Front office staff as medical educators,risk creators,and risk managers

It happened while I was walking from my office to my car late one afternoon. Out of the blue, the pain in one of my knees was excruciating. I nonetheless was able to drag myself the remaining distance to my car, drive home, and immediately undress and hobble into bed for the night. Thus began my accidental but illuminating education about the importance of front office medical staff in shaping not the quality of care provided by the physicians and other health care professionals in the medical practice, but rather the quality of life enjoyed, or suffered, by the patient in the course of his or her medical journey.

I had, of course, dealt with front office medical staff many times before, usually in reasonably pleasant, but sometimes in slightly annoying or frustrating, circumstances. The situation I presently describe, though, was different because I was in acute pain with every step I attempted for months and my experience with the front office staff of the large single-specialty practice I contacted was so negatively memorable.

The day after the onset of my pain, I telephoned the specialty practice and, when I finally got through to a human being after a long wait and then a confusing labyrinth of keyboard numbers to press, explained my plight and requested an appointment with the first available physician in the practice. I was brusquely informed that, because I had been seen two years earlier by a particular physician (Dr. X) in that practice for an unrelated problem, I could be scheduled for an appointment only with Dr. X, whose next available appointment was four weeks hence. I replied that I understood the importance of continuity of care and would be pleased to have Dr. X as my physician again, but I was in great pain, unable to function in terms of mobility and greatly impaired by the pain in other respects, and needed another member of this same group partnership to at least examine me and help with some temporary relief. I was abruptly told that my only option would be to formally, expressly terminate my relationship with Dr. X and make an appointment to begin a new relationship with one of his partners; however, because of my changed status as a “new” rather than existing patient under that arrangement, the first available appointment with a different physician would be more than a month away. Given the take-it-or-leave it ultimatum issued me by the appointment maker, I waved the white flag of temporary surrender and made an appointment with Dr. X for four weeks away.

When I had been treated earlier by Dr. X for an unrelated problem, I acquired his email address. Desperate to obtain some physical relief in my present situation, I took a chance and contacted him directly. He graciously replied personally to my message with an appointment for the following week; my impression was that this was not the first time that he had encountered the need to circumnavigate impediments created by the front office staff on behalf of frustrated patients. I somehow made it through that week based on my hope that my patience would yield relief that I was not obtaining by taking a (probably dangerous) slew of self-administered over-the-counter analgesics. At the visit, Dr. X examined me and gave me an injection of a medication, sending me away with the instruction to notify the front office if I failed to obtain relief within a few days, in which case Dr. X would order an MRI.

I was optimistic, but unfortunately my optimism was not warranted. I waited more than a few days, both to be certain and to avoid being (and appearing to be) a “nudnik,” but the pain did not subside a bit. I broke down and called Dr. X’s practice, relating my story (again after traversing the electronic phone system ordeal) to the staff member answering the phone. She promised to relay the information to Dr. X “as soon as she had time” and that the office would contact me to schedule the MRI. I dragged myself through the next two weeks of pain without hearing from Dr. X’s office, at one point even having my wife take me to a local hospital emergency department, where I was dismissed without medication because the ED physician assumed from his 5-minute exam that this chubby, 64-year-old university professor must have been a drug-seeker feigning symptoms. Having waited fruitlessly for two weeks, with increasing frustration and annoyance, I once again called Dr. X’s office to follow up on the MRI. After the staff member (of course, someone different than I had ever dealt with before) reluctantly agreed to check, she discovered after a 10-minute search that the note made by the staff member with whom I had spoken two weeks earlier had never been transmitted to Dr. X. She told me she would transmit the information to Dr. X. I waited a week and the office’s previous silence repeated itself. When I followed up at the end of that week, in tears (my not-unusual state of being because of the pain and accompanying anxiety and depression whenever I hobbled from chair to chair), the new (to me, at least) staff member put me on hold and then five or ten minutes later returned to the line to tell me, “Oh yes, that MRI has been scheduled for tomorrow.”

I had the MRI and was informed by the technician that Dr. X’s office would contact me “at the beginning of the week” to discuss the findings. Having heard nothing a week later, I (by this time grown pretty well emotionally numb but simultaneously deviating from my ordinary courteous way of interacting with others) called the office and was asked, as though there was nothing untoward in this situation, whether I wanted to make an appointment with Dr. X. I replied that such a course of action “might be nice.” Although my attempted sarcasm (I did still retain a small sense of humor that by now had turned into snarkiness) went completely over the head of the office staff member with whom I was dueling, she did make an appointment for me for the following week.

When that appointment time finally arrived, I was ushered into an examining room and waited more than three hours for Dr. X’s Physician Assistant to arrive. During that wait, no one from the practice entered the examination room to provide me with any information explaining the wait, let alone to check on whether I needed anything. When the PA arrived, he very briefly explained that the MRI confirmed a problem for which the only remedy was surgery. I was prepared for this conclusion and agreeable (indeed, desperately enthused) to proceed posthaste. The new surprise, however, was that Dr. X did not routinely perform the type of surgery indicated for me, but several of his physician partners did. I would be contacted, the P.A. vigorously assured me, by the office staff on behalf of the physician to whom my case was being immediately assigned.

Two more weeks ensued, as I futilely awaited the promised office contact. During this and previous intervals, I many times seriously considered just terminating my relationship with the less-than-accommodating group practice and instead pursuing a relationship with a large multi-specialty health care organization three hours away with a superb regional reputation for both technical quality of care and its thoroughly patient-centered service orientation. Having invested so much time and effort in my current organizational provider, though, I kept reluctantly deciding to double down and try to make the present relationship work. When I got through on the phone to office staff this time, the new person with whom I spoke relayed to me, rather matter-of-factly and without any apology or even acknowledgment of error, that the referral slip had been sitting on her desk but she would, as a favor to me, send it immediately to the nurse of Dr. Y, to whom I was being assigned for surgery. Mercifully, Dr. Y’s nurse did call me a day later, and from that moment forward I began the process of eventually getting my medical self and the other aspects of life that depend upon physical health and the control of pain and, yes, suffering, back.

1 Implications for medical education

Medical residents and students learn about clinical practice largely by following and observing attending physicians and how they interact with their patients. Much of this experiential education takes place in office-based settings. My recent personal experience as a patient has caused me to reflect on how this part of the educational process could be enhanced materially by exposing residents and students more, and in a more structured manner, to the front office staff who serve, positively or negatively, as the primary personnel interfacing with the physician’s patients.

As described above, I had a significant, painful medical problem that required the attention and active intervention of a physician in a procedure-oriented medical specialty. My physicians (both Dr. X and Dr. Y) were great in terms of the knowledge and skills they possessed and exhibited. They also were wonderful role models for residents and students as they interacted patiently and compassionately with me and demonstrated precisely the type of robust physician/patient communication necessary to assure that my agreement with their medical recommendation fulfilled the ethical and legal ideal of truly informed consent. Residents and medical students observing my physicians would learn positive lessons about practicing patient-centered care characterized by shared decision-making.

My interactions with the front office staff at the large, proprietary specialty practice corporation for which my physicians worked, however, was a totally different kind of experience. These were the people who served as the inescapable gatekeepers to the practice’s physicians, and who engaged in conduct toward me during the lengthy triaging, scheduling, assigning, and financial investigation stages that seemed to be anything other than compassionate and patient-centered; conversations with other people in my community inform me that my negative experience with this particular front office staff was not at all atypical. The lack of positive interpersonal skills that I encountered only exacerbated the physical pain and sense of emotional vulnerability and apprehension that I was dealing with until I broke through the logistical barriers put up by the front office and achieved care and protection under the wing of my physicians themselves.

As part of residents’ and medical students’ clinical education, there are several reasons that we should be exposing them regularly and systematically to the unwitting but invaluable mentorship of front office staff. First, if we want residents and students to eventually internalize and practice the values of compassion and empathy as part of patient-centered care, we need to expose them more to the totality of the patient experience. Patients spend substantial time and effort dealing, for better or worse, with front office staff. The time actually spent with the physician generally represents just a small portion of patients’ overall experience, so residents and students who base their impressions exclusively on observation of the direct physician-patient encounter are likely to come away with a very skewed, partial comprehension of what being a patient really is all about.

Second, more exposure to the behavior of front office staff will enable residents and students to better understand patients’ attitude and demeanor during their limited direct encounters with the physician. Upset patients who feel abused, neglected, or mistreated by front office staff are less likely to engage in a positive exchange with the physician, who in turn may be distracted from the central purpose of the visit by the need to apologize to the patient and rectify hurt feelings or unsatisfactory administrative performance.

Finally, exposure to the interactions between patients and front office staff will equip residents and students to someday do better in their practice environments in hiring, supervising, and generally setting the tone for their own front office personnel. Ethical clinical practice and patient welfare will benefit from physicians’ informed attention to this element of patient care. Moreover, good front office/patient interactions will contribute to higher patient satisfaction ratings and fewer disgruntled patients who might otherwise contemplate lawsuits in the event of disappointing medical outcomes.

Disclosures

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