Case Study
Lilly Walden describes herself as an active, athletic, and healthy woman. In her mid-forties she continues to run 2–3 miles 5 days per week. Lilly is married with three children and is employed by the local school district as a speech therapist. Lilly’s husband Tom is a pilot and he works for an international airline.

Lilly describes herself as health-conscious. Her diet is balanced, and she is a nonsmoker and drinks wine on rare social occasions. Lilly has a history of asthma, triggered by environmental changes, and it typically requires antibiotic therapy for bronchial infections 2–3 times per year. This morning, Lilly is awakened by mild intermittent right lower quadrant pain and a slight fever. Lilly applies a heating pad to the area and prepares a cup of tea that she hopes will help relieve what she believes are “gas pains.” During the next hour the pain and fever appear to be lessening and Lilly proceeds preparing herself and her children for school.

Around 10:30, Lilly notices that the pain in her right lower quadrant has returned. She is sweating and concerned that she may have a worsening fever. She contacts her supervisor and informs her that she is going to be out sick for the rest of the day. She telephones the office manager for her primary care physician, Dr. Maureen Woods, and requests an office visit.

Dr. Woods’ office manager is trained in the use of a practice-specific triage protocol, the details of which are outlined in a standardized computer algorithm. Patients with routine or non-urgent concerns are slotted into open appointment blocks, whereas more urgent issues (including Lilly’s call) trigger a telephone handoff to the nurse practitioner who is assigned to triage for that day. The nurse practitioner conducts a telephone interview and instructs Lilly to come directly to the physician’s office to be seen before the