Our whole training prepares us to skilfully balance social and medical needs, make fine judgments about investigation and referral, and ensure patients receive the best possible care and are not overly investigated.
It is usually our instinct that there are certain presentations where this can only be fully achieved face to face, and that remote care is a poor substitute if we are trying to provide real quality.
But it is worth remembering that complex problems remain complex regardless of whether they are addressed face to face or remotely. We should also acknowledge that at the current time, and possibly long into the future, many patients may prefer not to see health professionals in person and may wish to minimise their social contact.
With that in mind, it might be surprising how many appointments are just as effective remotely.
Here, we look at two scenarios – one relatively straightforward, one more complex.
Case 1: The swollen calf
A 48-year-old woman submits a written electronic consultation request stating that she has developed an acutely swollen and red calf. She is in generally good health, does not smoke, takes no medication and has no history of foreign travel. She has been self-isolating recently because her spouse is in an at-risk group.
This case can appear challenging as the differential diagnosis includes a single serious cause – deep vein thrombosis (DVT) – as well as musculoskeletal, infective and other causes. Our instinct here might therefore be to ask the patient to attend.
However, using the structured approach discussed last month – reviewing the submission in advance, noting risk factors, considering red flags that cannot be missed and looking at prior history – much of a standard face-to-face assessment can be achieved remotely.
You may decide patients can themselves measure, and check for tenderness and oedema if instructed
It is clear that we will not be able to feel for tenderness and oedema or obtain accurate measurements of the legs, all part of the Well’s score. The NICE DVT guideline1 states that patients suspected of having DVT should have a D-dimer in addition to a Well’s score.
But through a remote consultation, you may decide patients can themselves measure, and check for tenderness and oedema if instructed. A household member or care worker should be able to palpate the limb under your instruction. For example, to check for pitting oedema, you say: ‘Now please gently press the swollen area with one finger, then remove the finger and hold the camera close to the area’.
Myths about remote consulting
Remote consulting is a quick way of seeing patients
Although remote consulting is efficient, it is not necessarily quicker. Carefully undertaken, remote consultation should have quality of care and not speed as the primary goal.
Remote consulting is not appropriate for frail and elderly patients
Many older people have devices that can facilitate video consulting, and use them to keep in touch with family. In these challenging times of social isolation, video can be a good way of keeping closely in touch with our most vulnerable patients.
Complex presentations must be dealt with face to face
If important information cannot be obtained remotely the patient should be seen face to face. However, many complex presentations simply need adequate time, whether seen remotely or face to face.
To check calf diameter, ask if the patient has a fabric tape measure in a sewing kit. Instruct the helper to locate the tibial tuberosity – describe it as ‘the bump below the knee’ – and measure 10cm down, mark and repeat on the other side, then measure the circumference of both legs (in centimetres). Instruct the helper to gently palpate the calf to check for deep venous tenderness, noting any reaction and its site, while accepting the limitations of such indirect examination.
However, it will be up to you to then consider whether this indirect examination presents an information gap that warrants seeing the patient face to face.
In this instance, if the suspicion of DVT is supported by the consultation findings, the patient needs referral to a unit to exclude DVT through a combination of Well’s score, D-dimer and scanning if appropriate. While it might be useful to record a reported or directly assessed Well’s score, this in itself is not enough to exclude a DVT so there is likely to be little value in arranging for the patient to have a face-to-face assessment before referral. Clearly if the assessment suggests it is not deep vein thrombosis, other diagnoses can be considered.
Case 2: Frailty crisis
The daughter of an 83-year-old man contacts the surgery to explain her father has been less well over the past two weeks. The illness is non-specific, but he is less confident in mobilising, had a minor fall a few days earlier and seems muddled on occasions. She is reluctant to bring him to the surgery as he is self-isolating.
This scenario, of an evolving frailty crisis, can feel quite stressful, as you may instinctively wish to visit the patient and feel disadvantaged if you have to consult remotely. This is where it is important not to be rushed with the assessment, perhaps accepting that more than one mode of remote consulting will be useful.
Again, as part of the structured approach, review the patient’s medical record, in particular noting comorbidity and any previous frailty crises, and any agencies currently involved. It will be useful to review the patient’s medication before initiating the consultation – especially anything started recently – and you may wish to use a medication optimisation screening tool such as STOPP-START, recommended by NICE.2
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Tips for remotely consulting with hard-to-reach groups
• Ask the patient their preferences for remote consulting, and see if they would in particular like to consult via video.
• Find out whether patients already use adaptive technologies of any kind.
• Explore whether patients use video-based communication to talk to carers, friends and family. Patients who do not possess a mobile phone may have access to a tablet or other computer.
• Consider seeking consent to involve supporters in facilitating video calling. Carers and care workers may be willing to help when they are visiting the patient for other reasons. You could then, for example, set up a video link using the carer’s mobile phone.
It would be useful to draw up a differential diagnosis of possible causes for the deterioration, acknowledging that the causes may be multiple. You can categorise the potential causes broadly, such as infection, trauma, medication side-effects, metabolic or haematological causes. Also consider the more serious causes that shouldn’t be missed, such as subdural haematoma, since the patient has had a fall, or sepsis. It is also worthwhile considering the possible outcomes, which may include conservative management at home, referral to a rapid response frailty team, or immediate transfer to hospital.
You may wish to use a medication optimisation screening tool such as STOPP-START
When initiating the consultation, again consider whether to do this via phone or video and also whether to initially approach the patient’s daughter. Presume that disclosure of information to a third party should only be with consent, so it is worth checking if such consent is held on file. If consent is not evident, an information-seeking phone call with the daughter may still be useful and perhaps lead to an offer to facilitate the remote consultation with the patient.
It should not be assumed that video is unavailable for perceived hard-to-reach groups including the elderly (see box below).
The consultation with the patient, perhaps supported by his daughter, and informed by the details she provided, will address the patient’s concerns and expectations of the situation.
It is worth documenting observations; does the patient look well or unwell? Is he comfortable at rest or are there signs of distress? Is he able to sit, stand and walk independently, or with aids? Is he able to measure his lying and standing blood pressure and pulse? It would be helpful if he could take his temperature – if speaking to his daughter first, ask if she can ensure he has a thermometer and a blood pressure monitor.
Objective assessments such as the Timed Up and Go test can be carried out with assistance from carers and may be useful.
How to do a remote Timed Up and Go test
• Ensure the patient has a safe area to get up and walk without hazards.
• Ask a carer to measure a 3m distance from the patient’s chair and mark the floor.
• Ask the patient to get themselves up from their chair, walk to the mark (with their usual walking aids), turn around and sit down again.
• Time this and record, observing the patient throughout to seek clues about their functional ability.
The test has limitations but can be useful and reproducible, and is valuable to report to frailty teams.
It is likely that we will need further information to investigate the frailty crisis, such as blood pressure, if the patient isn’t able to measure this himself, blood tests, and urine assessment. These can usefully be carried out by nursing colleagues with a subsequent review by the GP. The review could also be carried out remotely, or if information gaps persist by a subsequent face-to-face consultation. In many cases, it can be difficult to pin down a cause for this type of scenario, in which case management will depend on other factors such as the wishes of the patient or relative, the availability of support, their tolerance for uncertainty, and the ability to offer a follow-up review by remote means. Arguably this may be easier to discuss via video than by phone.
Undertaking a follow-up face-to-face consultation should not be regarded as a failure of the remote consulting model, but as a success since it has allowed you to plan the later face-to-face assessment. This may be particularly useful if the initial consulting doctor, who knows the patient best, is unable to consult face to face because of personal risk issues, or if a visit has to be timed to allow the patient to have support. It may be that investigation results make the situation clearer and the information gap then becomes irrelevant. A further strength of remote consulting with this group of patients is that it removes the physical barriers of transporting a frail patient to the surgery or arranging a home visit.
Dr Jonathan Inglesfield is a GP partner in Surrey