telephone contact (used with permission from reference 2). Several patients had more than one action, so the percentages exceed 100%.With the increases in telephone use, the potential for telephone liability also will increase because there are major deficiencies in the quality of telephone medicine. Although it is believed that 80% of diagnoses can be achieved on the basis of history alone, and that physical examination and laboratory studies are merely confirmatory, the primary issue is the lack of a physical examination. In addition, telephone histories tend to be rushed and not as systematic as office or hospital evaluations. As a consequence, there is a greater potential for liability. In the ambulatory care setting, negligence frequently arises because of the acts of the obstetrician/gynecologist's employees. Clerical personnel have been found to provide medical advice in 1 of 10 telephone contacts, and 56% of nursing staff failed to establish a chief complaint or ask questions of the patient caller.1,16 As a consequence, the advisor has received insufficient information to make an appropriate treatment decision or is limited to only the history taking aspect of the clinical evaluation. Thus, this article explains the liability risks associated with the telephone and offers steps to reduce the obstetrician/gynecologist's telephone liability risks. Finally, this article is intended to be used solely for educational purposes and is not designed to provide legal advice.