By Dr Emma Davies, Medicolegal Consultant
The move to remote ways of working has been one of the key changes made in primary care during the COVID-19 pandemic. It has been essential in trying to keep patients and staff safe, especially those who are vulnerable. It has also transformed patient access to services. It is likely that remote consultations will remain part of a GP’s working day, but this does present new challenges and new medicolegal risk.
Already we have started to see a number of complaint and inquest cases that have raised issues and concerns around remote consultations. While remote consultations can be a quick way of resolving many simple patient queries, the lack of face-to-face contact does mean that important cues and signs may be missed. As doctors we are used to assessing a patient from the moment they walk into our consulting rooms: we pick up on abnormal gaits, non-verbal cues, pain, pallor or jaundice. We can often tell if what the patient says and how they behave is discordant, and therefore know when to dig deeper and question further.
There is also a risk of taking patients at face value and relying on what they tell us, a classic example being those patients who think their gout is flaring up but who may actually have an ischaemic foot; or the patient with back pain who assumes they must have pulled a muscle but has a slow leaking aortic aneurysm or upper gastrointestinal cancer. Patients will often approach us with a formed idea of what they think is wrong and it is our role to get the necessary information to be able to know if the patient’s hunch is right or not. We need to be more alert to tunnel vision and ensure we are asking the right questions of our patients.
It is clear that not all patients can be assessed remotely, and triaging out those who would benefit from a face-to-face consultation requires skill and experience.
The GMC's Remote consultations guidance includes advice on how to weigh up if a remote consultation is appropriate. This is based around access to the patient’s full notes and medical history, the complexity of the query and the need for a physical examination.
The following situations, conditions and presentations also merit careful consideration:
- Mental health illness, especially if new in onset
- Breathlessness or chest pain
- Abdominal pain
- Headache
- People who are unable to give clear history
- People who have additional needs such as hearing loss, learning difficulties, frailty or poor social support
- People who do not have sufficient access to or understanding of the technological requirements of a remote consultation
This list is not exhaustive. In general, we should assess each case on its merits and avoid using blanket policies which are intended to be a one-size-fits-all approach to this complex problem. Advanced communication skills and asking the right questions are going to be key in making our new ways of working safer for all.