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TELEPHONE CONSULTATIONS

TELEPHONE CONSULTATIONS. South Bristol Trainers Workshop Saunton Sands 1.4.11. Broad aims of phone consultation :. Make accurate assessment of clinical problem Provide appropriate advice or offer consultation (where?) Ensure patient safety (safety-netting++)

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TELEPHONE CONSULTATIONS

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  1. TELEPHONE CONSULTATIONS South Bristol Trainers Workshop Saunton Sands 1.4.11

  2. 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

  3. PHONE CONSULTATIONS... • Easy or tricky? • What makes them challenging?

  4. 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...

  5. 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)

  6. One thing is on our side... 80% of diagnosis comes from the history

  7. 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)

  8. 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

  9. 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

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

  11. 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

  12. Initiating the session • preparation • establishing initial rapport • identifying the reasons for the consultation Gathering information Providing structure Building the relationship • exploration of the patient’s problems to discover the: biomedical perspective; the patient’s perspective ; background information - context making organisation overt attending to flow using appropriate non-verbal behaviour developing rapport involving the patient Physical examination Explanation and planning • 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 Closing the session • ensuring appropriate point of closure • forward planning

  13. 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)

  14. 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)

  15. 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’)

  16. 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

  17. 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...)

  18. 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

  19. 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

  20. Ethical considerations of phone consultations? Possible teaching opportunity? • BENEFICIENCE • NON-MALEFICIENCE • AUTONOMY • JUSTICE

  21. 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”

  22. 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)

  23. 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

  24. Common errors... • In info gathering: - inadequate drug & allergy history - absence of key questions • In relationship building: - clinician anger & frustration psychosocprobs - pt anger at unmet expectations • In decision-making: - Premature decision-making, absent diagnosis, wellness bias • In explanation & planning: - unclear communication of instructions & Rxs

  25. 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&E • Appears safe • Pts just as satisfied as seeing face to face

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