Abstract
The COVID-19 pandemic has led to many changes in general practice for both GP trainees, GPs and patients. However, the biggest change so far is to the mode of consulting. In Part two, Dr Hana Patel discusses tips for telephone and video consulting.
During the remote consultation
Establishing and confirming the identity of the patient is even more important during a remote consultation, as there may be more than one person visible on a video consultation or someone may be asking questions about someone else, for example. It is important that the clinician has up-to-date information on the location and availability of a face-to-face appointment should one be needed after the remote consultation. The need for a face-to-face appointment should be evident early on in the consultation, once the clinician is aware of the patient’s presenting complaint, their needs and expectations of the consultation.
Speaking at the same time as the patient because of connectivity issues is a common pitfall, so try and ensure one person is speaking at a time. The usual affirmations and gestures used by clinicians during face-to-face consultations may hinder remote consultations; the use of eye contact and facial expressions may be less of an interruption. Regular summarising and checking of understanding may be necessary during some remote consulting. For example, with complex medical conditions, explaining prescribing decisions, side effects, dosages and interactions. Documentation is even more important during a remote consultation, including the consideration of a face-to-face appointment, management plan, safety netting and follow-up.
Clinical examination may be necessary during remote consultations and the RCGP and general medical council (GMC) have released guidance specifically related to this. Patients should only send pictures if requested during a consultation, with their use and storage being explained to patients. There is guidance for how pictures should be taken, so as to ensure patient anonymity. The need for intimate examination and related pictures should be considered before being requested. Consider how such information will change the clinician’s management and whether the risk of a face-to-face appointment is warranted. If an intimate examination is deemed necessary by remote consultation, then doctors should follow the GMC’s guidance on intimate examinations and chaperones, ensuring thorough documentation.
Safeguarding and remote consulting
As the majority of primary care appointments are now carried out remotely, it is important for practices to be aware of patients who are socially disadvantaged, have a disability or not have access to digital technology to make appointments. An alternative method of booking appointments and conducting consultations is required for these patients to ensure equity of access to healthcare. As discussed earlier, the usual nonverbal cues within face-to-face consultations may not be apparent during remote consultations and therefore the threshold for initiating a face-to-face consultation and examination should be lower if a safeguarding concern is suspected. The same principles of Gillick competence should be used for children under 16 years old for remote consulting.
Top tips for telephone consulting
In addition to the suggestions made so far, it is important to establish where a patient is during a telephone consultation, as they may be in a public area or a different address to that stated in their medical records. Some patients may have access to home monitoring devices and be able to give you up-to-date observations, for example on their blood pressure, pulse-rate and rhythm, oxygen saturations, blood sugar and temperature.
With COVID-19, it is important to establish whether a patient has pre-existing health conditions that may exacerbate a potential COVID-19 infection or actually be causing the symptoms. Patients may be self-medicating with herbal or unprescribed and unlicensed medications, so a thorough medication history is essential. The government guidance for patients who are diagnosed with COVID-19 or those self-isolating does change, as do testing sites and local services that patients can be signposted to. If your practice is not offering face-to-face appointments, be aware of the up-to-date sites where patients can be seen face-to-face and the specific guidance related to access.
Top tips for video consulting
As soon as you have confirmed the patient’s identity and the reason for consulting, it is important to try and obtain as much information about the clinical scene as possible. By visually assessing the patient, the clinician can, for example, observe the patient’s behaviour, respiratory rate, general demeanour and surroundings. The patient can also tap out their pulse or put their hand on their chest making it easier to see the respiratory rate and use of accessory muscles. Unlike face-to-face consulting, it is advisable to be direct when taking a history, almost following a disease–illness model of consulting, asking direct questions and being explicit about concerns. For dermatological conditions, it may be advisable for patients to send in photographs as these have a better resolution video images.
Final thoughts
Remote consultations are fast becoming the mainstay of general practice, with up-to-date advice and guidance being published by the Department of Health, RCGP, GMC, british medical association (BMA) and NHS England as the COVID-19 pandemic evolves. There is increasing anecdotal evidence emerging of rising dissatisfaction with remote consulting among general practitioners and patients alike. The NHS Long Term Plan envisaged digital first primary care being the norm by 2023/4. Unfortunately, due to the COVID-19 pandemic, the pace of change is causing stress to the primary care workforce and impacting upon the wellbeing and retention of GPs.
