The telephone rings…
BMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c861 (Published 12 May 2010) Cite this as: BMJ 2010;340:c861
All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
When I had the experiences described in my article I was a new GP
trainee. Initially, many of the telephone calls I made were because on
reflection or after discussing the case with my trainer, I changed my mind
about something after seeing the patient. I imagine this scenario does not
apply very often to experienced GPs, but in these situations my telephone
call to the patient was unanticipated on my part.
With time and after experiencing a few terse replies I tried where
possible to anticipate when I might need to contact a patient, and do what
several respondents described: gaining consent for this before the patient
left the room. This also gave me an opportunity to check their telephone
number as often this was out of date or not even recorded.
When telephoning patients, stating one’s name may be an option, but
if one’s first name is unusual like mine, it does little to maintain
confidentiality. With regards to home visits, I do not feel these are
comparable to telephone calls to patients, as usually the patient is the
one who has requested the visit. I think if someone else answers the door,
one would usually assume implied consent for that person to know that you
are the doctor.
Many GPs work in partnerships and often practices have a system
whereby one doctor deals with urgent results/queries for the day. If one
is the duty doctor, it is not unusual to find oneself dealing with a blood
result from tests one has not requested. In this situation one would not
have been in the position of checking consent to a telephone call. Of
course it would be helpful if all one’s colleagues gained and documented
consent for telephone contact, but I think this is unlikely.
Several readers have emailed me directly, questioning whether it is a
breach of confidentiality to state that you are Dr…… I imagine that there
are many doctors who introduce themselves in this way and the vast
majority of the time patients do not have a problem with this. We are all
aware of the situations where confidentiality is paramount: pregnancy
tests, sexual health, terminations of pregnancy to name but a few.
However, confidentiality is more than not revealing a patient’s
information; the fact that a patient has been to see a doctor is also
confidential.
I have looked for more explicit guidance on maintaining
confidentiality when telephoning patients and could not find anything on
the GMC website or those of the defence unions that refers to the
situation described. The only guidance I could find was from the
publication ‘GP Registrar’ 1 sent to me by the Medical Protection Society
when I commenced GP training. In their section on telephone calls they
state: ‘If you are calling the patient, remember that telling friends or
relatives that “it’s Dr Smith, here” could be breaking confidentiality. Be
cautious about revealing your identity, but when you have confirmed that
you are speaking to the patient, identify yourself clearly, including the
name of your practice or organisation.’
1. GP Registrar: Communication Skills. Autumn 2007. Medical
Protection Society, United Kingdom.
Competing interests:
I am the author of the original article.
Competing interests: No competing interests
My first reaction was that this was a joke but it's long past April
1st. My second reaction was this was anything but a joke for poor Dr
Mahendrayogam to deal with. Fortunately good advice came forth from other
responders, begging the question of where her trainer is/was in all this?
As for never or rarely identifying yourself on the phone, that is
surely an impossible rule for Dr Mahendrayogam to have to follow.
I won't entertain calls from people who won't say who they are.
Period.
And if I have to do a <spit> home visit, do I knock and then
refuse to identify myself until in the presence of the sick person? Surely
the same confidentiality rule should apply then if we are going to be
sticklers about this?
Competing interests:
None declared
Competing interests: No competing interests
The solution to the problem seems obvious. When a doctor sees a
patient and telephone follow-up of the consultation is a possibility,
simply ask the patient if it is possible that someone else might answer
the 'phone. If so, then ask for permission to say who you are when
calling. Then it is possible to respond to the question of identity with
"I am calling from the GP surgery with some information for Mr Smith".
Competing interests:
None declared
Competing interests: No competing interests
I do not like cold callers. People who phone and can not state the
reason for their call in simple words get told to get lost and not to come
back (often not so politely).
Most of my patients are the same.
Further, most of my patients will know me anyway by voice and accent.
So, keeping my call under wraps would be ridiculous.
Finally, in the few situations where e.g. a patient's abusive husband
should really not figure out that who it was that called, does the author
think that a call by a cagey caller of the opposite gender will not cause
just the same ruccus as an acknowledged call by a doctor could cause?
I suggest to the author to simply ask their patients at the end of
the consultation - "If there is anything wrong with those tests, do you
mind me calling on your home phone?" Yes - no problem. No? fair enouh, but
- well "how shall we contact you if something is really not right?"
Once consent is given - or explicitly withheld - the whole ethical
dilemma vanishes.
Competing interests:
None declared
Competing interests: No competing interests
Welcome to the world of general practice with its challenges and
dilemmas. Although confidentiality is paramount to the doctor-patient
relationship and a Good Medical Practice requirement the same applies to
effective communication and patient safety.
Would the majority of GPs worry more about the former when trying to
get hold of someone with a very high INR or potassium level or a very low
and dropping Hb after evening surgery on a Friday?
Most GPs including myself have to make smilar decisions of a bigger
magnitude at least on a weekly basis (e.g. when the above happens in out-
of-hours care). Imagine a situation where the patient must be contacted
urgently and the doctor finds that the phone number is outdated.
Confidentiality is no black-and-white issue, time is generally
limited and all this can be a source of unnecessary stress - this is why
lateral thinking is important in general pratice.
The following may all work:
1) My Name is Dr M (no mention of the exact capacity of the caller)
...
2) Mr Smith agreed to this call on (date of test or other prompt of
the call)
3) If Mr Smith is not available, can he please call (phone number)
A topic like this is makes a good discussion point for a tutorial, in
the VTS group or when the primary care team have a session with a
representative from one of the medical defense unions. It is also worth an
audit if there is no practice protocol for staff dealing with this kind of
scenario.
Competing interests:
MGC has a dislike of anonymous callers
Competing interests: No competing interests
Confidentiality on the telephone is a challenge for all
clinicians,(1) but it is important to keep it in
perspective. There is quite a difference between phoning a
teenager with the result of a pregnancy test and 78 year old
with the result of a warfarin check. We found in our study
that most clinicians and receptionists understand that and
some formally ask patients for permission to phone results.
Patients seemed much less concerned.
One way around the dilemma that Dr Mahendrayogam poses is
not to say she is a doctor but simply state her name. That
way spouses’ suspicions are unlikely to be raised although
there is still a risk that it is a doctor that is calling
will be revealed. If the person answering asks what the
contact is about it is reasonable to say you need to speak
with the patient. For most general practitioners of course
the relative answering the phone will often recognise their
voice anyway so dissembling is not an option. Perhaps when
tests are undertaken patients should be asked it they are
happy to be telephoned if necessary. Of course being
confident that you are speaking to the person you think you
are speaking to is another problem not helped by two
generations of patient with the same name in the same
household. However, that poses a greater problem for written
communication.
1. McKinstry B, Watson P, Pinnock H, Heaney D, Sheikh A.
Confidentiality and the telephone in family practice: a
qualitative study of the views of patients, clinicians and
administrative staff. Fam Pract 2009; 26(5):344-350
Competing interests:
I have been funded by the
Chief Scientist Office of
the Scottish Government
to carry out research in
telephone consulting
Competing interests: No competing interests
Interesting points
from Dr Mahendrayogam. Good to have this topic brought up to make us
think a bit.
First, though, is this relevant? Or are we getting into angels
dancing on pin-heads?
As in, has any GP ever had a complaint for calling a patient's home
and identifying himself/herself to a party other than the patient? Our
medical defence bodies should be able to answer that one.
I became a very serious proponent of telephone consulting over 20
years ago and have worked with doctors who easily outstrip my call rate so
it's not as if I have little or no experience of calling folks at home. I
always but always identify myself and most of the time the
spouse/sibling/partner/whoever already knows the whole story.
The absence of even a hint of a complaint from any quarter after
several thousand phone calls would have to mean that this is a non-issue,
at least in my work.
Second, in the places I work, home visits are often requested by
someone other than the patient but I have had cases where the patient made
the call and someone else answered the door and was surprised to see me.
Oh, I didn't know he had called you.....
My point here was not to compare home visits with phone calls; my
point was that if we aim for extremely high levels of confidentiality in
one area of our work then we have to ask why not expect the same level in
other areas?
Third, I agree that confidentiality applies to the fact that a
patient has been to see a doctor and I can see how the MPS writer made the
logical error of proceeding from that to advising against saying "It's Dr
Smith, here" to friends or family.
The error in the MPS thinking is that simple identification of oneself on
the phone implies absolutely nothing with regard to the patient's
attendance at the surgery or even relationship to the GP.
I often sit with receptionists in various surgeries and listen to
them making calls while I'm doing back-office stuff; the number of calls
made from the average surgery to patients is very high and the staff
always use surgery name or doctor name plus or minus own name, regardless
of who answers the phone in the patient's house.
I believe that calls from GP surgeries to patients at home or on mobiles
have become commonplace and are now part of the background of life. This
may well explain the paucity of advice from bodies like the GMC.
My thanks to Dr Mahendrayogam for stimulating discussion on this
point.
Competing interests:
None declared
Competing interests: No competing interests