Follow up by telephoneBMJ 1994; 309 doi: https://doi.org/10.1136/bmj.309.6968.1527 (Published 10 December 1994) Cite this as: BMJ 1994;309:1527
- Jammi Nagaraj Rao
It may be just as good to talk on the telephone as in a clinic
Health service workers seem to regard the telephone as intrusive. For patients and staff alike, mention of the telephone conjures up images of haughty, unhelpful receptionists and tardy, impolite switchboard operators. Its insistent ring demands immediate attention, interrupting the ward round and disturbing consultations. For patients a call from the hospital is often bad news, and they are expected to call the hospital only when absolutely necessary. Even in the newly consumer conscious NHS the interaction between staff and patients over the telephone can hardly be described as convivial.
And yet, with a little imagination, the much maligned telephone could be used to improve patients' care. Take several examples from the United States. Jones et al have shown that telephone follow up of patients attending an emergency room can be beneficial.1 In one month 281 patients (15% of the total) were selected for such contact. Two fifths of the patients needed clarification of instructions they had received on discharge, and six out of seven patients who reported a worsening of symptoms received medical intervention. More recently, a randomised trial tested whether telephone follow up can be used as a substitute for routine follow up in clinics.2 Doctors doubled the interval between clinic visits in the intervention group and contacted the patients by phone instead. Patients followed up by telephone received fewer drugs and had shorter stays in hospital. Costs were 25% less in patients managed by telephone.
Successful use of the telephone to communicate with patients in a planned and systematic manner has also been reported in clinical genetics,3 day surgery,4 obstetrics,5 neonatology,6 and community dentistry.7 Telephone follow up of a more technical nature has also been reported: patients with a cardiac pacemaker were successfully followed up over the telephone with use of a device to transmit details of the pacing and the electrocardiographic trace.8 These reports claim that systematic telephone follow up results in convenience for patients, better compliance with treatment, less crowded clinics, and financial savings.
Telephone follow up might well be substituted for follow up visits arranged to tell the patient the results of tests done previously and to ensure the patient's compliance with and understanding of instructions. Fewer patients at clinics would mean that those who attended would get more time. For the patients, travel would be avoided—the biggest bonus. Non-attendance at clinics is common; among the possible reasons is an apparent lack of negotiation between the patient and the care giver about the need, purpose, and method of follow up.9 Clinic managers should consider the potential offered by a programme of planned telephone follow up to reduce non-attendance and thereby reduce waiting times for clinic appointments.10
Planning is necessary
Obviously, much thought and planning are necessary before the introduction of a scheme of systematic telephone follow up. Doctors need to be enthusiastic about the potential benefits, and management and clerical support is essential. Telephone follow up must not be delegated to the most junior member of the team; as in day surgery a senior doctor (or nurse) must take personal responsibility. Selection of patients is crucial, and unambiguous criteria should be in place. At the appropriate clinic visit, follow up by telephone should be discussed with the patient and, if the patient is willing, a time and date fixed for the telephone call. Security and confidentiality are important, and the means by which the doctor and patient will identify each other should be established. Time must be set aside for the telephone calls. Case notes and results of investigations must be available, just as in an ordinary clinic. If a clinic visit proves necessary the doctor or nurse making the call should have the means to book an appointment. A note recording the substance of the conversation and any action taken or advised must become part of the case notes.
The option of follow up by telephone may not be available to the few people without access to a telephone, those with whom the health care professional cannot converse without an interpreter, those with a hearing or other disability that prevents them from using a telephone, and those judged insufficiently articulate to be suitable for telephone contact. Telephone contact will not be the only aspect of health care from which these groups of people are systematically excluded. Phoning patients at work may present particular problems; but faced with the alternative of taking up to half a day off work, many patients may well choose telephone follow up.
Problems don't stand up to scrutiny
And the possible problems? Patients may not be in at the appointed time; they may need urgent medical intervention; they may not feel satisfied that they have been attended to; and the whole process may be too time consuming. None of these stand up to scrutiny. Satisfaction among the patients will depend on appropriate selection of cases, and, given the short time that they usually see a doctor compared with the time spent travelling to and waiting in a clinic, most patients would probably prefer follow up by telephone.
Some doctors might be concerned about the legal implications of patient-doctor contact lacking an opportunity for physical examination. The situation is no different from face to face consultation. In both settings the need for an examination or other medical intervention will depend on what the patient tells the doctor or nurse at the time of the contact. An examination is not precluded by the fact that the contact is by telephone, though arranging one may take a little more effort. As always, clear, complete, and legible notes are the best safeguard against any complaint that may arise. Some doctors might find the loss of non-verbal cues unsettling, but telephone follow up is designed for routine follow up after a complete initial assessment. Its purpose is to confirm understanding by the patient of instructions, convey or repeat factual information about diagnosis and prognosis, and reinforce advice on changes in lifestyle.
Will patients accept the idea? We do not know for sure, but 90% of all households (and three quarters of households headed by unskilled manual workers) in Britain currently own a telephone,11 and increasing numbers of people in developed countries are using the telephone for other than essential social interaction. With tele-dating, telepolling, tele-marketing, and tele-shopping all becoming increasingly common, perhaps ordinary patients will be more receptive to the idea of tele-clinics than sceptics might think. Hospitals and general practices have nothing to lose and much to gain by adding telephone follow up to their repertoire of services. While it may not be possible for many patients, for some at least telephone follow up may prove to be the next best thing to being seen in their own homes.