In this episode of the AMA STEPS Forward® podcast, Alfred Atanda, MD, surgical director of the Center for Sports Medicine and director of clinician well-being at Nemours Children’s Health, shares his experience piloting a telephone consultation model aimed at reducing call burden for infectious disease specialists.
- Alfred Atanda, Jr., MD, surgical director, Center for Sports Medicine; director of clinician well-being, Nemours Children’s Health
- Jillian DeGroot, practice transformation and sustainability, AMA
Speaker: Hello and welcome to the AMA Steps Forward® podcast series. We'll hear from health care leaders, nationwide, about real-world solutions to the challenges that practices are confronting today, solutions that help put the joy back into medicine. AMA Steps Forward® program is open access and free to all, at stepsforward.org.
DeGroot: Hello everyone and welcome back to the AMA Steps Forward® podcast. My name is Jill DeGroot. I'm a new member of the AMA team and I'll be your host today. I'm joined by guest, Dr. Alfred Atanda, pediatric orthopedic surgeon and sports medicine expert. Dr. Atanda is chief of the division of sports medicine and director of clinician well-being at Nemours Children's Health in Delaware.
If you're a frequent Steps Forward® podcast listener, you may remember Dr. Atanda from a previous episode, titled “Small Interventions Matter,” where we discussed minimizing unnecessary patient transfers using digital technology. I highly recommend you check out that episode if you haven't already. But today, we're discussing Dr. Atanda's experience with a telephone consultation model that reduces the burden on infectious disease specialists. Dr. Atanda, thanks for being with us today.
Dr. Atanda: Oh, great. Thanks so much for having me, Jill. I really appreciate you sharing the time with me today.
DeGroot: Awesome. So telephone consultation models are frequently used to help streamline health care, avoid hospitalizations, and improve patient satisfaction. But while well-intentioned, they can sometimes place excess burden on the frontline specialists. Dr. Atanda, your organization developed a physician priority line that gives community physicians immediate phone access to physician specialists for high-level consultation and for increasing incoming referrals. How did the idea for this program first come about? Well, what was the problem at hand?
Dr. Atanda: It's interesting because as we see in a lot of large academic health systems, there's all sorts of initiatives and endeavors that we, as physicians, doing the frontline work or a part of and have to adhere to. But oftentimes, we don't even know where they came from. And you asked me that and I laugh about it now, but I had to do some digging and investigating to figure out where this PPL line came from.
It started probably eight to 10 years ago, with the idea to increase our accessibility to community primary care physicians. So if a physician had a patient in their office or in the emergency room or something, and they had some questions or concerns, the idea was that it was a way to reduce barriers between the primary care docs and us and give them direct access to us, for us to then be able to help guide that patient along their journey and help triage them accordingly.
And then also from a business perspective is just to increase our outreach to the community for purposes of business development. But that was a while ago, and for your average physician who was on call answering these PPL line calls, you didn't really even know why you were doing it. It was just part of your responsibility. But that was the inherent driving force behind it.
DeGroot: What can you tell us about this telephone consultation model and how it works?
Dr. Atanda: No matter what specialty you're in ... Obviously I'm in orthopedic surgery, so let's just say I'm on call this week or today, or what have you. Through the outside, our operator, outside physicians would call a particular number and then our operator would then text or call me. And then I would then call back a predetermined number and then, theoretically, I would be patched through to talk to this physician.
From a well-being perspective, it actually can be quite burdensome because, it's not that I'm just sitting in my office checking my email, watching TikToks or Instagram Reels, waiting for people to call me. I'm on call. I'm working. I'm invariably seeing patients in the clinic. I'm seeing patients in the emergency room. I'm doing surgeries. So it created a little bit of a stressful situation because the people who were there to receive these calls were invariably doing other things to help generate revenue and keep the wheels moving at the hospital.
That's from a well-being perspective, how I got involved because I would feel the stress. But I think this was much more stressful for a lot of our nonsurgical colleagues because a lot of these calls would be long 10, 15 minutes of listening to lab results and studies. Some of these would be patients of other institutions who'd been in the hospital for two weeks, so it'd be a lot.
I mean, for me, it'd be like, "Hey, I have this kid with a distal radius fracture. Should I send him home? Should I send him to your clinic?" So the calls, from my perspective, weren't particularly burdensome, but as I was talking to my colleagues, practically, I realized that it wasn't really working well for them because it was just really dumping more on their plate. That's when I got this idea to dig deep and look really hard into this model, why we were doing it, what the benefits were. Were we truly getting out of it what we thought we'd be getting out of it?
DeGroot: This particular model is targeted towards relieving burden on infectious disease specialists. Why infectious disease?
Dr. Atanda: Yeah. That's interesting because I know a lot of the infectious disease docs. And to be honest with you, given the recent COVID pandemic, we saw that the phone calls that they were receiving basically skyrocketed because everybody had questions about COVID and, "Should I be tested?" and what symptoms and what vaccine, and blah blah blah. So they seemed as a very good target to try to revamp and revitalize this model.
The model in itself works very well on paper, but practically, it was a bit of an issue. So the work that I did with them was really to figure out, "Okay. How can we effectively bring outside physicians to our system and get them the advice that they need without being so burdensome to our own specialists?" So what we did with infectious disease was we partnered with one of their nurses and set up a model such that, now, that when people call, the nurse would take the call. She would be the one that would triage the calls. She would categorize and she would list out what was needed. She would be that interface to those outside physicians.
And then she would, in turn, be able to say, "Okay. I'm going to now call the physician," who she knows, who she works with in infectious disease, give them a quick blurb, really package it in such a way that the physician can look at the whole consultation in a few minutes, like a quick one page or a few paragraphs and then be able to call that doctor back and say, "Okay. I already have the story. I know what's going on. We need to do X, Y and Z."
Our specialists were still calling those outside physicians, but they were doing it already preemptively prepared with information. Because in the traditional sense, we would just field all the calls, and you would be triaging and gathering information and having somebody else on the line sift through charts and records. And invariably, a lot of times, you would call back and the outside physician wasn't available. They'd be doing something. They'd be working. Then you'd have to sit on hold. So by having the RN freed up to do this, it allowed the physician to do whatever they were normally doing and they'd just get a quick streamlined way to provide their knowledge and their guidance with those outside physicians.
It was very interesting. We looked at probably about the first 100 and 125 calls, and what was very interesting is that we looked at the time in which the nurse would spend on the phone, and then the time that the physician who'd call back would spend on the phone. In the traditional sense, the physician would do all of those things. Now, it's only when the physician calls back, so were removed by 50% of the time.
We initially thought this was to be a great way to generate referrals, but looking at our experience over the first three or four months with this pilot, only about 7% of the time did those outside physicians actually have a patient that then followed up with us. So, we weren't even getting the referrals anyway. We were providing very valuable free advice, under the guise that it would be good for business development and good for referrals, but there were no referrals actually happening to the level that we thought. So, it really opened up our eyes.
This was a small little microcosm of what we envision is happening, happening pervasively through our organization. And it was very nice to do this on a small level, collect data, use the appropriate metrics, and then figure out ways that we can keep the ID folks with their streamlined process, but then spread the good work to other specialists in other specialties, to figure out how we can revamp their systems. And we're looking towards cardiology and gastroenterology next, as our pilot program subjects.
DeGroot: You mentioned delegating this role of fielding calls to an RN. Are there any tools or resources you used to help plan out this new model?
Dr. Atanda: Yeah. I mean, using the de-implementation checklist and other things that I've learned from the AMA is a guiding framework. I mentioned this initially. There's so many things that we, quote, unquote, "just do" every day. There are just ... When you sign on and you work with us, the PPL line is just part of your thing.
I think a lot of these endeavors are very well-intentioned and they come from a good place, but what I learned is the person who actually conceptualized the PPL line, that guy, he was a cardiologist. He retired like seven years ago. He's not even there. So when I was digging deep and asking around, nobody could even tell me why we were doing it and who came up with it. How did we know that it was successful? How did we know that we didn't need to pivot in a different direction?
I think, the de-implementation checklist really helped me look at things that ... We all had these checklists and these things that we do. And you have to be like an investigative reporter and really uncover why we're doing what we're doing and if it's beneficial. And figuring out a way to not really de-implement it and get rid of it, but really revamp it and overhaul it in the way that we can still provide value, but we're not doing it at the expense of our frontline physicians.
I think, for your average physician, they're just trying to help people, they're just trying to provide value, and they're just trying to do their jobs. And physicians, we kind of shoot ourselves in the foot because we are Type A, neurotic, perfectionist-type people who just push through, and we just get the job done. We are the masters of the workaround. And if we have to do X, Y or Z, and it's cumbersome or burdensome, we figure out a way to still do it, but it's usually at the expense of our own well-being, of our own productivity.
So I want to be the voice of the average physician of my hospital and really help overhaul some of these things because the amount of inertia and energy and time that you have to expend to improve something that the system has put in place, as a frontline individual doctor, is enormous. It's just easier just to do it because you don't know who's in charge of it. You don't know how you could change it. You don't know who even to call or email or set up a meeting with.
I feel like that's the true value that I have, as the director of clinician well-being, because I can do a lot of that heavy lifting for the physicians who don't always have a voice. Again, they're just in their own worlds and just trying to slog through the day, get their work done. So I think a lot of the tools and tricks that I've learned with my experience with Marie Brown and some of the other folks at the AMA has been very helpful to then translate that and bring that to the hospital, so the physicians don't have to feel that burden. I can feel that burden for them.
DeGroot: You mentioned that in measuring time spent on the phone, it seems like it's been cut, I think you said nearly in half. What other metrics, data or anecdotal evidence did you collect to measure success?
Dr. Atanda: Yeah. I mean, so for this new pilot, the big thing is we wanted to make sure that the time that the physician was spending on the phone was decreased. We also wanted to look at, "Well, what is the percentage of patients that are being spoken about by the primary care doctors, that could be handled by somebody other than the physician."
So we found that about 25% of the time, these calls can be handled simply with the nurse talking to the outside physician. Again, historically, the physician would field all of those calls, some of which could be handled by a nurse, some of which are unnecessary, and then some of which needed to be dealt with by the physician specialist. So this just set up a nice triage filtering system to help just remove that burden.
And then, lastly, again, we touched on that thing about referrals. That was very eye-opening because the whole goal was to try to improve the referrals. And that's where we're at now. We know that the referral rate is very low, so we have to figure out how we can revamp that with some of the verbiage that we put out to our primary care doctor calling, giving them information about phone numbers and clinics and follow-up patterns to get these patients in.
And then, on the flip side, we also want to engage with education and manage the expectations of these primary care docs because they always assume, when they call, they're going to get a specialist. They don't think that they're going to have a nurse or maybe an NP, or maybe a fellow or something, helping out.
And that's some of the other models that we've been exploring, but it does require not just us revamping our internal processes, but we have to manage the expectations of the people that are calling in. And slowly, over time, I think that will help change the culture. If people understand that they may not get a specialist, but you may get one of their representatives that can help triage things, and then eventually get you to that person, I think that's very helpful.
Long story short, delving into this model has taught me a few things as we move forward. It's not solely the idea of just implementing a new process, but within this process, you have to embed within it what are the metrics that you're going to realize and review over time to ensure that you're doing what you set out to do, that you are successful. Number two, how often are you going to measure those metrics? Is it going to be monthly? Is it going to be every two months? Is it going to be quarterly?
And then number three, if you do find these metrics aren't meeting your standards of what you anticipated to happen, what's your plan? What are you going to do? Are you going to just scrap the whole thing? Are you going to pivot, like a startup would pivot and change course when they realize they're not doing what they need to do? Are you going to just flip the model on its head and do something, plan B?
I feel like a lot of times, in health care systems, we come up with these new initiatives for whatever reason, but we don't really take it two or three steps further and have those metric pieces that I was talking about. That's really what I think the wave of the future is going to be because not only is it going to ensure that things are being done the way we intend them to do, but it's also going to minimize untoward stress and burden and different things. Because if you don't recheck in every so often, like we haven't, it's been eight years or so, you're not even going to realize that you're doing something that's burdening the frontline specialist physicians and then have a way that you can something about it.
DeGroot: Do you feel that the success of this model might inspire you to make other changes or try other things, going forward?
Dr. Atanda: This is just one tiny little thing that we've been able to do, that we've been able to explore. And we've seen some promising results when we've streamlined things. But again, it's a learning opportunity. We may find that if we have this kind of model for two, three other different specialties, it may not work for them. Part of the issue is not every specialty has a nurse that can be freed up to answer all these calls.
So part of it is to really work with the docs for this particular issue, the PPL line, and figure out what works best for which specialty. But again, this is one tiny example. We want to take this as a model that we can use this to answer 10, 15, 20, 30 different pain points that physicians are having, and then be able to tailor that and customize it to all the different specialties of different physicians. Because unfortunately, in the real world, people think, well, we're doctors. We're all the same. You have ... we all make a lot of money. We've worked really hard. You shouldn't complain about anything. But as you know, we're just people. We're just going to work, doing our jobs like everybody else does.
And I think finding solutions that are individually tailored to people and divisions and departments is key. I can't just say, "Oh, we have this great issue that we discover with the PPL line. So now every specialty in the hospital is going to have an RN answer all the phone calls," and this and that. That's not going to work either. And that's a lot of times a knee-jerk reaction in large academic health care systems.
So providing awareness of not just the nuts and bolts of the actual project that we did, but also the underlying theme behind it, of how we worked with the people for the people, doing something that they thought was most beneficial and can back them. It's very exciting stuff because it's not typically how we view things in health care systems today.
DeGroot: Great. What advice or pearls of wisdom would you give to an organization that might want to try to implement something like this or try something like this?
Dr. Atanda: Yeah. I mean, it's interesting because, in large organizations, you tend to have people that make decisions. And in health care organizations, a lot of the people that make decisions aren't physicians or they're not clinical. Or if they were a clinician, they're not practicing anymore.
So I would say, first and foremost, is to lead the people, you must walk amongst them. Go and sit down with the frontline providers who are experiencing or feeling whatever it is and just listen to them. Let them be heard. Just go sit there for an hour. Don't say anything. Just let them vent. Take notes. Figure out what all their pain points are, and then work with them to go through and prioritize the pain points and find the ones that are most valuable to them.
I think all too often, as an innovator myself, and as a thought leader, I always have a preconceived notion of how can help a group or how I can help an individual. And I insert my own biases, and to, "Oh, it'd be really cool if you try this," or "Maybe you should look at this metric." Let them speak for themselves.
That's a very, very critical skill that most physicians and most people in health care don't have. So just listen and let other people talk and empower them to come up with solutions and strategies to mitigate the issues and stress that they are feeling, in the way that they would think is most valuable to them. And if you do that and you do that well, you can create a lot of good for a lot of people.
DeGroot: I think that's a beautiful place to wrap up our conversation. I think our listeners will feel that a lot of what you said rings true and hopefully will inspire some more ripple effects. Thank you so much for your time today. I know you're very busy, so we greatly appreciate it. It's been a pleasure.
Dr. Atanda: Oh, thank you very much for having me. I had a wonderful time chatting with you.
Speaker: Thank you for listening to this episode from the AMA Steps Forward® podcast series. AMA Steps Forward® program is open access and free to all at stepsforward.org. Steps Forward® can help put the joy back into medicine by offering real-world solutions to the challenges that your practice is confronting today. We look forward to you joining us next time on the AMA Steps Forward® podcast series, stepsforward.org.
Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.