South Bristol Trainers WorkshopSaunton Sands1.4.11

Broad aims of phone consultation:Make accurate assessment of clinical problem

Provide appropriate advice or offer consultation (where?)

Ensure patient safety (safety-netting++)

Caller (may or may not be pt) satisfied with outcome

Dr satisfied

Appropriate use of resources

PHONE CONSULTATIONS...

Easy or tricky?

What makes them challenging?

Some of the challenge of phone consultations...Effective communication without the non-verbal

cues

Obviously makes assessment of physical condition harder (diagnosis & just how sick) but also...

Relative anonymity: psychological distance (lack of social cues) on phone...greater likelihood of expressing anger & anxiety, & potential for miscommunication, so...

Harder to make accurate diagnosis & appropriate Rx decisions than face to face

Harder to know if caller truly satisfied as can’t see them

Weighing up if face to face needed & if so where (matching pt’s ‘needs’, not necessarily ‘wants’, with appropriate resources)

One thing is on our side...

80% of diagnosis comes from the history

But...55% of communication relies on

observation of body language & facial expression...

8% comes from the actual words themselves and 37% from vocalisation (phrasing, emphasis, tone, pauses etc)

Survey of GPs’ concerns & confidence in phone consultations...(BJGP 1999)

4 most frequently mentioned ‘difficult calls’:

Difference of opinion on need for home visit Parental anxiety about children (& GP anxiety)Chronic conditions (symptoms suggesting something new

or part of continuing problem?)Mental health problems

Confidence levels in these same GPs...Far greater in own practice than OOH

Sense of risk & uncertainty worse OOH

Lack of info re pt’s medical & social history OOH

Different working relationships with colleagues OOH – less able to discuss tricky encounters than in own practice

Conflict twixt doing best for pt & duty to co-op – felt pressure to be quick& efficient & resist visits if possible

Not knowing outcome of phone advice given OOH

How can we as trainers help our registrars develop safe and effective telephone skills ?

Patient-centred models...Cambridge-Calgary consultation guide can help us,

applied with even greater depth & intensity to phone consulting:

InitiationGathering informationBuilding the relationshipStructuring the interviewExplanation & planningClosure

• exploration of the patient’s problems to discover the: biomedical perspective; the patient’s perspective ; background information - context

• providing the correct type and amount of information

• aiding accurate recall and understanding

• achieving a shared understanding: incorporating the patient’s illness framework

• planning: shared decision making

Initiating the session

Gathering information

Physical examination

Explanation and planning

Closing the session

Providing structure

Building the relationship

• preparation• establishing initial rapport• identifying the reasons for the consultation

making organisation overtattending to flow

using appropriate non-verbal behaviourdeveloping rapportinvolving the patient

• ensuring appropriate point of closure• forward planning

Top Tips...Even before picking up phone:

- check what’s known about pt- but avoid assumptions

Introduce yourself, Dr .... Calling from ....

How you start is really important...+ve attitude, make pt feel you’ll do all you can to help

If possible speak with actual patient (if 3rd party remember confidentiality issues)

Attentive listening: - note words used, tone of voice, emotion, pauses- encourage pt contribution (silence, “uh huh”, “I see”, “anything else you feel I should know” etc)- echoing, paraphrasing (checking your understanding)- cues

PMH, drugs

ICE (incs pt health beliefs)

Top Tips...Speak to listen rather than listen to speak...

Mental clipboard

Use of C-C techniques: periodically summarising, chunking & checking, signposting

You can’t examine...use caller’s senses to help you

Avoid ‘rigid hypothesising’ (or ‘mind snapping shut’)

Share your understanding of problem & negotiate management plan (without being unduly influenced by pressure of workload)

Matching pt need (not necessarilywant) with medical provision

If visit seems inevitable – offer early in consultation – reduces potential for conflict

And finally...If needs to be seen: PCC or visit? (quicker seen at PCC

& better facilities for assessing...?)

Safety netting – hugely important with phone consultations:

- specific instructions (“worse”?)- possible unexpected outcomes- how to seek help- check understanding

DOCUMENTATION (remember the 3 major failures...)

Potential pitfalls:Inadequate history taking

Incorrect assessment

Premature decision-making (mind snapping shut)

Conflict (eg over necessity for not for visit)

Failure to visit

Fear or anxiety can make pt seem uncompromising & antagonistic, need to recognise these emotions

In fact you could hit all 3 big potential failures in a phone consultation...Misdiagnosis

Failure to visit (when it was actually warranted)

Failure to refer

Ethical considerations of phone consultations?

Possible teaching opportunity?

BENEFICIENCE

NON-MALEFICIENCE

AUTONOMY

JUSTICE

Does the literature help?BJGP 1999 one of 1st articles

Everything between 1999-2007 pretty much summed up in RCGP Book “Telephone Consultations in Primary Care”

Most useful bits for jobbing GPs:

Negotiation more difficult than face to face

Different style of interviewing...more Qs (?signposting so doesn’t seem interrogation)

Suggested skills lists and approaches from phone skills courses & articles (handouts)

Specific skills to be encouraged:

cues from tone of voice, emotion, pauses, as well as words

overt expressions of empathy

Using pt or carer’s eyes & other senses to supplement history

Give info in small chunks & check understanding, reinforce by repetition

Common errors...In info gathering:

- inadequate drug & allergy history- absence of key questions

In relationship building:- clinician anger & frustration psychosoc probs- pt anger at unmet expectations

In decision-making:- Premature decision-making, absent diagnosis, wellness bias

In explanation & planning:- unclear communication of instructions & Rxs

Literature 2007-2010?

Not a lot...

15.2.08: Cochrane Review: Telephone consultation & triage: effects on healthcare use

& patient satisfaction – looked at 9 studies...50% calls handled by phone only (no need for face to face)Appeared to reduce visits to Drs & not increase those to A&EAppears safePts just as satisfied as seeing face to face