Risks of telephone consultations

Consulting on the telephone requires a different skill-set, relying on common sense and improvisation. Learning how to do this effectively is necessary to safeguard patients and your professional position, says GP and popular author Dr Tony Males 

Telephone consultation Consulting by telephone is commonplace in contemporary primary care and has evolved in order for practice teams and out-of-hours providers to adapt to increasing patient demand. Practices differ in their use of telephone consultations and GPs may experience a variety of models. Requests for urgent appointments may be triaged at an administrative or clinical level, with call-backs made by nurses, nurse practitioners or duty doctors

Routine care can be provided by telephone and calls may be initiated by the patient, for example, in wanting to find out and discuss the results of investigations, or by the clinicians, such as in the follow-up of a long-term condition. Thanks to the practically universal ownership, or access to, telephones, this medium of communication is equitable and efficient, language barriers notwithstanding. It is absolutely imperative that we make telephone consultations medicolegally and clinically safe and effective

Risk Management

It must be acknowledged that telephone consultations lack the nuances and richness of the face-to-face consultation. The doctor is deprived of the non-verbal cues that become apparent the moment the patient enters the consulting room. A full clinical assessment is therefore not possible, but if the limitations of the telephone consultation are recognised and a careful history taken and documented, patients can be managed in a reasonable, appropriate and safe way.

It is important to remember that you must put yourself in a position to justify the diagnosis and management plan you make in the context of a telephone consultation, and if there is any doubt then a face-to-face consultation should be arranged. Remember that consultations with third parties further amplify the pitfalls of telephone consultations and introduce extra dimensions relating to consent and confidentiality.

Prescribing by Telephone

Whether prescriptions should be issued on the basis of a telephone history alone is a personal matter for individual practitioners and a policy issue for practices and out-of-hours service providers. The GMC states in its guidance that:

Before you prescribe for a patient via telephone, video-link or online, you must satisfy yourself that you can make an adequate assessment, establish a dialogue and obtain the patient’s consent…¹

The guidance also states that you must prescribe only when you have adequate knowledge of the patient’s health, and are satisfied that the medicines serve the patient’s needs.

Features of a successful telephone consultation include:

• Identifying oneself and the caller, the latter being the patient whenever possible
• Gathering information from speech (content, rate, rhythm, tone and emotion) and nonspeech sounds (cough, wheeze, background noises)
• Addressing both the clinical history and patient’s perspective, including the social and cultural context
• Giving a diagnosis or interpretation of the patient’s problem with an explanation or a summary
• Signposting the point at which a triage or management decision must be made
• Negotiating the outcome with acknowledgement and sharing of the decision. If it is agreed that no face-to-face meeting is necessary, then appropriate advice must be given and you should ensure that the patient is content with the suggested management plan
• Making follow-up arrangements and providing safety-netting advice
• Making a thorough, contemporaneous note, including the telephone number that was used in the consultation

Common pitfalls

The key stages in the telephone consultation that are prone to error are information gathering, making a decision and giving advice. Studies in the USA in the 1970s identified deficiencies in information gathering by trainee paediatricians conducting simulated telephone consultations.23456 For example, they missed out questions about medication given to the sick child, allergies and immunisation history. They failed to explore how well a child with a cough was breathing, or how well hydrated a child was with diarrhoea. The use of protocols improved the standard of history taking, but did lead to a higher number of patients being invited to attend the emergency department

In other studies involving simulated cases of sick children, nurses and doctors seemed to ignore additional information offered or concerns expressed beyond the point at which the clinician made a diagnosis or a decision about what to do.789 When GPs and community-based paediatricians were compared with hospital-based colleagues, the severity of a dehydrated baby’s illness was underestimated. The primary care doctors were described as having a wellness bias, as they were used to operating in a context with a low prevalence of serious disease.

We must be aware of making premature decisions in telephone consultations, keeping an open mind throughout and being willing to change our mind or management plan. We should include rare or serious conditions in our differential diagnoses, while we are listening to our patients’ histories and be prepared to convert our calls into face-to-face consultations if we pick up symptoms, or cues, that deviate from the common pattern.

Giving advice is a communication skill that is just as important as listening. It is amenable to being structured through checklists and protocols and can be backed up by written information that can be posted to the patient or accessed online. Resources such as the Minor Illness Manual are valuable for all clinicians in primary care.10 Good advice empowers patients and enables them to learn from one episode of illness to the next and may reduce their need for professional help. More advanced and unlikely to be provided by practices are decision-support software packages that support telephone triage by prompting clinicians to give comprehensive advice on conditions that may not need a face-to-face assessment. Organisations offering health advice and out-of-hours providers use these packages. 

Information governance with respect to telephone recordings

Some practices and out-of-hours providers record incoming and outgoing telephone calls. These electronic sound files form part of the patient’s records and can provide useful information in the event of a complaint or claim. Such recordings must be made, stored and disclosed under the provisions of the relevant legislation, and the patient must be informed of the fact that the call is being recorded.

Under the provisions of the Data Protection Act (1998), patients have a right to be provided with copies of information that is held about them and this would include recordings of telephone consultations. The GMC have produced some helpful guidance about the recording of patients in their publication entitled Making and Using Visual and Audio Recordings of Patients, which states that you must not make secret recordings of calls from patients (paragraph 56).11

In the context of a complaint or claim, a recording may provide information beyond what is in the records that can be of assistance to the doctor, but this is not always the case. MPS dealt with a case of a sessional GP working in the out-of-hours setting who accidently prescribed Penicillin to a Penicillinallergic patient. Unfortunately the patient had an anaphylactic reaction which required in-patient hospital treatment and a claim ensued.

The sessional GP had not recorded a history of allergy, but was adamant that their usual practice would have been to enquire about allergies before issuing a prescription and that the patient must not have given any indication that they were allergic to Penicillin. The triage telephone recordings were reviewed, from which it was clear that the patient (without any prompting) volunteered that they were allergic to Penicillin and on this basis the claim was settled.

Some general practices that should be considered in telephone prescribing are:

• The prescriber should ensure that the patient is content with the proposed management plan
• The regular medications (including overthe-counter medications) taken by the patient and any drug sensitivities should be known or elicited by the clinician
• The rationale for treatment should be explained together with its risks, benefits and burdens
• Adequate provision for follow-up in the event of no improvement, worsening symptoms or side effects should be made
• The patient or a carer should be in a position to attend a pharmacy, surgery or out-of-hours centre to obtain the prescribed item
• The drug prescribed should be efficacious, cost-effective, prescribed at appropriate dose and in the appropriate quantity
• For infections for which there is equivocal evidence for the effectiveness of antibiotics, the prescriber should consider the option of issuing a “delayed” prescription that can be redeemed by the patient at a future date should symptoms not improve spontaneously
• Controlled drugs should not usually be prescribed on the basis of a telephone consultation alone

Ethical considerations

Ethical issues arise when one considers that healthcare delivery by telephone is prone to error compared to its gold standard counterpart, the faceto- face consultation. What is the balance between the advantages and disadvantages to the patient?

How can the rights of the patient be reconciled with the duties of the practitioner? Beauchamp and Childress’ “four principles” ethical framework helps in the analysis of ethical questions from four different viewpoints: beneficence (doing good), nonmaleficence (avoiding harm), autonomy and justice.12

In circumstances when a patient or carer specifically requests “telephone advice”, you must not assume that the request can be managed by way of a telephone consultation. Conversely there may be occasions when you initiate a telephone consultation in relation to a routine matter that it may become apparent that a face-to-face consultation is required.

A frequent cause for complaint is when a patient or carer calls and requests a home visit, but instead receives a telephone call. It may of course be entirely reasonable to manage the problem by way of a telephone consultation, but if there is an adverse outcome then this frequently construed as a refusal to visit.

The avoidance of harm has long been a central tenet of medicine. Both patient and health professionals are at greater risk of harm through telephone consultation compared to the face-to-face encounter. The patient is vulnerable to the adverse health outcomes associated with an inadequate or inaccurate history, “wellness bias” and premature decision-making. The health professional who does not put herself in the best possible position to make a diagnosis and therefore provide appropriate treatment and advice is vulnerable to complaint and litigation if the patient suffers as a result of her negligence.

Clinician-initiated telephone consultations

• Monitoring of long-term conditions (cancer, heart failure, COPD, sometimes supplemented with data from assistive technology)
• Follow-up of acute conditions, eg, after home visits or after hospital discharge
• Informing patients of abnormal investigations and sharing the decision about further management
• Follow-up of patients who are quitting smoking
• Inter-professional conversations with primary care team members, hospital colleagues or professionals from other health or social care organisations.

Summary

Telephone consultations are an integral part of contemporary practice and form a useful tool for the assessment and management of both acute and chronic conditions. Telephone consultations have inherent risks, but as long as you are aware of these, have a low threshold for arranging a face-to-face consultation, put yourself in a position to make the diagnosis, make thorough records and ensure that the patient is content with the proposed management plan then these risks can be minimised.

References

1. GMC, Good practice in prescribing and managing medicines and devices (2013)
2. Ott J, et al, Patient Management by Telephone by Child Health Associates and Paediatric House Officers, Journal of Medical Education (1974)
3. Brown S, Eberle B, Use of the telephone by pediatric house staff: A technique for pediatric care not taught, Journal of Pediatrics (1974)
4. Greitzer L, Stapleton F, Wright L, Wedgwood R. Telephone assessment of illness by practicing paediatricians, Journal of Pediatrics (1976)
5. Strasser P, Levy J, Lamb G, Rosekrans J. Controlled Clinical Trial of Pediatric Telephone Protocols. Pediatrics (1979)
6. Levy J, et al, Development and Field Testing of Protocols for the Management of Pediatric Telephone Calls: Protocols for Pediatric Telephone Calls, Pediatrics (1979)
7. Perrin E, Goodman H, Telephone management of acute pediatric illness, New England Journal of Medicine (1978)
8. Goodman H, Perrin E, Evening Telephone Call Management by Nurse Practitioners and Physicians, Nursing Research (1978)
9. Yanovski S, et al, Telephone Triage by Primary Care Physicians, Pediatrics (1992)
10. Johnson G, Hill-Smith, Ian, Minor Illness Manual, Radcliffe (2012)
11. GMC, Making and using visual and audio recordings of patients (2011)
12. Beauchamp TL, Childress FJ, Principles of Biomedical Ethics, Fifth Edition, Oxford University Press (2001)

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