Telephone Medical Advice

The telephone has been in widespread use for many decades.  It is now an integral part of the modern healthcare system1.  Telephone consultations may reduce the doctor’s workload and improve access to health services.  However, it is still viewed with a degree of apprehension by some doctors in their clinical practice.  They remain concerned about giving medical advice over the phone to their patients.  This is partly due to lack of training in how to conduct a consultation over the phone.  As a consequence there is considerable variation in how doctors perform when using this form of communication.  The advice provided to patients is not standardized and protocols are not in general use.  The barriers to change need to be explored. If we agree that telephone consultations are important, we need to ensure that doctors have the adequate skills. 

In 1984 Obelklaird et al stated that it was not acceptable that outside lines should be dealt with in an ‘ad hoc’ manner2.  He urged that dedicated phone services should be set up with health professionals.  It is recommended by a number of commentators that patient simulators should be used to teach telephone communication skills.  This type of role play can be very beneficial for trainees.   One approach is to design an interactive programme with scripts representing the 10 most common conditions that doctors receive from patients3.  The MPS point out that the approach may differ between various specialties4.  The primary care doctor may have a wellness bias as they encounter a low prevalence of serious illness.  The hospital-based doctor, on the other hand, may have an illness bias leading to a higher conversion rate to a face-to-face consultation.   

There are a number of useful pieces of advice.  Conduct the telephone consultation in a quiet room using a landline.  The use of a headset frees both hands for tasks such as making notes and going through charts.  The call should have a beginning, middle, and end.  The beginning is related to the introduction.  At the outset confirm the patient’s name, and other identifiers such date of birth.  Introduce yourself and explain that you are calling from the GP surgery or the hospital.  It is important to come across as welcoming and supportive.  It will help to reduce the patient’s anxiety and it more likely that they will explain their symptoms or concerns more clearly.  The character of one’s voice is the only way that the patient can assess you.  If it is too loud it may come across as aggressive and uncaring.  If too soft it may give the impression of lacking in confidence.  A slower pace of speaking is easier to hear and allows space for dialogue.   

The middle is about the information exchange.  Active listening and critical thinking are important.  The doctor needs to be clear about what the patients is saying, and the story must make sense.  Don’t jump to conclusions before the patient has had time to adequately explain himself.  Written documentation is important similar to a face-to-face interaction.  The length of the conversation should be recorded. The written note of the interaction should be placed in the patient’s notes.

The end is about summarizing what has been discussed.  The action plan should be confirmed.

One needs to be aware of red flag symptoms.  There are different bundles of red flags depending on the age group of the patients.  In an infant, symptoms such as irritability and drowsiness may be indicative of meningitis. 

In many situations the calls from patients are frequently answered and dealt with by nurses.  In the UK, 40% of the contacts to NHS Direct are about children.  In general, these services are very much appreciated. Families are looking for a valued opinion that is safe and reliable.

It is common for parents worried about their young infant to phone through to the maternity hospital.  In one study 55% of called were handled by the nursing staff, and the remainder by the doctors5.  The outcome of the consultation was that one third of the parents were simply given advice, one quarter were told to attend the ED department, and the remainder were advised to attend their GP or the baby clinic the following day.   The high level of referral for a clinical examination reflects that in the case of young infants phone calls are difficult because visual clues are such an integral part of the assessment.  The level of concern expressed by the parent also influences whether the infant is brought in for a physical examination.

There are many persisting perceptions about the telephone consultation that are inaccurate.  It is incorrect that telephone consultations are mostly for GPs and are of less value to hospital medical staff.  It is incorrect that telephone consultations are favoured mostly by younger patients.  On the contrary many older patients find them very helpful and they reduce the number of trips to the surgery.  It is incorrect that consulting over the phone makes it more likely that a doctor will be sued.  Similar to a face-to-face consultation the key criteria are keeping good documentation of the information provided by the patient.  Understandably there are some limitations to the telephone conversation. One may not be sure about the nature of the problem.  A physical examination may be necessary.  The patient may have hearing or cognitive problems.

One of the real strengths of the telephone is that it can be very supportive in the management of long-term conditions such as epilepsy and diabetes.  It is useful in conveying the results of tests.  It serves as a reminder to patients about up-coming appointments.

In summary while very useful, telephone consultations require a different skill set.  Common sense and improvisation are important.  The inherent risks can be avoided as long as one is aware of them.  There must a low threshold for changing to a face-to-face examination.  A good written record of the interaction is of paramount importance.  Before concluding the conversation, it is important that the patient is content with the advice provided and the management plan.  One needs to take special care with answering machines.  There is a risk that it is the incorrect number or that the message could be picked up by someone other than the patient.  Ideally it is best to leave a brief message asking the patient to ring back.

JFA Murphy

Editor

References

1. Van Galen LS, Car J. Telephone consultations. BMJ 2018;360
2. Oberklaid F, Bell J, Duke V. Paediatric telephone consultation- a neglected area of health service delivery. Aust Paediatr J 1984;20:113-4
3. Vaona A, Pappas Y, Grewal RS, Ajaz M, Majeed A, Car J. training interventions for improving telephone consultation skills in clinicians. Cochrane Database Syst Rev 2017;1:CD010034.28052316
4. Medical Protection Practice Matters. Risk of telephone consultations. www.medicalprotection.org/uk/practice-matters-june-2015/risks-of-telephone-consultations.
5. Travers CP, Murphy JFA. Neonatal telephone consultations in the National Maternity Hospital Ir Med J;2014;107;P251


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