South Bristol Trainers Workshop Saunton Sands

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 cant see them Weighing up if face to face needed & if so where (matching pts 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 pts 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: Initiation Gathering information Building the relationship Structuring the interview Explanation & planning Closure

exploration of the patients problems to discover the: biomedical perspective; the patients perspective ; background information - context providing the correct type and amount of information aiding accurate recall and understanding achieving a shared understanding: incorporating the patients 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 overt attending to flow using appropriate non-verbal behaviour developing rapport involving the patient ensuring appropriate point of closure forward planning

Top Tips... Even before picking up phone: - check whats known about pt - but avoid assumptions Introduce yourself, Dr.... Calling from.... How you start is really important...+ve attitude, make pt feel youll do all you can to help If possible speak with actual patient (if 3 rd 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 cant examine...use callers 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 necessarily want) 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 1 st articles Everything between 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 doesnt 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 carers 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 ? Not a lot : 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&E Appears safe Pts just as satisfied as seeing face to face