An increasing number of patient consultations are being conducted by telephone. Some 10-20% of in-hours contacts between patients and GP surgeries take place by phone.
First contact with GP out-of-hours service is also usually by telephone, with a large proportion of contacts being managed entirely over the phone.
Consultations by telephone do have risks but they can be a safe and appropriate way to consult with a patient, provided the doctor is fully aware of the limitations of assessing patients this way.
Diagnosing on the telephone
While telephone consultations are regularly used to triage calls, patients can also be diagnosed by doctors this way. However, the key issue is to recognise when this mode of consultation is not sufficient to properly assess the patient and address the problem, and to arrange a face-to-face consultation instead.
In our experience, failure to see the patient face-to-face when it would be appropriate and sensible to do so is the main area of risk for doctors. Difficulties can arise when doctors try to reach a diagnosis via the telephone when the complexity of the patient or the condition means a face-to-face consultation is required.
Other notable risks include failure to safety net or provide sufficient advice in the event of a patient’s condition deteriorating. Adequate provision for following-up should therefore be arranged in the event of the patient showing no signs of improvement.
Minimising risks of phone consultations
There are certainly ways to minimise such risks during telephone consultations. A recognised structure for clinical encounters by telephone is actually very similar to that in face-to-face consultations.
The doctor needs to establish the clinical facts, including relevant history, and obtain the patient’s perspective about the issues at hand. A management plan that can be understood by the patient should be agreed with the aforementioned safety net in place should things not go as expected.
Recording the call with appropriate data protection protocols can be of great value and assistance when things go wrong.
What is missing, of course, is the absence of both proximity and visual clues during the conversation, which means that the doctor needs to compensate. The subtle and more obvious face-to-face cues obtained through non-verbal communication are lost and any incongruity of affect present is more difficult to detect from words and tone of voice alone.
What you can’t see in a telephone consultation are the obvious and sometimes subtle facial expressions, gestures and postures that often provide evidence as to an individual’s true thoughts and state of mind.
Ask more questions
When on the phone, it can help to talk more slowly and clearly (the so-called telephone voice). Doctors should also ask more questions than they might otherwise in a face-to-face consultation to ascertain facts and to ensure the patient clearly understands what is being said.
It can be helpful to ask the patient to repeat back to you what has been discussed and agreed. Consider asking the patient to write down the details of any agreed management plan and what to do if things don’t go as expected.
Adopt a lower decision-making threshold about reverting to a face-to-face consultation and be mindful of the potential outcome in any delay getting a patient in front of you. For example, a two-hour gap before examining a patient could be long enough for serious deterioration in certain cases.
Some other practical risk reduction measures to consider include:
- dedicated and protected telephone consultation times (i.e. no interruptions)
- enhanced documentation to compensate for the absence of physical examination
- standardised protocols for managing the more common conditions, similar to those used by NHS 24
- appropriate training for all staff involved in the telephone consultation process
When to use phone consultations
Taking all of this into account raises some interesting questions and challenges about why telephone consultations are offered in the first place? Certainly, for discussing test results or administering regular repeat prescriptions, it can save the doctor and patient time without impacting on patient safety.
However, if a more risk-averse approach were adopted through increased scrutiny and enhanced safety netting, then by default a telephone consultation could quite easily take up more time and resources than seeing the patient face-to-face in the first place.?
- Alan Frame is a risk adviser at MDDUS www.mddus.com/risk-management