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Ten top tips on telephone consultations

Telephone consultations can be difficult without the normal visual cues that a GP is used to. Trainer Sally-Anne Pygall gives her advice on how to make sure patients are satisfied and any clinical risk is minimised.

Telephone consultations can be difficult without the normal visual cues that a GP is used to. Trainer Sally-Anne Pygall gives her advice on how to make sure patients are satisfied and any clinical risk is minimised.

Telephone consultations can be complex and are inherently fraught with clinical risk.

There is no ‘one size fits all' when it comes to telephone work – as each call must be viewed within its own context – but these tips are basic principles that can be applied to give support and structure to staff carrying out telephone consultations.

1. Know what you are aiming for

Many surgeries don't have a clear understanding of what they are aiming to achieve through telephone consultations. This can lead to a lack of confidence, inappropriate outcomes and dissatisfaction for patients and staff. So what are you aiming for?

• Are you looking to manage requests for same day appointments or requests for home visits?

• Do you want to prioritise patients according to urgency or try and give as many as possible telephone advice (when it is safe to do so)?

• Do you want to use the telephone for reviews only?

Whatever your reason for doing telephone consultations, if you are not confident about when to avoid an inappropriate face to face consultation and you revert to seeing all patients ‘just in case' or ‘because you can' i.e. not because of clinician need, you may need to reconsider if it is worthwhile doing telephone consultations in your practice.

2. Allow enough time


Telephone consultations can be shorter than face to face consultations [1], but when you can't see, touch, or smell the patient it's reasonable to assume the care episode may take longer.

If the patient isn't present or is unable to speak, staff must allow adequate time to gain the information they need for a safe conclusion. Failure to do so could result in a delay or denial in care, unnecessary face to face consults or the potential for a dissatisfied caller because the GP ‘didn't listen to me" or ‘they weren't interested' [2].

The average time for a telephone consultation in GP surgeries is thought to be 7.1 minutes [3]. This is a good benchmark to use in your own practice with.

3. Develop TeleCharisma™

Poor communication is a source of clinical risk [4], but you lose 55% of your ability to communicate effectively when you can't see the other person.

The tone of your voice and how you say things is vital as it accounts for 84% of your ability to communicate on the phone and can convey confidence in what you say, your state of mind and your attitude.

TeleCharisma™. is a telephone personality that engages the caller almost immediately (essential when dealing with life threatening situations) and is exhibited through a voice and manner that lets your caller know you are interested in them and want to help them as best you can.

4. Have a systematic approach

Having a structure or model for telephone consultations minimizes the risk of missing something, will improve information gathering allows the caller to think with more clarity.

A structure can be as simple as a beginning (introduction), middle (history taking) and end (management plan).

Remember confidentiality and to check the location of the patient, especially with a mobile phone number.

The history-taking should be systematic and include the problem history, patient history and social history; excluding red flags quickly. Failure to take an adequate history is a fault in telephone consultations [5].

The end or closing of a call should be an agreed management plan and safety netting. This is the ‘get out of jail free' card!

Adequate safety netting requires more than a general ‘call back if anything changes or you're worried'. It requires specific instructions on what to watch out for, when to make contact again and with whom.

5. Listen actively

Listening actively means tuning in 100% of the time and picking up on what's not being said as well as what is said. It's simply paying attention but it's not always easy in a busy practice and noisy environments (on both sides of the phone call!).

If you've missed something, don't be afraid to ask the caller to repeat it – they can't see you so you can always say something distracted you (even if you're by yourself!).

6. Use open and closed questions

Open the call with an open question. This allows the caller to express their concerns, opinions and expectations. It can also get them to realise the extent of their problems.

Be careful of handing control over to the caller; on average 30 seconds – 1 minute is adequate time to find out what the problems is. After this you may need to take control back if the caller is rambling (or unable to communicate effectively).

Continue to use open questions as much as possible and appropriate for the context of the call. You will gain a lot more information and may not need to ask as many questions yourself.

Closed questions are useful for taking control of the call and should be used when you need specific information, but they can be leading and close the caller down.

Closed questions are more appropriate to sum up a conversation, whilst facilitative questions are useful in crisis situations, as they help narrow down the information without leading expressly.

7. Summarise the call

Paraphrase and summarise back to the caller what they have said throughout the call. This shows the caller you are paying attention; they will be more engaged with you and more likely to comply with your advice.

8. Check your understanding matches that of the caller

In 1/3 of calls, the patients' understanding of the reason for the call doesn't match the clinicians.

Throughout the call, paraphrase and summarise back to the caller what you have heard to ensure you are on the same page throughout and avoid ‘wrong train syndrome' [6].

9. Document the call adequately

One of the biggest risks is inadequate documentation or record keeping.

Telephone consultations may have two or three different forms of documentation – electronic record, hand written record and voice recordings.

Use of a telephone consultation proforma or protocol will improve documentation and information captured as well as standardise practice and improve information sharing or messaging. Minimum standards should include:

? Date and time of call from caller/patient and returned call

? Nature of call

? PMH, meds, allergies and over the counter medications/treatments

? What the caller plans to do

? Self care information given (evidence base)

? Any referral arrangements

? Safety netting advice

10. Access good training

Telephone consultation work is a clinical subspecialty which requires particular skills and knowledge. Face to face assessment and communication skills are not immediately transferable to telephone work.

The lack of sensory input and the comprehension of the caller are the most obvious differences which make a safe and appropriate outcome more difficult to achieve. Many calls are third party calls i.e. someone calling on behalf of someone else and therefore even more of a risk.

Good training will provide your staff with the best tools and techniques to manage these risks.

Sally-Anne Pygall is a nurse and director of training company Telephone Consultation Services; www.telephoneconsultationservices.co.uk

Ten top tips on telephone consultations Common pitfalls and cardinal rules

a. Inadequate safety netting
b. Overreliance on the caller or being dismissive of their concerns
c. Insufficient history taking (layers of safety)
d. Over reliance on previous consult
e. Premature closure
f. It's your responsibility to gain the information not the caller's to give it
g. Have a systematic approach
h. Always try and speak to the patient
i. Always assume the worst until proven otherwise
j. Document thoroughly (even with voice recordings)

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