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"Unable to reach patient, × 2."

This was the notation under the comments section when I clicked on the referrals tab for one of my patients. I was wondering why, when the patient had come for a follow up visit, they had not yet been evaluated by a specialist I'd referred them to at their last visit. The "× 2" meant that the specialist's team had tried to contact the patient twice, and then they were done.

Over the course of the previous two or three visits with me the patient had expressed some new symptoms, for which I'd done some preliminary testing and evaluations, and then when things had persisted despite what we tried, I made the decision to send them on to see a specialist. Under our current system, when we place an internal referral for a patient to see a specialist or to get imaging done, these get routed into the work queues of schedulers at the individual departments. Imaging requests go to Radiology schedulers, dermatology goes to Dermatology schedulers, etc.

At that point, there is apparently a process for each department whereby patients are contacted and scheduled for the appropriate appointments. Some of these happen electronically, and patients may be alerted through the portal that Dr. Pelzman has requested they get a CT scan of their abdomen and pelvis, and the system offers up available scheduling times for them, from which they can select with the click of a button. Smooth, no problem, one and done.

Apparently, many departments still use telephone schedulers, which leads to the problem at hand. Each of these departments and their schedulers has a work queue, their own procedures and metrics, and some system of prioritizing referrals.

For instance, when we place a referral to a specialist, we can select Routine, Urgent, or Emergency. I imagine that depending on which button I've clicked, it bumps people up in priority, in terms of dates being offered. I know that due to limited access, folks at these practices have a triage process of their own, someone looking through the referrals and deciding which ones need to be seen today or can wait till later.

Many years ago, patients stopped at our front desk after their visit, and the registrars would see what referrals we had placed for them. "I see that Dr. Pelzman wanted to see the cardiologist; let's see what appointments they have that may work for you..." Often patients left with something on the books, sometimes they just left with the cardiologist's number so they could set something up later.

Several years ago, before our current system was in place, we discovered that all referrals to a particular department ended up in a pile of faxes that went into the physical mailbox of one of the clinic fellows, and once every few months they would go through these referrals and decide who was "worthy" of an appointment. But now I think someone at the department gets this referral, it comes to the top of their queue, and then they go about contacting the patient.

However, many patients have told us that no one from these departments has ever called them. I expect that many of them are seeing some sort of generic hospital phone number pop up on their caller ID, and they're ignoring it, thinking it's some random after-visit survey, a fundraising request, or someone asking them when they're going to pay their bill.

I think we need to do a better job of connecting patients to the services we want them to have. How can it be that after two phone calls, everybody gives up? We clinical providers have made a decision that someone needs to see a specialist, and just because no one answers the phone on the first two tries, that's it -- we're done?

I know everyone has limited resources, and the schedulers probably have a lot of people they need to try to reach. I'm sure their work queue protocols say you only need to try twice, but I think it's about time that we start building a foolproof system, something where no one can fall through the cracks. We should be able to track the electronic trail of what happened -- whether the phone number they were trying was wrong, or the patient wasn't home, whether someone actually tried to reach them, and then extend these efforts on to completion.

How was it that someone decided that two tries were enough, that after that this healthcare issue was considered "settled", that it was going to be okay for them not to see the doctor that we had asked them to see? Sure, we could build a system that then sends me yet another message in the portal, "We've been unable to reach this patient; do you want to try?" But adding yet another set of messages saying that the scheduling system has failed the patient and now it's up to me to do something about it seems like a less-than-ideal solution.

Maybe we need to be clear with patients, letting them know that someone is going to call them from this number, or text them, or send them an email, within 48 hours, and it's going to be from the person who's going to help them see that doctor that I wanted them to see, so please make every effort to get this scheduled. Because if, after a few weeks or months, they return to see me and this consultation never happened, we're often back to square one, no closer to solving the clinical dilemma this patient has.

Figuring out the right tech checks and balances, the right safeguards, a way to make sure that all loops get closed, can make a difference -- a big difference -- and can go a long way toward making sure that everyone gets the healthcare they need, right when they need it.

Every time, × 2.

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