General practice has undergone a digital revolution during the COVID-19 pandemic, and telemedicine now underpins many doctor-patient interactions. The Secretary of State noted last year that while the proportion of telemedicine consultations had dropped since the beginning of the pandemic, about 45% of primary care appointments are now being carried out remotely.
In an MDU survey, 97% of GPs reported increased use of phone consultations during the pandemic, while 75% and 55% said they had increased their use of video consultations and online triage systems, respectively. More than three quarters (77%) of the 172 respondents anticipated they would continue to use remote working practices frequently after the pandemic.
Remote consultations have allowed GPs to continue to practise efficiently and support patients during the pandemic, while reducing the risk of exposure of patients and staff to coronavirus. However, research body The Health Foundation has recommended that more research is carried about the impact of remote consultation on the 'quality of care, patient experience and access and workload.'
Getting the most out of remote consultations
For effective remote consultations, it can help to divide the consultation into three parts:
First things first - give your name, explain who you are and what your role is. Then check you are talking to the right patient and find out whether anyone else is in the room with them.
If you're consulting the patient by video, explain to them that you may need to consult your computer notes and record the information. Reassure them that although you may not be looking at them, you are still listening.
Explain that if you feel it's necessary, after having taken a history and carried out a remote examination you might also ask them to come to see you for a face-to-face consultation or for investigations, such as blood tests. Taking time to do this will make sure the patient understands the process and doesn't feel rushed.
The history of the presenting complaint and past medical history is of paramount importance, particularly during a remote consultation. Non-verbal communication and soft cues will be more difficult to pick up on then during a face-to-face encounter, so ask open questions and allow the patient to speak uninterrupted, going on to ask direct questions where necessary.
Avoid jumping to conclusions and keep an open mind, but specifically ask about worrying symptoms and red flags. Patients may not appreciate the importance of these and may only mention them if asked directly. Some symptoms may be more difficult to evaluate remotely, such as pain, so a good history is essential and will allow you to determine whether a remote consultation will suffice or if the patient will need to be seen face-to-face, particularly for an examination.
It's also important to put the patient at ease before going on to carry out further assessment. If you plan to carry out a remote examination, communication is just as important as during a face-to-face examination. The patient needs to understand what examination is going to take place and why, and needs to be given clear instructions. Make a careful record of the discussion and your examination findings, including any relevant negative findings, recording the fact that this was done remotely and its limitations.
Reflect back to the patient your understanding of their concerns and ask them to explain their understanding of your discussion and next steps. Consider the information you have obtained critically and your differential diagnosis.
If the patient needs a follow-up appointment, arrange this for them before they leave and check they have been given appropriate safety netting advice and know how to seek further help.
Think about whether you have obtained all the information you need or if that's only possible having formally examined the patient. Some observations can be made remotely, such as respiration rate, but ask yourself if other vital signs need to be measured and recorded - was the quality of the video good enough for you to be confident that you have successfully gained the information you need to make a diagnosis?
Check the location of the patient
Because of the issues and restrictions caused by the coronavirus pandemic, some patients may have found themselves stuck in another country, or have chosen to relocate for a period of time.
Most countries would expect the doctor consulting with a patient to be registered with the professional regulator in that country, and if a patient has moved abroad, even temporarily, it's important to consider whether it's appropriate for them to remain registered with your practice and for you to consult with them.
As well as implications for your registration, a remote consultation with a patient abroad may not be included in your professional indemnity. With this in mind, it might be best to ask the patient to seek medical advice in the country where they are currently living.
Below we cover some of the key areas to consider when carrying out a remote consultation.
Get familiar with the technology
- Check the equipment you're using and that the patient can see you clearly.
- Check your setting, background, appearance and privacy settings, especially if you're working from home.
Focus on communication
- Communication skills are the cornerstone of a good consultation, but there may be additional barriers when communicating remotely compared to a face-to face-consultation.
- Put the patient at ease by introducing yourself and explaining how the consultation will work.
- Remember to look at the camera in order to make eye contact with the patient, rather than at the screen.
- Is this patient new to you or the practice or someone you already know well? If they're unfamiliar, have you reviewed the notes (including hospital records if available) and any relevant investigation results?
- Does the patient have any specific concerns, and what is the purpose of their contact?
Assessing the patient
- Using an unfamiliar format to consult with patients can be off putting. Don't forget basic principles of history taking and examination.
- Is this a chronic condition or a new presentation?
- Has there been a change in their presentation or any new symptoms?
- Has the patient already been seen by a colleague either remotely or in person?
- Has the patient had multiple consultations about the same matter?
- What are the social circumstances and could these be relevant?
- Is this a physical or mental health problem and what is the patient's emotional state?
- Are there any special considerations in view of the patient's age (very young or elderly)?
- Do you need to conduct a remote examination? Can you do this entirely remotely, or will you need to arrange a face-to face-consultation - for example, because you need to observe vital signs to fully assess the patient?
- Do you have appropriate consent for the examination?
- Is a chaperone necessary and is it possible to arrange this remotely?
- Are there any red flags?
- Are you in a position to exclude a serious diagnosis?
- What is your differential diagnosis and have you recorded this?
Safety netting advice
- At the end of the consultation, check the patient understands the plan and knows how to seek further help if needed.
- Make sure you give safety netting advice, especially as you have not physically examined the patient.
- Consider whether a face-to-face appointment is needed and arrange this within a suitable timescale.
- Allow for the potential for uncertainty in remote consultations by making sure key points of your discussion are noted.
- If a follow-up appointment is needed, arrange this for the patient before they leave (if possible).
This article originally appeared on GP Online and has been edited for publication.
Dr Kathryn Leask
Dr Kathryn Leask
BSc (Hons) MBChB (Hons) LLB MA MRCPCH FFFLM MRCPathME DMedEth
Kathryn has been a medico-legal adviser with the MDU since 2007 and is a team leader, trainer and mentor in the medical advisory department. Before joining the MDU, she worked in paediatrics gaining her MRCPCH in 2002 and did her specialty training in clinical genetics. She has an MA in Health Care Ethics and Law, a Bachelor of Law and a Professional Doctorate in Medical Ethics. She is also a fellow of the Faculty of Forensic and Legal Medicine and has previously been an examiner and deputy chief examiner for the faculty. Kathryn is currently a member of the faculty’s training and education subcommittee and a member of the Royal College of Pathologists (medical examiner).
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