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Telephone consultation

Speaking to a patient on the phone may save on appointments, but don't

be too accessible, says

Dr Melanie Wynne-Jones

Any telephone discussion with a patient is a consultation, and should be treated with as much care as one conducted face-to-face.

Unfortunately, the pace of general practice means that we can often be caught unawares by staff asking if we can 'just have a word with.....'. The first task therefore is quickly to check:

·Whether the receptionist has ascertained why this patient wishes to speak to you

·Whether speaking to you is the most appropriate course of action or whether the receptionist can/should take a message, or, depending on the nature of the query, should refer the call to someone else (duty doctor, the practice or district nurse, the secretary and so on)

·Whether the call is truly urgent; if not, is it convenient to you to speak now, or should the receptionist take a number for you to call back (at the end of surgery, for example, or during specified 'telephone time')?

·Whether you need any more information (such as an X-ray result) or need to have completed some action (for example contacting the patient's consultant) before you can have a meaningful discussion.

Time management is important; GPs rarely refuse outright to speak to patients, and telephone consulting can save overload on appointments, but being too accessible causes its own problems. Unless we are careful, we may waste time on matters that could be more appropriately handled by other members of the team, limiting our availability to those who really warrant our attention.

Unfortunately, a few patients either do not understand, or refuse to accept this, but inappropriate demand must be actively managed. Having agreed to speak to a patient, make sure that you do so in as near ideal conditions as possible; if necessary, explain that you need a few moments before you can listen to what they have to say. Ideal conditions include:

·Checking exactly whom you are speaking to, and their relationship to the patient if not the patient themselves. You may need to check their bona fides (for example if they claim to be calling from the PCT or hospital) or to get the patient's consent before divulging any information. Alternatively you can indicate you are willing to listen to their concerns, but not to comment at this stage.

·Asking what number they are calling from, and where they are (in case you get cut off, or need to check something after the end of the consultation, and because patients nowadays use their mobiles to call their GPs from all over the world!).

·Relative privacy, for confidentiality and so that you can concentrate without noise or interruptions.

·Access to any information you may need from the practice computer or paper records (beware patients with similar names), or from the BNF/other sources of reference.

·The ability to document the consultation fully (for example access to a free computer terminal).

·Recording of all telephone consultations (regularly used already by out-of-hours providers).

Only then can you move on to the consultation proper. A major difference, and potential for trouble, between telephone and face-to-face consulting is that you cannot 'read' the patient's body language, and they cannot 'read' yours. However, a telephone consultation often contains a surprising number of cues, such as uncertainty pauses, or the tone of voice. Both you and the patient are more likely to rephrase questions in other ways, clarify, summarise, and double check, both as you go along, and at the end. As a result, a telephone consultation may even be longer than one conducted in the surgery.

The patient will often freely mention some ideas, concerns and expectations; asking about these is, if anything, even more rewarding than in face-to-face consultations. Other consulting techniques, including suggesting options, reaching agreement on the outcome/next steps, and safety-netting are also just as important.

The next steps may include an urgent/routine appointment, arranging a blood-test/X-ray (or obtaining a result), referral to another agency (such as the podiatrist, a consultant or social services), a prescription or simply an agreement to wait-and-see and/or discuss the issue again within a specified time.

If you rapidly decide that the patient actually needs to be seen, further discussion may be unnecessary, although you may identify further information that must be gathered for the face-to-face consultation to be productive.

Fully documenting telephone consultations is medicolegally essential, but also helps the problem-solving process; your record should include any advice you gave the patient, in case of later dispute or complaint. Make your record, and a note of any action required immediately; it is only too easy to be distracted after you put the phone down by someone else asking 'can you just....?'.

Melanie Wynne-Jones is a GP in Marple, Cheshire

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