Giving advice over the telephone has been an integral part of general practice in the UK for decades, and for the most part works to the satisfaction of both patient and doctor.
The golden rule is for the doctor to ensure that he/she has put him/herself in a position to make a sound clinical judgment before offering any form of medical advice. In many instances this is possible from a history taken over the phone, particularly if this is combined with previous knowledge of the patient.
Occasionally, however, it goes wrong, and when it does some familiar facts usually emerge. A recent review of 1000 consecutive claims against GPs revealed that 77 claims were associated with out-of-hours contacts, and 51 of these involved a cooperative or a deputising GP.
Straightforward communication problems, including language difficulties or the patient or doctor failing to make him/herself understood, may be frustrating, but if the doctor cannot glean sufficient information over the phone to get a clear idea of what is going on then something else needs to be done to assess the patient, e.g. face-to-face consultation.
Even where there are no obvious communication problems, it may prove difficult to obtain all the information required.
Patients suffering with chest pain, for example, may want reassurance that it is only a bit of indigestion, and it may be tempting for the doctor to go along with the idea, especially if the patient has had it before. Unfortunately, myocardial infarction and ischaemic heart disease are among the more common missed acute diagnoses.
In the review of 1000 claims, 34 were linked to ischaemic heart disease, of which 27 resulted in death. The presumptive diagnosis made by doctors in these cases included undiagnosed chest pain (8), dyspepsia or oesophagitis (7), congestive cardiac failure (3), muscular pain (3), chest infection (2), undiagnosed shortness of breath (2), angina (2) and miscellaneous (7).
- Confrontation: Some telephone consultations result in confrontation between the doctor and patient or carer. The danger here is that the patient or carer and the GP will dig themselves into entrenched positions, with the GP being none the wiser about the patient's illness. This will result in assessment being no more than guesswork unless something urther is done to assess the patient.
- Failure to arrange appropriate follow-up: Where telephone advice suggesting a certain line of management is given, it is essential to explain to patients what they should expect by way of improvement, significant symptoms to report, or when to phone back if they are simply not getting better.
- Failure to record the consultation properly: just like surgery and domiciliary consultations, telephone consultations should be properly documented, including:
- all relevant details of the history
- negative responses to important direct questions
- management advised
- symptoms to report immediately
- follow-up arrangements.
- Failure to copy the notes to the patient's usual GP: When covering for another doctor, it is important to make sure that a copy of the note is passed to the patient's usual GP to ensure continuity of care.
- Failure to check existing medication when prescribing new medication: When advising a patient to take medication, it is essential to check that there are no contraindications to, or in particular potential interactions with, existing medication. The most common mistake here is to advise the use of an over-the-counter non-steroidal anti-inflammatory drug when the patient has a history of peptic ulceration or asthma, or is taking warfarin.
Many GP cooperatives and some GP practices now routinely tape-record telephone calls. In the event of a subsequent complaint or claim, this may prove invaluable in proving exactly what was said and by whom, and provide further insight into the consultation pauses and intonation can be more telling than the recorded word.
In October 2000, new legislation came into force in the form of the Regulation of Investigatory Powers Act 2000. Unfortunately, this is a very complex piece of legislation. It probably does apply to the tape recording of consultations but we will only know this for sure when the point is tested in the courts.
The Act does not prohibit the recording of telephone conversations that is authorised, provided that the patient/carer consents to the recording. The Act says that if there are reasonable grounds for believing that consent has been obtained, then recording is authorised. Consequently, the caller should be told that the telephone conversation is being recorded. If no objection is registered, then it can be assumed that consent has been obtained.
Once the recording has been made, the tape should be treated like any other medical record and be kept securely to prevent loss or inadvertent damage.
As with any other form of medical record, the patient is entitled to access to the record in intelligible form. However, as the tape is likely to contain recordings of consultations with other patients, it is important to protect their confidentiality. This may be achieved either by re-recording the section of tape relevant to the patient in question or by providing a transcript.
As in any other branch of people management, success in providing telephone advice to patients is dependent upon developing sensitive antennae to detect dissatisfaction before the receiver is replaced.
- Keep the caller on side, making allowances for any anxieties that he/she may have, allowing time for him/her to explain the problem, and of course remaining courteous throughout. Asking yourself what the patient's agenda might be is one means of obtaining an insight into the situation that might not otherwise be available.
- Ensure that you are in a position to reach a sound clinical judgment before the call comes to an end. It might not be possible to make a diagnosis, but conditions requiring urgent management must obviously be excluded and the caller will require advice about when to contact the doctor again if the situation changes for the worse or fails to improve as anticipated.
- Always keep the safety net in place. Ensure that the caller knows when you would want him/her to call back, and understands that if something is bothering him or her it is perfectly reasonable to call back at any stage.