Telemedicine now underpins many doctor-patient interactions. The first part of this series looked specifically at how to avoid risks when consulting patients remotely.
Give your name, explain who you are and what your role is. Check you are talking to the right patient and find out whether anyone else is in the room with them.
If you are consulting the patient via video explain to the patient that you may need to consult your computer notes and also record the information. Reassure them that although you may not be looking at them, you are listening.
Explain to the patient that if you feel it is necessary, after you have taken a history and carried out a remote examination, you may ask them to come to see you for a face-to-face consultation or for investigations, such as blood tests.
Taking time to do this will ensure that the patient understands the process and does not feel rushed.
The history of the presenting complaint and past medical history is of paramount importance, particularly during a remote consultation. Non-verbal communication and soft cues will be more difficult to pick up on.
Ask open questions and allow the patient to speak uninterrupted. Where necessary, go on to ask direct questions. Avoid jumping to conclusions and keep an open mind.
Specifically ask about worrying symptoms and red flags. Patients may not appreciate the importance of these and may only mention them if specifically asked.
Some symptoms may be more difficult to evaluate remotely, such as pain, so a good history is essential and will allow you to determine whether a remote consultation will suffice or whether the patient will need to be seen face-to-face, particularly for an examination.
It is also important to put the patient at ease before going on to carry out further assessment. If you plan to carry out a remote examination, communication is as important as during a face-to-face examination.
The patient needs to understand what examination is going to take place and why and needs to be given clear instructions. Make a careful record of the discussion and your examination findings, including any relevant negative findings, recording the fact that this was done remotely and its limitations.
Concluding the consultation
Reflect back to the patient your understanding of their concerns and ask them to explain their understanding of your discussion and next steps. Consider the information you have obtained critically and your differential diagnosis.
If the patient needs a follow-up appointment, make this for them before they leave and ensure they have been given appropriate safety netting advice and know how to seek further help.
Consider whether you are happy that you have obtained all the information you need or whether you can only do so having formally examined the patient. Although some observations can be made remotely, such as respiration rate, do other vital signs need to be measured and recorded?
Was the quality of the video good enough for you to be confident that you have successfully gained the information you need to make a diagnosis?
Missed diagnoses during remote consultations
The following anonymised cases, based on the types of issues raised by MDU members, illustrate some of the difficulties of remote consultations:
A 68-year-old patient complaining of left hip pain consulted a GP over the phone just as the first lockdown began. She felt the pain had started after she’d been gardening but it wasn’t settling with rest or paracetamol.
After some discussion, the GP felt this was musculoskeletal pain. The GP advised the patient to continue taking paracetamol and, as there were no contraindications, to take ibuprofen.
Following this consultation the patient had a further five telephone consultations with different GPs at the practice. An assumption was made that the pain was musculoskeletal after the first appointment and management involved advice and trying different forms of analgesia. Physiotherapy was not available at the time.
On the fifth appointment, a different GP spoke to the patient and, noting she had already had several consultations, asked her to come in for a face-to-face review. On examination the GP found that the joint was hot and red. Blood tests were carried out which showed the patient had a raised CRP. The patient was referred to hospital and was found to have a septic arthritis.
A GP carried out a video consultation with a 45-year-old patient with abdominal pain and altered bowel function. The patient was otherwise fit and well and reported no red flag signs at the first consultation.
The GP felt that this was likely to be viral gastroenteritis. He was able to establish the site of the pain on the video and did not think a face-to-face consultation was necessary at that time.
The patient’s symptoms didn’t settle and he contacted the practice a further seven times with similar symptoms. He was given dietary information and advised that recovery from a viral gastroenteritis can take some time.
The GPs who spoke to him did not ask any direct questions about red flag signs after the first consultation and the patient did not volunteer the fact that he had now lost some weight and had experienced an episode of rectal bleeding.
At his last consultation, the GP arranged a face-to-face appointment. On examination the patient was found to have an abdominal mass and pain. He was referred urgently and was found to have a colonic carcinoma.
Learning from remote consultations
We discussed in the previous article how sharing experiences of remote consultations within the team can help to improve learning. Consider updating your general communication skills training and carrying out specific training on conducting remote consultations. For example the RCGP’s elearning course.
Consider whether the practice procedures and protocols need to be updated to reflect remote consulting? Clinical templates may be appropriate for some consultations, acting as a prompt for history taking, highlighting red flag signs and symptoms and ensuring important features are documented.
A template can also ensure that multisystem checks are carried out which can be important in helping to identify other symptoms which may help to point towards a particular diagnosis.
New modes of consultation are likely to continue to evolve and adapt and it is incumbent upon all of us as professionals to satisfy ourselves that whatever mode of consultation we are using it is appropriate in the circumstances and allows for robust clinical care.
- Dr Leask is a medico-legal adviser at the MDU
The MDU’s website has further guidance on this issue.