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Phone Intervention: Every Word Matters

During this time of social distancing, it seems appropriate to discuss remote (telephone) intervention. In 2011, we at the Alabama Physician Health Program, where I was then medical director, examined intervention outcomes over the previous 10 years. We found that of the 328 interventions that had been conducted, almost half, 161, were telephone interventions.

In the analysis below, referral date was defined as the date we received the initial referral. We excluded cases where no intervention was conducted (usually because there was inadequate information or it was an inappropriate referral). Intervention was defined as the initial contact with the identified physician with the goal of either the individual complying to undergo an appropriate evaluation or enter treatment.

By 2011, we had gradually evolved to almost exclusively conducting interventions by telephone. Between 2001 to 2006, there were a total of 137 interventions of which 30 (22%) were conducted by phone however, from 2006 to 2011, there were 191 interventions of which 178 (93%) were conducted by phone. Statistical analysis revealed that phone interventions were conducted more rapidly, an average of 1.4 days following the referral date (range of 0 – 4 days) whereas in-person interventions were conducted an average of 9.2 days (range 2 – 21 days) following referral date. Otherwise there were no differences. The success rates (defined as compliance with recommendations), comparing in-person vs phone intervention, were not statistically different (94% vs 97% respectively). There were no untoward events.

In the earlier years, almost all interventions were conducted in the traditional “in-person” style. In-person interventions usually involved the medical director and at least one other individual, usually someone from the PHP supervisory committee, scheduling a “surprise” meeting with the identified physician. This approach was almost always awkward and inevitably caused obvious embarrassment for the identified physician, either when appearing at their office or having them come to some meeting location. When appearing at their office, the doctor’s staff invariably sensed that something serious was happening when two or more physicians show up to meet with the doctor and the situation lacked discretion. When the identified physician was invited to a meeting location, usually under some guise such as a meeting with the administrator, the shock of having misled the individual was evident. Only one intervention over that 10 years was the traditional Johnson Model intervention where family members were involved. All other interventions were a Professional Model intervention (explained below).

The transition to telephone intervention was motivated by at least two events. One was an intervention in which, on the day of the intervention, we were informed that the identified physician carries a concealed weapon. This introduced the obvious concern regarding safety. Following this intervention, which was successful without violence, a meeting with the supervisory committee resulted in the recommendation that the medical director obtain a concealed weapon permit and training in self-defense, something the medical director did not wish to do. The other event that motivated more phone interventions was a situation in which the identified physician eluded numerous meetings, in a distant city, resulting in much inconvenience and delay.

Thus, phone intervention became the norm. Over time, a dialogue was developed for phone intervention which was gradually edited and became useful. As new staff came on board, they were trained in the dialogue. They found the practice very useful and effective.

Then in 2011, the medical board expressed concern regarding telephone intervention. They felt that in-person intervention was superior as a matter of etiquette. This led to the statistical analysis of results above which was presented to the board.

Below is the dialogue that was developed. Obviously, it might need to be modified for different settings by different PHPs.

Dialogue for Phone Intervention

(Can be used for physician health programs or wellbeing committees.)

Prior to Call

Four things must be determined prior to attempting contact:

  1. Is the concern legitimate (from a hospital medical executive committee or wellbeing representative, medical group, colleague, etc.)? If not (ex-spouse or anonymous), then further investigation might be necessary before proceeding with an intervention.
  2. Is it okay to let the identified physician know who made the referral or do they wish to remain anonymous?
  3. Should the identified physician be asked to discontinue practicing prior to evaluation?
  4. Who is going to pay for the evaluation?

General Principles Regarding Phone Intervention

Attempt to keep the conversation light and friendly. Never threaten the identified physician. Never attempt to coerce. Remember, the PHP or wellbeing committee is voluntary to assist physicians. Most physicians in crisis actually want help but are afraid. Therefore, be courteous and helpful. However, before concluding the intervention, let them know if they chose not to voluntarily participate, the matter may well go to the medical board which will likely open a disciplinary process that likely will compel the same action we recommend, an evaluation.

Voicemail

If the identified physician does not answer, leave a voicemail. Introduce yourself as representing the physician health program or wellbeing committee and ask them to return the call as soon as possible and that it is important. Call back frequently.

Conversation With Physician

When you speak to the identified physician, introduce yourself as representing the physician health program or wellbeing committee. Ask if they have ever heard of the program or committee. Explain that the program was created to assist physicians as an alternative to medical board or medical executive committee investigation and discipline and that the program is authorized to deal with situations in a confidential manner. Explain that there has been a referral to the program or committee  by a legitimate source, concerned that you might have a problem with ____________ (i.e. alcohol abuse). Pause and then ask if they have a problem with ____________ (i.e. alcohol abuse)? If the answer is yes, then advise the physician that we can help and let them know the entire process can be kept confidential at this time. Then skip to Recommendation below.

If the answer is no, which will be the most common response, then you may say that is good and offer to let us help deal with this situation.

Let the identified physician know that because the concerns come from a legitimate source, it will be necessary for them to undergo a comprehensive evaluation and a thorough checkup to document if there is a problem or not. Explain that whether or not there is a problem, the goal is to get them back to work as soon as possible. If there is no problem, we will document it and if there is a problem, we will help them get appropriate care. Pause briefly. If they ask who made the complaint, and the referent preferred to be kept anonymous, let them know that the program is confidential and makes every effort to assure that the concern is from a legitimate source and that the source of the referral must remain confidential at this time. Explain that their comprehensive evaluation must be conducted at an approved facility familiar with evaluating physicians and that the evaluation must be conducted soon. Let them know whether they must discontinue practicing based on the referring sources opinion.

Note: If the identified physician begins trying to explain what they think or believe and begins giving a history of events, let them know that all of this information will need to be explained to the evaluation program. Try to avoid taking a history and getting into details over the phone.

Recommendation

Thank the identified physician for their time and attention. Review the conversation: In summary, a referral has been made to the physician health program or wellbeing committee in lieu of referring the matter to the medical licensing board (or medical executive committee). The concern is serious because it is from a legitimate source. The process for clearing up the issue is to undergo a comprehensive evaluation at an authorized facility. The evaluation will need to occur soon. Let the identified physician know if they will have to pay for the evaluation. Thank them for speaking with you and that we want to help.

Find out how the identified physician would like to receive a letter, email or fax, and get that information. Following the conversation, immediately send a letter summarizing and listing the authorized evaluation programs and the time frame they are expected to schedule and undergo the evaluation and whether it is recommended they discontinue working until the evaluation is completed. Ask for confirmation of receipt of the letter.

Note: If the PHP or wellbeing committee is not prepared to conduct a full and thorough evaluation (including physical exam, labs, drug testing, addiction medicine, internal medicine, psychological and psychiatric evaluation, and interview of collateral), then do not engage in discussion of details. Let the identified physician know that the details should be discussed with the evaluation program staff.

If the identified physician expresses a desire to have his/her attorney involved, then ask the attorney to make contact. Explain to the attorney the program policies emphasizing that if the identified physician is willing to voluntarily participate and undergo evaluation, then the medical board or medical executive commit

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