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How to make the most of phone consultations

Most GPs have had no formal training in communicating effectively on the phone – Dr Sabena Jameel looks for practical advice in the literature

By Sabena Jameel

Most GPs have had no formal training in communicating effectively on the phone – Dr Sabena Jameel looks for practical advice in the literature

Telephone consultations are becoming increasingly common in primary care. But the nuances and dynamics are different from those in a face-to-face surgery consultation.

Both the medical and non-medical literature has interesting and useful advice to improve these skills.

Imagine the two skills of speaking and listening (‘high touch') and another two of problem solving and local resources or knowledge (‘high tech') are each the legs of a table. All four are vital to keep the table up. The so-called high-touch skills are those needed for an effective interaction – and on the telephone the non-verbal aspects of communication are minimised. One report has suggested that 85% of what's recalled from a telephone encounter is based on tone of voice and only 15% is based on actual content (1).

Effective listening

When thinking of communication skills we often think about speaking – but active listening precedes speaking and is often overlooked. The blockers to active listening include (1):

• Environment distractions – is the surgery busy? Is someone waving paperwork in front of your face? Is your mobile ringing? Despite all these you need to focus.

• Third ear syndrome – two ears are listening to the patient but the third ear is listening to the supervisor in the background or the teenager having a tantrum outside your room.

• Jumping ahead – we can think at 500 words per minute, we can hear 300 words per minute and we speak at 125-150 words per minute. It is easy to jump ahead in attempts to be more time-efficient.

• Emotional filters – is it a heartsink patient calling again? Good listeners will stop the emotional filter unfairly influencing the interaction.

• Mental side-trips – it's your fourth call of the day giving out diarrhoea advice and what you are really thinking about is what you want for your lunch.

A BMJ paper (2) concluded that doctors were ill-equipped to recognise emotional cues and could end up displaying the following blocking behaviour:

• offering advice and reassurance before the main problems have been identified

• explaining away distress as normal

• attending to physical aspects only

• switching the topic

• ‘jollying' the patient along.

Having identified some of the problems in listening, the ‘do' list is generally common sense:

• Pay attention

• Assess the emotional climate of the call (3)

• Assess the patient's level of knowledge

• Read between the lines

• Consider hidden agendas and unspoken requests.

Effective speaking skills

In Dr Tony Males's book Telephone consultations in primary care (4) there is a useful summary of the main communication skills, presented here in modified form.

• The telephone handshake – mutual identification of clinician and caller, enabling rapport building, trust and social proximity.

• Information gathering using the patient's own narrative, eliciting the social and clinical history. Paying attention to non-verbal cues.

• Addressing the biomedical model and the patient's perspective – with empathy.

• Giving an interpretation of the problem with well-pitched explanations or summary.

• Signposting the point at which a triage decision must be made and involving the patient where possible.

• Negotiating the outcome according to local or organisational guidelines. Be aware that it is here where workload and other pressures can influence your decisions.

• Make follow-up arrangements and ensure there is a safety net.

• Keep good records and prepare for the next call.

Fairly early in the consultation you need to get to the red flag questions. This will guide the triage decision. If there are no red flags, your own level of anxiety about missing something important can drop a notch and the call can take a more leisurely pace.

Here are seven speaking tips (1):

• smile

• use the caller's name

• reflect back important points

• acknowledge the emotional climate

• use courteous remarks

• mirror the patient – using similar vocabulary, if appropriate

• tape or monitor your calls.

Finally don't use jargon or abbreviations, don't mumble and don't use negative language. For example don't say: ‘I'm sorry you can't have a visit for this problem.' Say: ‘The quickest way to be seen would be if you were able to attend a treatment centre. I realise this is an inconvenience for you, but we will ensure your problem is attended to.'

Telephone consultations are here to stay and it won't be long before technology means we can see our patients face to face digitally. Then the art of effective telephone consultations will evolve.

Dr Sabena Jameel is a GP and primary care medical educator in Birmingham

Be aware of the 'third ear syndrome' when in the middle of a phone consultation

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