General practice has undergone a digital revolution during the COVID-19 pandemic with many more appointments offered remotely by telephone or video. Telemedicine now underpins many doctor-patient interactions.
In an MDU survey 97% of GPs reported increased use of phone consultations during the pandemic. Meanwhile 75% said they had increased their use of video consultations and 55% had increased their use of online triage systems. More than three quarters (77%) of the 172 respondents anticipated that they would continue to use remote working practices frequently post pandemic.
Remote consultations have allowed GPs to continue to practise efficiently and support patients whilst reducing the risk of exposure of patients and staff to coronavirus, during the pandemic. However, research body The Health Foundation has recommended that more research is carried about the impact of remote consultation on the ‘quality of care, patient experience and access and workload.’
How to avoid risks
As with all areas of medical practice it is important to reflect on the care we provide and learn lessons where things don’t go according to plan. Some of the key areas to consider when carrying out a remote consultation.
Get familiar with the technology
- Check the equipment you are using and ensure the patient can see you clearly.
- Check your setting, background, appearance and privacy settings especially if you are working from home.
Focus on communication
- Communication skills are the cornerstone of a good consultation but there may be additional barriers communicating remotely compared to a face to face consultation.
- Put the patient at ease by introducing yourself and explain how the consultation will work.
- Remember to look at the camera in order to make eye contact with the patient rather than at the image of the patient on your screen.
- Is this patient new to you or the practice or someone you already know well? If they are unfamiliar, have you reviewed the notes (including hospital records if available) and any relevant investigation results?
- Does the patient have any specific concerns and what is the purpose of their contact?
Assessing the patient
- Using an unfamiliar format to consult with patients can be off putting. Don’t forget basic principles of history taking and examination.
- Is this a chronic condition or a new presentation?
- Has there been a change in their presentation or any new symptoms?
- Has the patient already been seen by a colleague either remotely or in person?
- Has the patient had multiple consultations about the same matter?
- What are the social circumstances and could these be relevant?
- Is this a physical or mental health problem and what is the patient’s emotional state?
- Are there any special considerations in view of the patient’s age (very young or elderly)?
- Do you need to conduct a remote examination? Can you do this remotely or will you need to arrange a face to face consultation, for example, because you need to observe vital signs to fully assess the patient?
- Do you have appropriate consent for the examination?
- Is a chaperone necessary and is it possible to arrange this remotely?
- Are there any red flags?
- Are you in a position to exclude a serious diagnosis?
- What is your differential diagnosis and have you recorded this?
Safety netting advice
- At the end of the consultation, does the patient understand the plan and do they know how to seek further help if needed?
- Ensure safety netting advice is given especially as you have not physically examined the patient.
- Consider whether a face-to-face appointment is needed and arrange this within a suitable timescale.
- Due to the potential for uncertainty in remote consultations make sure key points of your discussion are noted.
- If a follow up appointment is needed arrange this for the patient before they leave, if possible.
Missed diagnosis examples
The limitations of video consultations were highlighted by a recent case reported in the national press in which a toddler’s eye cancer was allegedly missed during a video consultation.
It may be that subtle physical signs are difficult to pick up during a remote consultation. When consulting with children remotely, it’s important to acknowledge and investigate parents’ concerns. Consider whether you need to conduct a face-to-face examination to fully address those concerns.
In another anonymised cases, based on the types of issues raised by MDU members, a patient who was diagnosed with a migraine during a phone consultation later collapsed and was admitted to hospital.
During the phone consultation, the patient explained the headache had been present since the previous day and they had vomited twice but had no fever, skin rashes or neck stiffness. The pain was worse on movement but relieved when the patient lay still in a darkened room. The patient described what the doctor felt was visual aura.
The doctor felt this was likely to be a migraine and gave advice about analgesia. The patient was advised to get back in touch if the pain didn’t settle. The patient contacted the practice again the next day, still in pain but reported no new symptoms.
As the pain had not got any worse and there were no new symptoms the doctor advised the patient to continue with the analgesia and gave safety netting advice. The patient later collapsed and was taken to hospital by ambulance. The patient had high blood pressure and a right hemianopia following a stroke.
On reflection the doctor felt that they did not ask all of the pertinent questions, for example, about the onset or severity of the pain and that an examination should have been carried out.
While the move towards more remote consultations has been positively received by both GPs and patients alike, there is likely to be variance between colleagues. Sharing experiences can help to improve learning and any complaints or concerns should also be discussed at a significant event meeting.
The MDU recommends you have a low threshold for asking patients to attend the surgery for a face-to--face consultation, where possible.
In the next article, we examine some techniques to help you to get the most out of remote consultations.
- Dr Leask is a medico-legal adviser at the MDU
The MDU’s website also has further guidance on remote consultations.