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Telephone consultations
Improving quality and safety of telephone based delivery of care: teaching telephone consultation skills
  1. J Car1,
  2. G K Freeman1,
  3. M R Partridge2,
  4. A Sheikh3
  1. 1Centre for Primary Care and Social Medicine, Imperial College, London, UK
  2. 2Department of Respiratory Medicine, National Heart and Lung Institute, Imperial College, London, UK
  3. 3Division of Community Health Sciences (GP Section), University of Edinburgh, Edinburgh, UK
  1. Correspondence to:
 Dr J Car
 Department of Primary Care and General Practice, Centre for Primary Care and Social Medicine, Imperial College, London W6 8RP, UK; josip.carimperial.ac.uk

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High quality telephone based health care delivered by appropriately trained staff should be available to all

The opportunity to consult by telephone is now an integral part of any modern patient centred healthcare system.1 The public values the option of consulting by telephone, citing advantages of quicker access to care, greater convenience, and more choice in the way health care is received.2 In the United States up to a quarter of all primary care consultations are now conducted over the telephone, but there are also risks associated with this form of communication.3 Key approaches and skills that clinicians need to acquire to minimise these risks include use of detailed protocols for the organisation of a telephone service, structured evaluation of the urgency of calls, and issues to do with confidentiality. None of these has so far been incorporated into doctors’ formal training, and this needs to change.

Telephone contacts are increasingly used as an extension of, or substitute for, traditional face to face contacts with a range of primary and secondary healthcare professionals. Telephone services now include delivery of routine and emergency care, facilitating health promotional interventions, obtaining results of laboratory investigations, and repeat prescriptions.2 Many doctors are, however, still reluctant to provide this form of service and this probably reflects lack of confidence, perceived vulnerability and, underpinning these, a lack of appropriate training.4,5 This is unsurprising because, although there are a number of skills that are common to all forms of consultation, consulting by telephone does require an additional range of skills. These include a more refined appreciation of the importance of verbal cues and focused history taking to compensate for the inability to examine the patient.

The British Medical Association’s guidance for general practitioners, Consulting in the Modern World, warns doctors on the one hand of the limitations of telephone consultations: “During a telephone consultation the doctor cannot see, touch, examine, investigate, smell or, in the strictest terms, even hear the caller/patient” and then advises that: “telephone consultations when correctly conducted can be considered to be safe and acceptable practice”. Both the limitations and the advantages of telephone consultation are therefore apparent, but doctors and medical students are given little advice or training in how to conduct telephone consultations correctly or develop the requisite skills. Most other professional and commercial services, including health related nurse run telephone services, insist on training for those who develop telephone based services.

Training courses need to help clinicians build appropriate attitudes, skills, and knowledge and should include both generic and specialty specific modules. In addition to verbal cue sensitivity and more focused history taking, generic topics include training in the adequate documentation of telephone encounters and awareness of when telephone consultations are inappropriate (for example, where there are language difficulties or where there is a clear necessity for clinical examination or need for use of investigative facilities) and an appreciation of relevant medicolegal issues. Clear guidance is needed regarding the “substitution” of questions for examination such as asking the patient to measure her/his temperature, blood pressure, peak flow or blood glucose level; exploration of strategies for home management including self-monitoring; negotiation of a plan and assessment of its feasibility; follow up arrangements; and management of expectations for a home visit. In addition, medical managers need to be aware that planned telephone consultations must require availability of medical records, a confidential telephone line in a quiet area, and the resources to document the consultation and to communicate this to others such as the general practitioner and the patient. There must be opportunities for early face to face consultation if the need becomes apparent during the telephone consultation. Hospitals should also consider offering morning or evening “commuter” telephone clinics for patients in employment.

Each specialty must consider its specific telephone training needs. We anticipate that these may focus on issues such as “warning signs and cues” for various disorders, guiding patients in performing limited self-examination (for example, determining if a rash blanches or, for asthma, asking an adult patient to record his/her peak flow or the mother of a child with asthma to assess the pulse rate or respiratory rate) and prescription guidelines (for example, prescription of non-steroidal anti-inflammatory drugs in acute low back pain).6 Professional bodies need to provide clinicians with evidence (or state the absence) of the effectiveness and safety of such interventions to allow clinicians to undertake an evidence linked assessment of the advantages and limitations of telephone consultations. Future versions of guidelines, such as the British Thoracic Society/Scottish Intercollegiate Guidelines Network (BTS/SIGN) asthma guidelines, might include key questions to be asked during a telephone consultation.7,8

There is evidence that clinicians’ performance, confidence, and satisfaction with delivery of care by telephone can be improved by short educational programmes.9–14 As for teaching traditional consultation skills, simulated patients are the cornerstone of teaching programmes aimed at improving telephone consulting skills.15 Such training should become an integral part of the consultation skills programmes that now run throughout undergraduate, general practice, and specialist training. For established clinicians, training opportunities need to be offered as part of continuing professional development.

A number of studies have identified substantial variation in the quality of telephone consultations.16,17 Monitoring and assessing the organisation and quality of telephone consultations is essential, and this appraisal should extend to receptionists and other essential team members. Many of the quality indicators for telephone consultations can be adapted relatively easily from other organisations such as The Telephone Helplines Association, UK.

With over 90% of the UK population now having ready access to a telephone, and with an increasing array of services now available on the telephone, it is essential that mechanisms are developed to ensure that high quality telephone based health care delivered by appropriately trained staff is available to all. NHS Direct (and similar developments in a range of commercial services) have heralded a much needed shift in culture, and it is now time that mainstream primary and secondary healthcare services followed suit.

High quality telephone based health care delivered by appropriately trained staff should be available to all

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