Telephone consultations: Hanging up on the risks
Delivery of clinical care via telephone is becoming more common but the practice carries unique risks to both doctor and patient; Charlotte Hudson looks further into the issue
The telephone has been used as a tool for delivering healthcare since 1876 when Alexander Graham Bell invented the device. In fact, the very first telephone call was also the first telephone call for medical assistance after Bell spilt sulphuric acid on his clothes.
Not long after its appearance, physicians were answering the telephone even during consultations with other patients in the room, which, today, would breach patient confidentiality. The Lancet then proposed a rule that “calling up the doctor on the ‘phone should be limited to urgent cases”.
As the 20th century evolved, however, the Lancet insisted that practitioners must make themselves available by telephone.1 In 1906 there was an entry in the Lancet stating how a man had phoned his doctor for professional advice and when the patient was billed for the advice he refused to pay. On the question of whether or not it was proper to consult by telephone, the judge ruled that it was the doctor’s duty to decide whether he might safely give further instructions by telephone provided he had previously seen the patient.
Today, telephone consultations are widely used by GPs and patient satisfaction is high. Speed, improved access, convenience to patients and possible cost savings are the principal advantages of consultations by telephone.2 Talking to a patient on the phone, however, exaggerates the difficulties of a face-to-face consultation because there are fewer cues to pick up on.3 From the moment a patient walks into the consultation room you can immediately see their facial expressions and, sometimes, their symptoms.
A full clinical assessment is not possible by telephone, 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.
Talking to a patient on the phone, however, exaggerates the difficulties of a face-to-face consultation because there are fewer cues to pick up on
Benefits of telephone consultations
In March 2012, 165,371 qualified health practitioners in both public and private sectors were registered with the HPCSA. This includes 38,236 doctors and 5,560 dentists.4 Scarcity of healthcare practitioners is experienced around the world, but the situation seems worse in African countries, as reported by the Department of Health. A report issued in March 2008 highlights the fact that Africa carries 24% of the world’s disease burden with only 3% of the world’s health workers.5
The doctor-to-population ratio is estimated to be 0.77 per 1,000 but because the vast majority of GPs – 73% – work in the private sector, there is just one practising doctor for every 4,219 people. In this environment, with a shortage of doctors and medical specialists in both rural hospitals and the referral centres, telephone consultations can help ease the pressure on doctors and allow them to help more patients without the patients having to travel from one area to another.
During a telephone consultation with a patient you should ensure that your conversation cannot be overheard by other people, and you should make sure that it is the patient you are speaking to on the phone and not a relative or friend, as this is a breach of patient confidentiality.
During a telephone consultation with a patient you should ensure that your conversation cannot be overheard by other people
In the HPCSA guidance Confidentiality: Protecting and Providing Information (2008),6 the principles that should be applied are set out, including: “Patients have a right to expect that information about them will be held in confidence by healthcare practitioners. Confidentiality is central to trust between doctors and patients. Without assurances about confidentiality, patients may be reluctant to give practitioners the information they need in order to provide good care.”
Some hospitals 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. Provided all reasonable steps have been taken to inform callers, telephone calls may be recorded. Secret recordings are not permitted.
Prescribing by telephone
The General Medical Council (GMC), which regulates UK doctors, states 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. You should identify when you should see a patient in person, for example, if the symptoms aren’t clear or you can’t evaluate the patient over the telephone.
The rationale for the treatment should be explained together with its risks, benefits and burdens. Adequate follow-up in the event of no improvement, worsening symptoms or side effects should be made. The World Medical Association (WMA) states: “While the practice of telehealth challenges the conventional perception of the physician–patient relationship, there is a ‘duty of care’ established in all telehealth encounters between the physician and the patients as in any healthcare encounter.”7
Relevant legislation and regulations that relate to patient decision-making and consent should be applied to telephone consultations. To the extent possible, informed consent should be obtained by the physician before starting any service or intervention. Where appropriate, the patient’s consent should be noted in the documentation of the consultation.
Tips for an effective telephone consultation
- Obtain and document a thorough history. Telephone consultations do not give a doctor the opportunity to assess clinical signs.
- When calling a patient, remember not to breach confidentiality – be cautious about revealing your identity until you have confirmed that you are speaking to the patient. You should only discuss details with a friend or relative if you are sure that the patient has given their consent. Try to take the call in a quiet room on your own.
- Inform the patient when recording a telephone consultation. There should be robust procedures in place for storage, retrieval and transcription of the call.
- When gathering information on the caller’s problem, make sure you ask some open questions and closed questions, ensure that you are in a position to reach a sound clinical judgment, agree a plan of action with the patient, and check that they agree with it and understand it.
- Request that the patient repeats advice given (several times throughout the consultation).
- Document the consultation accurately and contemporaneously.
- Be able to justify any course of action that is taken, eg, diagnosis.
- Follow-up: check existing medication when prescribing new medication, explain to patients what they should expect by way of improvement, significant symptoms to report, or when to phone back if they are not getting better.
Case study 1
Surgeon Dr S performed a laparoscopy on Ms L for suspected endometriosis. However, during the procedure Dr S became worried about the possibility of a bowel perforation; he requested that general surgeon Dr K perform a sigmoidoscopy. No damage was detected.
Dr S was to be away from the hospital for a week and advised Ms L to inform Dr K immediately if there were any complications. Four days later, however, Ms L’s husband contacted Dr S directly with concerns over the pain his wife was suffering.
Instead of advising Mr L to take his wife to see Dr K, Dr S reassured him that the symptoms were in fact normal and that Ms L was probably improving
Instead of advising Mr L to take his wife to see Dr K, Dr S reassured him that the symptoms were in fact normal and that Ms L was probably improving.
Two days later, Ms L was taken to see her GP and was admitted to hospital with septic shock; she underwent an emergency laparotomy and colostomy. Mr L made a claim against Dr S.
Dr S knew he could not evaluate Ms L’s condition over the phone and admitted that he should not have relied on Mr L’s interpretation of his wife’s symptoms. He should have referred her to Dr K. The claim was settled for a low sum.
Case study 2
Mr Q was admitted to casualty with abdominal pain. Surgeon Dr P, who was at least five hours away from the hospital, was phoned and asked to take over management of the patient. After a brief conversation with the referring casualty doctor Dr P asked that the patient be admitted in the ward and kept nil-by-mouth.
When he arrived, Dr P saw Mr Q: he realised that the patient was sicker than he had thought and required an urgent laparotomy; Dr P’s working diagnosis was that the patient had a dissecting aortic aneurysm. On opening the abdomen it was clear that Dr P’s diagnosis was correct and the patient bled profusely from an underlying dissecting aorta aneurysm. Unfortunately attempts to stop the bleeding were unsuccessful and Mr Q died.
Mr Q’s relatives made a claim against Dr P. Expert opinion was that all the symptoms of impending aortic aneurysm rupture were present when Mr Q was first seen: the patient had back and/or chest pain, hypertension and dilated bowel loops on abdominal X-ray. Although not all this information was initially passed on to Dr P, he should have excluded it prior to having accepted Mr Q.
The problem in the case really revolved around the referral of a patient with an acute abdomen where Dr P was not immediately available
The problem in the case really revolved around the referral of a patient with an acute abdomen where Dr P was not immediately available. Under the circumstances, he should have tried to exclude conditions that would have been life-threatening in the short-term; here aortic aneurysm was one of the possibilities and, had he interrogated the doctor, then he would have been aware of the fact that the signs and symptoms were all present. The claim was settled for a substantial sum.
Telephone consultations are a useful tool for the assessment and management of both acute and chronic conditions. They have inherent risks, but as long as you are aware of these risks, have a low threshold for arranging a face-to-face consultation, put yourself in the position to make the diagnosis, make thorough records and ensure the patient is content with the proposed management plan, then those risks can be minimised.
- Aronson S, The Lancet on the telephone 1876– 1975. Medical History, 21, pp 6987 doi: 10.1017/ S0025727300037182 (1977)
- Car J, Sheikh A, Telephone consultations, BMJ 326:966 (2003)
- Brand South Africa country portal, Healthcare in South Africa – www.southafrica.info/about/health/health.htm
- Kekana M , Noe P, Mkhize B, The practice of telemedicine and challenges to the regulatory authorities, South African Journal of Bioethics and Law, Vol 3, No 1 (2010)
- HPCSA, Confidentiality: Protecting and Providing Information (2007)
- WMA, WMA Statement on Guiding Principles for the Use of Telehealth for the Provision of Health Care – www.wma.net