Telephone consultations form a large proportion of consultations and are ever-increasing in number to improve efficiencies within the primary care service.
They also now form part of the work-placed based assessments in the form of audio COTs and are likely to appear as a station in the CSA. And they will make up a large part of your out-of-hours work.
Although they now form part of the WPBAs, they are worth listening to on an ad-hoc basis as they are a useful learning tool.
Telephones consultations can be:
- In-hours triage (for acute problems)
- Routine planned telephone consultations
- Telephone reviews arranged by a clinician i.e to discuss results an acute prescription request.
- Out-of-hours triage
The term triage is derived from the french verb trier meaning 'to sort'
Telephone consultations should be approached in a similar way to face-to-face consultations. They can carry more risk in comparison to face-to-face consultations due to the inability to see the patient, but a methodical approach using verbal and non verbal cues should allow for a safe acceptable disposition for both you and the patient at the end of the consultation.
Prior to the call, ensure you are in a quiet environment free from distractions.
A planned call means the patient will likely be expecting a call at a certain time so try and avoid running late where able.
Review the patients records. There maybe some information as to why the telephone consultation has been booked. Are there any recent letters? Are there any recent blood results or imaging?
Familiarise yourself with the patients medical history and medication list. Are there any relevant documents e.g advanced care plan, emergency health care plan? Are there any safeguarding issues? Has their been any recent consultations whether face to face or telephone.
If the telephone consultation is not planned, in other words for an acute problem (which make up the majority of telephone consultations out of hours), then the same pre consultation preparation applies although you may not have the full medical record. In this case ensure to use any 111 information and any information you have via the summary care record. Remember you require the patient's consent to access this.
Ensure you introduce yourself clearly and check at least one piece of patient identifiable data e.g date of birth. Signpost how the consultation will progress. Structure your consultation as you would in a face-to-face consultation.
Try to speak to the patient where you can – this is still possible with young children and those in a nursing home or residential home setting.
Start with an open question and allow the patient to tell their story. Avoid any early interruptions. Be alert to verbal cues although this is more difficult over the telephone.
Take a focussed history and used closed questions where appropriate. Identify any emergencies early on in the consultation e.g cardiac sounding chest pain, acute dyspnoea, acute abdominal pain.
Explore the patients social situation. If the patient is elderly, how are they coping at home with activities of daily living? Is there any family support or external support e.g carers?
Enquire about the patients home life and how their symptoms maybe affecting them at home?
Does the patient work? If so, what do they do? Are the symptoms impacting them at work?
Driving may also be relevant and also consider safeguarding issues.
If applicable, explore the patients ideas, concerns and crucially what they were hoping for at the end of the telephone assessment.
Although most examination is not possible over the telephone, some information can be gathered e.g is there any sign of respiratory distress or wheeze? Could you ask the patient to count their own pulse, or a parent to count the childs breathing rate? Is there a recorded temperature? Do they sound distressed? Do they have a BP machine at home?
Currently certain data that can be obtained via smartphones, for example oximetry, is not validated, so caution should be used with any interpretation of this information.
If you are using video software that allows text messages, can patients text images of any skin rashes or email them to the surgery for your attention?
After your assessment, share your thoughts with the patient. Let them know what you feel the problem is and draw on their Ideas, concerns and expectations to help you tailor your explanation. Find out what the patient already knows about the problem.
Ensure your explanations are jargon free. It is much more difficult to gauge whether a patient is following what you say over the phone. Use your skills of chunking and checking to ensure patients are clear on what you feel the problem is.
If appropriate, use a shared decision making approach, providing the patient with options to their problem. Knowing what the reason for the call is, will be useful at this point.
Possible dispositions post telephone consultation include:
- Telephone advice and intervention.
- If the disposition is telephone advice then consider what resources you could provide to the patient e.g PIL via SMS, other websites e.g joint exercises, mental health resources.
- You may wish to covert the telephone consult to a video call using the appropriate software.
- Need for a face-to-face consultation in surgery.
- Need for a face-to-face consultation at your local 'hot hub'. if you dont have access to a hot hub then ensure you have a designated hot area in your surgery for suspected COVID-19 patients.
- Need for a face-to-face consultation at home, in which case you must wear the appropriate PPE.
- Need for a face-to-face consultation with another health care professional, e.g district nurse or physiotherapist.
- Need for a social assessment via a social worker
- Need for an emergency response i.e 999 or direct admission via non-urgent ambulance.
- If the consultation is an out-of-hours consultation, then appropriate safety-netting back to the in-hours GP maybe appropriate for an ongoing chronic problem.
Careful safety-netting will be important.
Safety-netting, red flags and follow up
Regardless of outcome, ensure you provide the patient with an adequate safety net for what to do if things do not progress as expected. Be very clear to the patient on who to call and what to look out for. Be very specific with red flag symptoms and time frames.
Phrases to consider:
- 'I would expect X to last X weeks.'
- 'If your symptoms are no better in X weeks then please seek medical advice as we may need to investigate your symptoms further, or if before this you develop x, y or, z then contact us before X weeks.'
- 'If you develop X then please call 999.'
Consider what follow-up you feel the patient needs. If out of hours, do they need to see their own GP or the practice nurse? If in hours and an intervention is made over the telephone, do they need a telephone review or a face-to-face consultation in 48 hours? A number of factors will determine how you action this, including local systems in your area.
Signpost patients to NHS Choices or patient.co.uk for relevant patient leaflets.
Microcommuication skills applying to telephone consultations. These include:
- Empathic statements
- Echoing patients words.
- Chunking and checking pieces of information
- Avoiding jargon.
Unsuccessful telephone consultations are most likely when:
- Demographic details aren't checked
- You don't speak directly to the patient
- Asking leading questions
- Too many closed questions
- Lack of empathy
- Failure to discover the reason for the call and the patients concerns.
- Failure to review the patient's record if able.
- Distractions around you.
Ensure you keep good records and document them in a timely manner. Make it clear in the record (if in-hours) that this is was a telephone consultation. Your system may have a code for 'telephone triage appointment'.
If you convert the telephone call to a video call, make this clear in the records and use the appropriate code e.g consultation via video conference.
You may wish to add that appropriate PPE was worn for any face-to-face consultations.
A 58-year-old taxi driver has called the surgery for a sick note. This has been marked as an urgent on the day call. He states that he has low back pain, that has been present for one week and is progressively getting worse. He has been taking his wife's naproxen, which helps a bit, but his mobility is restricted and he cannot get out of the house at present.
Only when specifically asked, it is revealed that he has numbness and tingling down both legs, that is getting worse plus he has been incontinent once in the last four days. His bowels are okay. He has also lost some weight in the last four months. There is no trauma and he feels that he has just sat a bit more awkwardly during a long taxi shift.
He is very concerned about the impact his back is having on his driving as he is struggling to use the pedals and nearly crashed yesterday. he did not tell anyone about this. He is worried that he will be told that he cannot work and cannot afford to be off work as he has a young family. His grandfather also had rheumatoid arthritis and he wondered about this as this started in his low back. He was hoping for an MRI scan today.
He lives with his wife and two children. He is normally fit and well, is an ex smoker. He works full time. He had a perforated stomach ulcer 11 years ago.
The key issues
- Recognition that there are multiple red flags that require further evaluation.
- Recognition that the naproxen may not be safe to take given his medical history.
- Recognition that a surgery face to face assessment may not be possible
- An explanation that his back pain maybe more serious.
- The impact his symptoms are having on his work
- Identification of the concerns that he has around finances and his grandfathers symptoms being similar.
- The safety implication around work and need to tell him to report what happened to his employer.
- As you suspect cauda equina syndrome, an emergency admission is warranted.
Dr Singh is a GP trainer in Northumberland