Abstract
In the last 25 years, the number of telephone consultations in general practice has increased significantly, whereas the number of consultations in patients’ homes has decreased. A study of over 100 000 000 GP and practice nurse consultations found that the average consultation rate per person had increased from 4.67 in 2007–08 to 5.16 in 2013–14 (Hobbs et al., 2016). Telephone consultations over the same period doubled. With workload increasing consistently, in excess of both population growth and the number of primary care practitioners, use of telephone triage has increased. Evidence does not support this as a strategy to reduce clinical workload. It may have the harmful effect of reducing disease prevention activities (Hobbs et al., 2016). Although telephone consultations are usually shorter than face-to-face consultations (mean duration 5.4 minutes compared with 9.22 minutes (Hobbs et al., 2016)) caution is required when seeking to reduce workload and save time. Same-day telephone triage is not shown to reduce overall workload. Approximately one-third of telephone calls result in a subsequent surgery consultation (Campbell et al., 2014; Holt et al., 2016). The ESTEEM study found that following doctor triage, there was a 22% increase in patients seeking medical help out of hours (Campbell et al., 2014). The National Association for Patient Participation do not support telephone triage noting increased anxiety and use of urgent care for patients following telephone triage (Pereira Gray and Wilkie, 2017; Wilkie and Pereira Gray, 2016).
The first contact with out-of-hours services is usually by telephone and many cases are managed entirely over the telephone. Offering advice over the telephone can be appropriate for many problems. Telephone advice can offer greater convenience to patients, particularly those at work, or with limited means of travel. Telephone consultations may be initiated by patients (for example, those wishing to discuss test results and further management from a previous consultation) or GPs. GPs may choose to discuss reports, discharge letters or results over the telephone. Although this can be a useful strategy in some circumstances for some patients, it risks raising expectations inappropriately. It is important to appreciate the limitations of telephone diagnosis and management and recognise when face-to-face consultation is necessary.
Risks
Telephone consultations are diminished by the loss of non-verbal communication, although being attuned to verbal nuances, such as hesitations, pauses and changes in tone can mitigate the loss. It is important for clinicians to be able to justify the diagnosis and management plan following a telephone consultation. When a third party (such as a carer) calls, patient consent and confidentiality must be respected (Males, 2015). It is not illegal to issue prescriptions following a telephone consultation, including antibiotics and controlled drugs (notable exceptions being non-surgical cosmetic products, e.g. Botox), but the doctor must have adequate knowledge about the patient and the problem to prescribe appropriately (General Medical Council, 2013).
Always consider whether physical assessment or other examination is needed and whether access to the patient’s medical records is required. Consider other practical issues around patients answering (or not answering) the telephone, calls going to answer-machine or voicemail, or even calling an incorrect number. These issues often hinder the utility of telephone consultations.
Successful consultations require efficient information gathering to ensure that all the relevant medical history is elicited. What medication is being taken? Does the patient have any allergies? Are there any red flags that might influence decision making? As with any consultation, establish the patient's ideas, concerns and expectations.
There is a risk of patient harm and litigation from telephone consultations, through inadequate or inaccurate history and premature decision-making (Males, 2015). It is important to develop skills, insight and flexibility when consulting on the telephone. It may be more appropriate to advise physical attendance or admission to hospital. Such advice does not imply failure of the telephone consultation, but recognises that a telephone consultation alone may not be adequate for safe decision making.
Patients may find telephone communication difficult. English may not be their first language. Communication may be impeded by learning disability or sensory impairment. In these circumstances face-to-face consultation is needed.
Some practices record telephone calls with patients’ consent and transcripts or recordings can be included in patients’ records. These can be an invaluable learning resource for trainees, and may be important medicolegally or in dealing with complaints.
It is important to emphasise that a request for ‘telephone advice’ from a patient, carer or colleague does not always mean that the problem can be managed over the telephone. Complaints may arise when a home visit is requested and the clinician manages the request appropriately with a telephone consultation. In the event of an adverse outcome giving telephone advice rather than visiting may be construed as a ‘refusal to visit’ (Males, 2015).
Improving telephone consultations
For GP trainees, telephone consultations are often a new and challenging experience. They are a part of everyday general practice and form part of the Clinical Skills Assessment (CSA). Inclusion in the CSA puts information gathering, patient-centred care and effective communication skills under scrutiny (RCGP, 2018). Trainees are advised to practise telephone consultations for the CSA. The introduction of Audio-COTs in ST3 (and as recommended in ST1/2) Workplace-based Assessments emphasises the importance of telephone consultations in training and has been written about in InnovAiT (Sales, 2017).
First identify both yourself and the caller. Speak slowly and clearly with telephone consultations. If not speaking to the patient, obtain verbal consent to consult with the other party. Gathering information, fact finding and checking understanding require more questions than with face-to-face consultations.
Be sure to address history and symptoms from the patient’s perspective and to explore their ideas, concerns and expectations. Non-verbal communication is lost, but clues can be gleaned from speech, background noises and what is not said (in pauses, silence and not answering questions). Be clear about any diagnosis offered and ask the caller to repeat and information or advice given to check patient understanding. Negotiate and share the management plan and decisions with the patient. Invite the caller to write things down as this can help communicate diagnosis and management plan.
Be clear with safety netting and follow-up advice. It is often appropriate to ask patients to attend. If the history is concerning, be prepared to admit a patient to hospital. This is particularly relevant when asking patients to attend might delay urgent treatment or when attendance is unlikely to change management.
Avoid the temptation to type notes while on the telephone. This causes distraction and vital clues may be missed. Document the consultation contemporaneously and thoroughly. Dedicated appointments for telephone calls can reduce interruptions. Familiarise yourself with protocols for managing common conditions. Review resources for signposting patients. Shared learning with experienced reception staff can improve telephone manner and effective triage of patients. Observation and feedback will help improve telephone consultation skills. If your practice can record calls, it is useful to study them within tutorials.
In summary, telephone consultations are an essential part of general practice and a convenient way to communicate with patients. However, there are pitfalls and good, safe telephone consulting requires skills that can be learned and developed.