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One of the questions we've been asking ourselves now, in this constantly connected 21st century world, is how to deal with continual access through answering services, the patient portal, cellphones, emails, and texting.

Many years ago, when a doctor's office closed, that was pretty much it. Phones used to be answered with a recording, "The doctor's office is closed. If this is a medical emergency, please hang up and dial 911 or go to the nearest emergency room." Eventually, doctors' offices started using answering services, where the telephone lines after normal business hours would roll over to some operators sitting in the basement of a building somewhere, who then paged the on-call doctor, who was sometimes a member of the practice sharing overnight call and sometimes a moonlighter being paid to cover the practice at night.

Before shared electronic medical records, most of these doctors wouldn't have access to your office visit notes, your problem list, or your medications -- and most likely not your recent blood test results -- and thus had a limited ability to do much in terms of interventions. Hence the origin of the phrase, "Take two aspirin and call me in the morning."

Doing What We Can

Often, given the limits of what we can glean through a telephone call, we can dispense some sage medical advice, call in a prescription for something like an analgesic or an antibiotic, review some warning symptoms that a patient should watch for, and tell them to call back or go to their local emergency room or urgent care center if things worsen. Over and over again we've seen these things written out in documentation of phone calls: "Patient was advised to call 911 immediately if they experience any chest pain, shortness of breath, abdominal pain, headaches, fevers, chills, or other worrisome symptoms."

And these days, without calling the practice, patients also can send a medical question to the doctor anytime through the portal, often ignoring any written notices posted there about not using this method for emergencies, or for issues requiring urgent intervention.

Much has been written lately about the excessive burden of this increased and incessant availability. In the modern iteration that we have now, doctors are more connected to their practices, with messages popping up on their phones or even their smart watches, telling them late at night that a patient's labs are back with critical findings, or that some other provider wants to speak to them about a patient of theirs. Some patients are even able to directly reach their provider through the portal/email/texts during off hours.

Unfortunately, many of us are logging onto our electronic medical records late in the evening, often to complete documentation from a busy practice session and get through the older messages sitting there in our in-baskets, and many of us see the ongoing influx of messages from patients and feel compelled to deal with them right then and there.

The Right Care -- At the Right Time

Access to care -- the right care at the right time -- is a critical part of successful healthcare. Our patients shouldn't be waiting if they need care, but we also have to make sure we set some limits. That doesn't mean setting up roadblocks, but it does mean not always making it so incredibly easy for anybody to get in touch with all of us all of the time. There's a delicate balance between appropriate access and too much access.

On the overnight calls I've taken recently, I've often been paged about chronic issues, things that somebody wants to discuss with their doctor (any doctor?) and they just didn't feel like waiting until the next day. Months of fatigue, years of insomnia, a rash that has persisted for weeks -- these are definitely not problems the on-call doctor is going to fix at 2 a.m. Or they list a vague set of non-specific symptoms, followed by a request for us to reassure them that this is nothing bad.

Sometimes patients have already done a Google search of their symptoms, and given how this almost always includes impending death or cancer or something equally terrible that's likely going to kill or maim them immediately, things that people used to just wait out and see how it goes are now something they feel compelled to call the doctor about and get a definitive answer to, no matter the hour, no matter who they are waking up and how unreasonable this expectation might be.

I know many practices that say quite explicitly before the operator answers that the office is closed, but that if you wish to speak to an on-call provider about a medical emergency, they will be able to reach out to a covering provider. At our practice, we do not have people in place to screen these calls, mostly because we don't want nonmedical providers making decisions about what should or shouldn't come to the on-call physician. But some of my colleagues have put non-physicians on these calls to do some first- level screening, to weed out for simple things that might just need some common-sense advice or a simple refill, or things that can definitely wait until the next day.

Recently, I've learned of several providers who have sent out notices to their patients telling them about the excessive burden of all of this contact, all of this ability for them to be reached over sometimes incredibly trivial things or things that can wait another day or two -- or for an appointment -- and how this has added to physician burnout.

Finding Good Alternatives

I'm not suggesting we should go back to the old days; I think having a system where a patient can be screened and evaluated effectively, and given some sound medical advice and treatments, is a reasonable thing to expect of a modern healthcare system. But given how much the system we have is already burdening those of us on the front lines, I think we need to think about ways that alternative advice givers -- more nursing support and even the use of some screening algorithms using artificial intelligence -- might make things better for everyone involved.

I can certainly understand patients' frustrations. They quite often feel that many of their questions were not addressed during their sometimes rushed, sometimes quite short, office visits with their providers, and the portals seem to offer an ideal opportunity for them to ask more questions. I really do like the idea of saying that anything related to a visit we just had can certainly be reviewed over the telephone or through a portal message sometime in the next day or two.

But a new medical issue, something where I need to use my medical expertise to answer a new question about a new set of symptoms, should be formalized into a more structured type of visit: a scheduled telephone call, a video visit, or an in-person visit if needed.

If we build up systems that give patients all the information they need about their medical conditions; provide resources with answers to questions they might have about their medicines, medical conditions, and symptoms; allow access to nurses who can provide education and pharmacists who can review side effects; and connect them with other providers who can do dose escalation of chronic medications or follow up on mental health issues, then we may go a long way towards alleviating some of the burden on physicians who are dealing with all of this.

Today, tonight, every day.

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