What Patients Hear When Your Practice Is Closed

By Comron Saifi, MD, Co-CEO, ClinicFlow. 

I had never called my own practice at 9 p.m. Most surgeons I know have not either. Our patients do it constantly. That gap bothered me enough to start calling practices after hours the way a patient would. What I heard was rarely a technology failure. It was a set of design decisions nobody remembers making: who answers, what they collect, and who decides whether the call can wait until morning.

The call you are judged on is not the one you planned for

Daytime volume is a staffing question. You can watch the queue, count the abandons and add a person. After hours behaves differently, because the volume is low and the variance is enormous. Most nights nothing happens. Then a patient 10 days out from a craniotomy calls at 11 p.m. because she is more confused than usual and has vomited twice, or a fusion patient calls because a leg has gone weak, and the entire arrangement is judged on that one call.

What is clinical and what is clerical

This is where after-hours coverage usually goes wrong, and it goes wrong in both directions.

Deciding whether a new neurologic deficit needs to be seen tonight is clinical. Deciding whether a post-op wound question can wait until morning is clinical. Deciding which surgeon covers which service on a Saturday is not. Collecting the patient’s name, date of birth, surgery date and a working callback number is not. Reaching the right person is not.

Practices collapse these together in one of two ways. The common one is a service that takes a message and pages whoever is on the list, which treats every call as clerical and hands the clinical judgment to a surgeon reading 20 words with no chart in front of him. The rarer one runs the other way: the surgeon is woken and then spends 10 minutes working out who the patient is and what operation they had.

The split worth holding is that the clerical half should be complete and accurate before any clinician is involved, and the clinical half should never be decided by someone without the criteria to decide it.

Which raises the question of whose criteria.

Write down the criteria you already use

Most practices have escalation criteria. Few have them written down. They live in the head of whoever takes the most call, and they get applied differently depending on who answers the phone.

Writing them down costs nothing and is the highest-yield item on this list. Not a triage protocol in the clinical sense. Just your practice’s own answer to three questions: what wakes me up, what waits until morning, and what the person answering has to collect before either. Post-op day, procedure, symptom, red flags by service. A page or two.

Once it exists, three things become possible that were not before. Whoever answers can apply it the same way twice. You can audit whether it was applied. And you can change it deliberately instead of by attrition.

Measure your own line before you change it

Call your own main number at 9 p.m., and again on a Sunday afternoon. Do it twice each time: once as a new patient trying to book, once describing a post-op symptom. Write down what happened, how long it took, and whether someone in pain would have stayed on the line.

Most practices find at least one thing they did not know was true. A voicemail box that is full. A tree that loops back on itself. A service that takes 4 minutes to reach a person and then offers only a callback.

That test takes 20 minutes and costs nothing. It is the only step here that produces a number specific to your practice, and every decision after it is better for having one.

What I would not claim

Automation does not resolve the clinical question. Whatever answers the phone, somebody still has to decide what wakes the surgeon, and that decision belongs to the practice rather than to a vendor or a piece of software. The gains available after hours sit almost entirely in the clerical half: answering at all, collecting the right information, and routing to the right person with the record intact.

The clinical half is yours. It is worth writing down before anyone automates around it.