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Telemedicine is the remote diagnosis and treatment of patients by means of telecommunications technology. The advantages of telemedicine include reduced travel time/cost and enhanced access to healthcare. The coronavirus pandemic in 2020 has necessitated the rapid implementation of remote consultations across all healthcare platforms, in most cases without any formal training. We present an educational framework for conducting telephone consultations in secondary care to help fill this gap. There are five key steps in a telephone consultation; patient introduction, information gathering, establishing a working diagnosis and plan for clinical care, planning the next step and closing the consultation. By focusing on what each step entails, this paper aims to help those new to telemedicine techniques and those responsible for training them, to shorten the learning curve.
CPD/Clinical Relevance: This article aims to help clinicians become proficient and comfortable in conducting telephone consultations by providing a structure to the consultation which they can customize to their specific setting.
Article
Deirdre Coffey
Telemedicine is the remote diagnosis and treatment of patients by means of telecommunications technology.1 This includes interactions via telephone, video consultations and email communications. Telephone consultations are widely used and are an essential element of modern patient-centred healthcare, with approximately 25% of consultations estimated to be conducted via telephone in general medical practice.2
Due to the coronavirus pandemic, all elective NHS procedures and appointments were cancelled in mid-March 2020.3 This created a sudden halt in traditional methods of patient care, with the rapid implementation of remote consultations across all healthcare platforms. In many regions, dentists were deployed to roles involving telephone consultations, often not for dental patients, eg in NHS 111, family liaison, as well as dental triage calls.
Lack of training4 in remote consultations can lead to large variation in clinicians' behaviour over the telephone.5 Improved training can reduce variation and improve the quality of the consultation for both patient and clinician.
Aims and objectives
The main learning objectives of this guide are to:
Enable clinicians to understand the steps involved in conducting a telephone consultation;
Enhance awareness on the key aspects relating to a safe and effective telephone consultation;
Increase knowledge on the application of telemedicine in healthcare in general and in Oral and Maxillofacial Surgery;
Obtain an appreciation of the limitations and challenges associated with telephone consultations;
Build foundations on which a clinician can extend skills and knowledge to other aspects of telemedicine, such as video consultation.
Conducting a telephone consultation
An informative guide to conducting a telephone consultation is outlined in Table 1. It is based on existing guidelines for use in primary care in the UK,6 combined with a recently published document from the National Health Service.7 These have been adapted for patients in a secondary care setting. This educational framework is primarily aimed at dental professionals/trainees working in Oral and Maxillofacial Surgery (OMFS) but is generic enough to be applied to other disciplines also.
STAGE
TITLE
DESCRIPTION
0
Preparation
Select a quiet room
Ensure you have all necessary equipment (eg headset) and connection
1
Patient introduction
Record date and time of call
Identify yourself (name, professional role, location)
Confirm identity of patient (name, date of birth, location)
If not the patient, confirm identity and relationship to patient (try speaking directly to patient if possible)
2
Gathering information
Clarify reason(s) for call – source of referral, point of contact
Encourage patient contribution
Explore patient's concerns/expectations
3
Establishing a working diagnosis and a plan for clinical care
Take a detailed history
Make appropriate working diagnosis
Draw up a treatment plan
4
Planning for the next step (if any)
Devise action plan for further care (or discharge):
Information/advice only
Telephone follow-up required
Video consultation required
Face-to-face consultation required
Further information required
5
Closing the consultation
Summarize key points covered
Confirm patient's understanding
Provide appropriate safety-netting and follow-up instructions
Order any required tests or investigations
Complete documentation
Stages of a telephone consultation
Preparation
Adequate preparation prior to a telephone consultation will streamline the experience for both patient and clinician. A space should be chosen to limit any interruptions or distractions. The clinician should access any relevant patient records (previous paper/electronic records, imaging, bloods, pathology results, etc) and have these readily available. In addition, the clinician should have the patients' notes ready to document the consultation in a timely fashion. If a specific window/time is not scheduled for the telephone consultation in the same manner as you would for a traditional consultation, it can be perceived as a cold-call. To avoid this, a reminder letter or text should be sent to the patient with a short summary of the purpose and provider of the consultation. A specific time window ensures punctuality of both parties and avoids the issues associated with unscheduled appointments, including missed appointments, patient confusion about reason(s) for consultation and time constraints for clinicians. If the call is pre-arranged, check that the patient is expecting the call. If not pre-arranged, explain that it is a routine call and not an emergency to avoid alarming the patient.
Patient introduction
An appropriate time should be allocated to the initial phase of a telephone consultation to establish a solid foundation for the remainder of the interaction. This includes ensuring confidentiality, obtaining consent, where necessary, and establishing a good rapport with the patient. Key details to obtain are outlined in Table 1. If the consultation is recorded or being monitored, the patient should be fully informed on who is listening to the consultation, eg a consultant trainer/supervisor. The patient should feel confident that the information obtained during the telephone consultation will not be discussed outside of that setting and any material used will be treated in the same manner as a patient's medical record. If a consultation is to be recorded or listened to for training or research purposes, consent must be obtained at the beginning of the consultation and confirmed again at the end of the activity.8
Gathering information
The clinician should confirm that the patient is aware and understands the purpose of the consultation. It allows the patient the opportunity to express his/her concerns and expectations and, in so doing, aids the clinician in focusing the remainder of the consultation towards addressing these concerns. Clinicians should actively listen for patients' emotional state and remain empathetic, calm and supportive. This involves controlling tone of voice, careful selection of words and use of both open and closed questioning.9 Many patients may not be familiar with this form of appointment, especially in a secondary care setting. The clinician should reassure patients that telephone consultations are a common alternative to face-to-face communications and that they are receiving the same quality of care as they would with a traditional consultation.10,11
Establishing a working diagnosis and a plan for clinical care
A detailed history of the presenting complaint, along with a thorough medical and dental history, should be taken, as is normal for all consultations. At this point, all available information should be collated and used to establish a working diagnosis and a tentative treatment plan.
The lack of a physical examination and visual cues can be challenging for clinicians at this phase in formulating a diagnosis and plan.12 It may be useful to present a summary of key points to the patient and ask if anything important has been missed. The lack of a physical examination should be taken into consideration when devising plans for further care – the next step.
Planning for the next step (if any)
The purpose and form of the next step in the patient's care should be clearly outlined and agreed (Table 1). Further investigations can include obtaining patient images via email, sourcing test results from other hospitals, multidisciplinary discussion and liaison with other healthcare professionals. Patients should be fully informed of the nature and their level of involvement in any investigations or tests. Although it is not common practice, patients can potentially be listed for a procedure following a telephone consultation, if deemed suitable.13,14,15 In these cases, the process of consent is started as a detailed conversation with the patient. This will aid in facilitating the formal consent process on the day of the procedure and avoid unnecessary hospital visits. Patients can be sent information leaflets or given links to online resources to help prepare them for surgery. Clear instructions should be provided when prescribing medications.
Closing the consultation
This final step is essential to address any remaining patient concerns and ensure their understanding of the consultation and outcome(s). Clinicians should ask patients to clarify any uncertainties and to summarize key points from the consultation to ensure complete comprehension, ie ask to ‘read back’ advice given. The clinician should complete all documentation, including patient notes, letter to referring practitioner, dentist and/or doctor and a copy of the letter to the patient. This last step can be optional in some units, but a letter is a form of documentation to the patient clarifying what was discussed and what plans were made and so is especially valuable when a telephone consultation has replaced a usual face-to-face appointment. The letter can also contain details of arrangements for follow-up and discharge processes, along with any other outstanding administrative tasks. Finally, it is good practice to allow patients to disconnect first so that all their concerns have been raised and the clinician is not prioritizing his/her own time over the patient.
Telephone consultations; the pros and cons
Telephone consultations are a very useful communication method for both patients and clinicians. Patient acceptance is high with telephone consultations, with many being amenable to the concept for future care.16 Patients' positive attitudes towards virtual clinics are mainly related to reduced travel time, reduced waiting times to be seen in hospital, reduced costs associated with travel and parking and fewer difficulties obtaining time off work. Clinicians' experience with telephone consultations is also positive, with many finding it a good alternative to face-to-face consultations in certain clinical scenarios.10 Whilst this guide mainly focuses on telephone use for initial consultations, it can also be a beneficial and cost-effective method of post-operative follow-up after minor surgical procedures.17
Telephone consultations do have some notable limitations, with the most important being the medicolegal risks associated with establishing a diagnosis in the absence of a physical examination.12 In OMFS, this is of particular importance when screening urgent cancer referrals and accurately detecting emergency clinical situations. The development and implementation of formal written standards would aid in minimizing the risk of liability. In addition, clinicians should be aware of their defence unions' guidance on remote consultations. For patients, the lack of familiarity with clinicians/departments often encountered in secondary care can pose an initial communication barrier or stress. In primary care, the patient may be aware of, or have met, the clinician calling them and where they are calling from, which is not always the case in secondary care.
Careful triage of referrals and clinic lists can identify patients who are most suitable for remote consultations and those where face-to-face appointments may be more appropriate. In light of the coronavirus pandemic, particular caution should be exercised when scheduling patients at an increased risk of adverse sequelae from the virus. This includes those with co-morbidities (including cancer) and on immunosuppressive therapies.18 Patients who are shielding should be managed remotely if possible.
Conclusion
Telemedicine has been an important advancement in modern patient care. It has become even more valuable in light of the coronavirus pandemic and the need to connect remotely with patients. Telephone consultations are generally well accepted by patients and clinicians and can enhance access to healthcare, along with reducing travel time and cost.
Structured training in telephone consultations can improve the quality of the activity for both patients and clinicians. This paper outlines an educational framework to guide clinicians in conducting effective and safe telephone consultations. Although there are many similarities with face-to-face consultations, the lack of visual cues and a physical examination in a telephone consultation can be challenging. Utilization of this guide has enhanced the knowledge of both trainees and trainers in conducting remote consultations, whilst also optimizing the experience for the patient. The guide is also beneficial to trainers when supervising trainees and is less intrusive than a physical presence in the clinic room during a consultation.
