The Telephone
Dr Julian Tomkinson Nov 2012
Aims of session
• Discuss use of telephone in general practice
• Look at some of evidence written
• Case scenarios / practice
Curriculum
2.01 The GP Consultation in Practice
Recognising how consultations conducted via
remote media (telephone and email) differ from
face-to-face consultations, and demonstrating
skills that can compensate for these differences
Curriculum
3.03 Care of Acutely Ill People
Communicate effectively with patients, relatives
and carers over the telephone in order to
accurately assess a patient who is acutely ill
Any worries about
using the phone?
Any help you need?
CSA
The circuit of 13 cases in the CSA
examination may include one
telephone triage case
New RCGP Building
Euston Square
What do we use the telephone for?
• To communicate with patients – in acute and
follow-up situations
• To communicate with other doctors and team
members
• Administrative tasks
Telephone use with patients
• Straightforward consultation
• To discuss results / prescription requests etc
• For Triage
• Review
Some statistics regarding telephone
consultations
• c.25% of primary care
consultations are telephone
based
• Up to 55% of all OOH service
calls are advice only.
• In Bolton (where I do a weekly
OOH shift) all OOH calls triaged
by GP or Nurse
Benefits
To the patient
• Perceived as more
convenient and quicker.
• Easier access to self-care
advice and
• Increases access for who
find getting to surgery
difficult
Benefits
To the doctor
• Improving efficiency by
moving the information
instead of the patient
• Triage - patients who need to
be seen can be given
appointments at times when
demand is high
• Can reduce workload - about
50% telephone consultations
result in telephone advice
alone.
GMC Guidance
The GMC has emphasised that phone (or e-mail)
should not diminish the quality of care patients
receive.
This is most likely to occur where:
• The patient is not previously known to the
doctor.
• The assessment may be helped by examination.
• There is little or no provision for appropriate
monitoring of the patient or follow-up care.
What are the differences?
Phone vs Face to face
Face to face
7%
36%
57%
Body language
Tone of voice
Words
Telephone
WORDS
TONE OF VOICE
16%
84%
Communication outcomes
• More biomedical and less psychosocial or
affective information is exchanged.
• Shorter interactions account for variation seen
in areas such as rapport building, patient
education and counselling.
• Doctors behave in a less patient-centred way
on the telephone.
Circumstances surrounding use
of phone
Ideal situation
Time to prepare and not doing anything else
Opposite
An interruption ie. doing something else / no
preparation time
Suggested approach to a telephone
consultation
• Answer the telephone promptly.
• State your name
• Obtain caller's name and telephone number (in the event the patient has to
be called back by another member of the team or the call becomes
disconnected).
• Speak directly with the person who has a problem.
• Record date and time of call.
• Record person's name, gender and age (obtain person's medical record, if
available).
• Take a detailed and structured history. (REMEMBER ICE)
• Provide advice on treatment/disposition.
• Specific advice regarding follow-up and when to contact a doctor.
• Summarise and record the main points covered.
• Request caller to repeat advice given (several times throughout the
consultation).
• Ask if the person has any outstanding questions or concerns.
• Let caller disconnect first.
Training in telephone consultation
skills should focus on
• Active listening and detailed history
taking
• Frequent clarifying and paraphrasing
(to ensure that the messages have been
brought across in both ways)
(chunking and checking)
• Picking-up cues (eg pace, pauses,
change in voice intonation)
• Offering opportunities to ask questions
• Offering patient education
• Documentation
History
•
•
•
•
•
•
•
Chief complaint
What else is happening?
Character of symptoms
Onset
Duration
Location
Alleviating or worsening factors
DON’T FORGET TO DO WHAT YOU
NORMALLY DO
•
•
•
•
•
•
PMH
Risk factors, e.g. Foreign travel
Pregnancy
Medications/otc
Allergies
Lives alone?
Things to remember
• Ask if there is anything else worrying them
• Be ready to take control ... nicely
• Check that your final understanding of the
problem matches yours.
• Beware of previous assessments clouding
your judgement but.... 2nd calls about
same problem should be red flags.
• Safety net with time frame, what to watch
out for and ensure understanding. Who to
call ?
Management Plan
•
•
•
•
Prepare to negotiate
Ambulance calling and refusal
Be ready with another plan if they disagree
Educate .. how long? What changes to look
out for?
• Meet anger with acknowledgement and
calmness
• RECORD EVERYTHING
Closure
•
•
•
•
Make sure not premature
Let the patient disconnect first
Everyone is clear on what happens next.
Eg in OOH setting
– Advice?
– Home visit?
– Coming to centre? (+ where do they come)
Records
• Document all incoming and outgoing calls
with patients (and third party informants).
Even brief contacts can be critical and notekeeping must be as reliable as for a face to
face contact.
Appropriateness and safety
• Always ask yourself, "Is telephone
management appropriate in this
situation?".
• Revisit this question several times
during the consultation.
• As the assessment is based solely
on the history, and the
management plan cannot be
reinforced with non-verbal cues,
being systematic in covering all
issues is especially important.
Common errors in telephone consultations
Type of error
Information gathering
Common examples
•Inadequate drug and allergy history
•Absence of key questions
•Clinician anger and frustration with
psychosocial problems
Relationship building
•Patient anger over unmet
expectations
Decision making
Explanation and planning
Techniques to prevent error
•Open question
•Triage protocols
•Checklist
•Attentiveness to verbal and non-verbal
cues
•Overt expression of empathy
•Clarify reason for call
•Supervision and feedback from regular
call recordings.
•Premature decision-making or too
early closure in the consultation
•Absent diagnosis
•Wellness bias
•Frame problems in terms of disease
and illness
•Involve patient in decision-making
•Unclear instructions and treatment
explanation
•Smaller chunks of information.
•Ask patient to repeat information to
check understanding
•Safety-netting
Medico-legal points
• MPS report 22% of complaints about
rudeness and attitude of clinician (lack of
visual clues can make you sound rude)
• Your duty of confidentiality means you need
to ask yourself if you can guarantee any
message you leave will remain confidential
and will reach the patient
• Take care speaking to / about patients on
phone when away from work
• Organise protected time and a confidential
environment for telephone consultations
Check List
1.
2.
3.
4.
5.
6.
7.
8.
9.
Prepare – gather info/breathe/ smile
Introduction
Check patient information
Find out what is happening – open start
Check patient’s thoughts, feelings and wishes(ICE)
Remember red flags
Formulate a diagnosis / strategy
Check / Safety net / Close
NOTES
References
• Car J, Sheikh A; Telephone consultations. BMJ.
2003 May 3;326(7396):966-9.
• GMC; General Medical Council; Providing
advice and medical services on-line or by
telephone; (1998); (pdf)
• Males T, Telephone consultations in primary
care: a practical guide. RCGP 2007. ISBN: 9780-85084-306-4