Hello, doctor?

THE TELEPHONE WAS invented in 1876 and it was only three years later that the first relevant medical use was noted in The Lancet (a child with respiratory symptoms). Since then there has been an inexorable rise in the use of the telephone between doctors and patients – with an accelerating trend in recent years.¹

Latest data suggest that 10-20 per cent of all daytime contacts between patients and GP surgeries happen on the phone. Some practices now use the telephone to screen all patient requests for daytime appointments for ‘new’ problems using a service called the Stour Access System.

In secondary care, the phone is used to allocate patients to clinics (more or less formally triaged) and for follow-up by phone (e.g. test results, response to medication, etc). First contact in out-ofhours (OOH) GP services is usually by phone and a significant proportion of cases are managed via telephone. Dental emergencies – at least OOH – are formally screened on the telephone and dentists use it in follow-up of some patients.

So do patients approve? The answer is probably ‘yes’ but only just so long as they see the telephone as an addition to face-to- face service rather than as a barrier to access. A well-run telephone consultation option is part of modern primary care.

Where do the clinical and medico-legal risks arise? No published studies look specifically at this important matter and it is rarely mentioned in case reports. Understanding comes from research into the mechanics of telephone consultations, opinions from experienced teachers and researchers and (importantly) from the reports of medical defence bodies (e.g. MDDUS) and the NHS ombudsmen.

Three themes tend to recur: failure to see the patient, failure to pass on important information (e.g. a test result) and failure to provide sufficient advice in the event of a deterioration. There are certainly ways to minimise such risks in telephone consultations. A sound structure for clinical encounters by telephone is similar to that in face-to-face consultations. We need to:

• establish the clinical facts
• the patient’s perspective
• “examine” (ask the patient or other third party to describe things, e.g. skin lesions)
• come to a decision about what is going on and tell this to the patient
• offer some explanation
• predict the future course of the illness
• hatch a management plan
• ensure that this plan is understood
• create a safety net in case things don’t go as well as we hope.

Of course, the lack of both proximity and visual clues means that we need to adjust our behaviour. In dealing with patients on the phone it helps to talk more slowly and clearly (the ‘telephone voice’). You should ask more questions (to be certain about the facts) and ensure the patient clearly understands what is being said. Seriously consider asking the patient to write down the details of any management plan and what to do if things don’t happen as expected (i.e. the safety net).

In the event that either the clinician or the patient remains unsatisfied after completing these steps, it is wise to arrange a face-to-face consultation. Even if you are going to see the patient, some attention to the above steps remains necessary – e.g. a two hour delay before physical consultation is long enough for deterioration in acute cases.

The telephone can also help us to reduce risk – notably by passing on the results of investigations and assessing progress in follow-up. It may be easier to telephone a patient three weeks after an outpatient clinic, say, than it is to have the patient attend another clinic. Most GP surgeries have a system for logging all results and ensuring that they are communicated to patients. The telephone can make this task more manageable.

It’s clear that patients benefit from an appropriate and well-run telephone service. A short paper by Car and Sheikh² offers an excellent summary and I finish with their key risk management recommendations:

• staff training for all involved
• standardised protocols for managing common scenarios
• dedicated telephone time for clinicians
• increased and improved documentation
• low decision threshold for organising face-to-face consultations.

Dr Malcolm Thomas is a GP and founder of the training company EPI.

REFERENCES
1. Males T. Telephone consultations in primary care. London: RCGP; 2007
2. Car J, Sheikh A. Telephone consultations. BMJ 2003; 326: 966-9