Telephone consultationsBMJ 2018; 360 doi: https://doi.org/10.1136/bmj.k1047 (Published 29 March 2018) Cite this as: BMJ 2018;360:k1047
- 1Department of Internal Medicine, VU University Medical Centre, Amsterdam, Netherlands
- 2Centre for Population Health Sciences (CePHaS), Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore 308232
- 3Global eHealth Unit, Department of Primary Care and Public Health, School of Public Health, Imperial College London, London W6 8RP, UK
- Correspondence to: J Car
What you need to know
Check that the patient can hear and understand you, and is in a suitable place to talk
In the absence of other cues, the tone and content of speech is important
Gain information from an indirect physical examination by asking the patient to describe signs such as breathing and vital signs and rashes
Provide strong safety-netting and remember that a face-to-face consultation or home visit may be needed
Up to a quarter of patient-physician interactions occur via telephone in settings such as US internal medicine and UK primary care.1 Telephone consultations have the potential to improve access, convenience, and choice and are the most common alternative to face-to-face consultations.2 Comparative studies show that patient are equally satisfied with both forms of consultation.345 However, randomised controlled trials and time series studies show that telephone consultations do not necessarily reduce workload for clinicians.56
There are times when they may be unsuitable. The lack of visual cues and inability to examine the patient are key disadvantages that necessitate careful consideration whether phone consultation is safe and effective.37 Phone consultations tend to narrowly focus on presenting symptoms, and patients are often not comprehensively assessed.8 A recent Cochrane review underlines the lack of training in phone consulting competencies, and audits suggest unwarranted variation in physicians’ behaviour on the phone.89 Based on best available evidence (sometimes expert opinion), we present an approach to telephone consultations in primary care that is largely applicable to other settings such as outpatient clinics. A subsequent complementary article will present a suggested approach to video consultations.
Sources and selection criteria
We searched PubMed and the Cochrane Library to identify original research studies (primarily randomised controlled trials and systematic reviews) evaluating the role of telephone consultations in medicine. We searched Medline using Mesh terms “Telephone” plus additional search terms for “Consultation,” “Patient outcomes (satisfaction),” and “Cost-effectiveness.” We searched Web of Science using the terms “telephone* AND consult* OR teleconsult*.” The initial search was in January 2017, with an updated search in January 2018.
We checked references of identified articles to find additional literature, and we gathered guidelines and protocols on the subject using UK and Dutch national guidelines available online. We used personal networks to investigate the use of telephone in other countries.
Phone consultations are used to substitute or supplement face-to-face consultations for a wide range of patient needs. For example, for triage and management of different acute and long term conditions, psychological therapy for depression, counselling for smoking cessation, and with patients who might find it difficult to leave their house, take time off from work, or keep an appointment.10111213 Questions at the start of the consultation, such as asking patients whether they are in a quiet private space and whether they can hear you well will allow you to assess the suitability of consulting the patient over the phone.
Speaking to third parties and confidentiality
It is important to speak directly to the patient (including a child if old enough) whenever possible. Telephone consultations involving friends, family, and relatives are common, for example, for a child or for an elderly relative who may prefer someone advocating for them. Only share information with a third party after discussing this with the patient. Document a consultation with a third party in the patient’s notes. Do not feel obliged to discuss any concerns immediately; arrange a return call if you need more time, such as needing to consult a colleague.7 For talking to a third party without the patient’s presence, you may agree in advance with the patient a simple password (recorded in the medical records) that the patient could share with the third party as a confirmation that the patient has agreed to the person sharing information about them.14
Telephone consultations with or about children may need extra thought. Explore children’s and/or parents’ worries, expectations, and emotions. If speaking directly to a child, ask the parents to put the phone on a speakerphone so that they can listen in to the conversation. If the parent is not reassured, or your assessment of the seriousness of the condition differs from that of the parent’s, always err on the side of caution and arrange a timely face-to-face consultation.
Triage and management of acute conditions
This can be and is often performed by trained non-clinical staff or nurses. They usually use protocols that include assessing the urgency and reason for the call and provide information such as the call-back timeframe and reachability.11516 In a patient with, for example, back pain triage includes questions such as “When did the pain begin, and what were you doing at the time?” and checking for “red flags.” As with face-to-face consultations, it is important to systematically cover relevant domains of history such as medication use.3 Ensure strong “safety-netting” by giving guidance on how to recognise deterioration: describe warning signs and appropriate ensuing actions (such as, “There is a small chance that this will deteriorate. Call back right away if the pain changes at all, if you develop any new symptoms, such as difficulty passing urine or having a bowel movement or numbness in the ‘saddle area,’ or if you are worried”).1
For young children, discriminating questions include asking about appearance such as skin colour, physical activity, hydration status, respiratory status, and neurological cues such as seizures.1517 Have a low threshold for seeing children face-to-face, especially those under 2 years old.
Long term conditions
Telephone consultations can support management of long term conditions such as, diabetes and depression. Before agreeing on a telephone follow-up, aim to have at least one face-to-face consultation to confirm the diagnosis, treatment, and action plan. It may be helpful if the patient prepares a written list of their concerns and queries before the consultation.
Patients are often told about results of investigations by telephone. When ordering tests, discuss the option of communicating the results either through phone or face-to-face before the test is ordered. If the results may not be appropriate for a telephone consultation (such as when requiring further evaluation or discussing ensuing treatment options), invite the patient to make an appointment by phone or letter within a certain time frame for further discussion once the results are ready, or consider a home visit.18
Telephone calls can be used to raise vaccination rates and uptake of screening programmes, among others.1213 Interventions could vary from a one-off phone call to intensive motivational education programmes. Consider using other telephone consultations as opportunities for health promotion: create prompts or scripts for non-clinical staff to advise patients about diet and exercise when sharing cholesterol results.1920
How should I conduct a telephone consultation?
How should I begin?
Where possible, conduct telephone consultations in a quiet room on a fixed line telephone. Use a high quality headset to free up your hands for taking notes and accessing resources that can support your decision making and follow-up actions.
When calling a patient let the phone ring to allow sufficient time for answering it. Verify the person’s name, date of birth, and location, if relevant. Begin by introducing yourself and where you are calling from (such as your clinic name). Check whether the person is in a private, quiet space and that it is a convenient time to talk. Whenever possible and required, speak directly to the person who has the problem (this includes children), unless you might be specifically calling people for collateral history.
What specific communication skills might help?
As with any consultation, be empathetic and supportive with a welcoming attitude, which is demonstrated in both words and the tone of voice. What and how you speak becomes very important in telephone calls. Since a large percentage of face-to-face communication is non-verbal, and this is largely lost in phone communication, we present some specifics for telephone communication competencies based on our clinical opinion and evidence.
Knowledge of names and location of body parts can differ surprisingly widely (especially in non-native English speakers). Clarify what the patient means by each term first. In the absence of visual cues and the patient being able to precisely point at a body part, for example, common understanding is critical.
Check two-sided comprehension (by asking the patient to summarise the key points back); the lack of visual cues prevents you seeing nodding in agreement, etc. Since supporting written material cannot be provided immediately, consider inviting the patient to make notes. If applicable, direct the patient to a website for supplementary information.
If you need additional help or advice from colleagues or others, advise the patient and report when you will call them back. Provide explicit safety-netting: ask the patient to call back if they have any concerns, if symptoms develop or deteriorate, or they do not improve as anticipated. Unlike when a patient steps out of a clinic room, there is limited opportunity for patients to discuss or check things after the telephone consult.
Let the other person disconnect first to ensure that he or she has no further issues to raise.
How can I examine the patient?
Some information from indirect examination can be gleaned by phone. Where relevant, ask the patient to conduct self examination or a parent to examine their child.11516 Consider using laymen’s expressions or the patient’s choice of words, such as tummy or stomach instead of abdomen. Box 1 provides guidance on conducting an indirect examination.
Tips on how to assess physical problems by telephone consultation (based on others’ and our clinical opinion)11516
Begin with red flags, which will differ for different conditions (for example, back pain has red flags for the symptoms of cauda equina compression)
Review organ systems systematically by guiding the patient through the examination and asking, as appropriate, neutral questions and specific open and/or closed questions (avoid leading questions) to assess possible presence and severity of different symptoms and signs. For example,
With a patient with low back pain: “Can you bend forward and, if so, how far? Is this less than usual?”
With a parent of a crying child with high fever: “Does the child have neck stiffness? Can she turn and move her head around and touch chin to her chest?” “Could you gently press on your child’s ear—first left, then right? Does it hurt?” “Could you use your mobile phone’s light to look into the child’s mouth and tell me what you see?” etc
For visible complaints such as rashes, check:
Position: “Where is the rash?”
Size: “What is the size approximately in cm?”
Shape: “What is the shape, and is it symmetrical?”
Colour: “What is the colour?”
Surface: “Is it smooth or rough?”
Distribution: “How is it distributed over your body? Is it on the inside or outside of your joints?”
Presence: “Does the rash go away when you press it?”
Sensation: “Does the rash itch?”
Examples of other patient self examination may include assessment of vision, mobility, muscle strength, changes to appearance, and listening to patient’s cough
For long term conditions where telephone consulting is planned, discuss aspects of self examination and how to use devices such as a thermometer, blood pressure monitor, glucose meter, peak flow for self examination at home. Offer a face-to-face consultation to allow these skills to be practised. During a telephone consultation, ask for specific results: “What does it say after pulse rate and before beats per minute?” “Please take the temperature from your child’s ear.” “Could you measure blood glucose from your finger?”
Let the patient know that you are making notes as you speak (to explain the sound of typing during the call). Be sure to record signs and cues that may not necessarily be documented in a face-to-face consultation. For example, a consultation with a patient with a cough would include whether the patient was able to talk in full sentences and the frequency of coughing. Include all answers, including negative ones; the patient’s expectations, emotions, and comprehension; anticipated risks; and follow-up plan.2122
When might additional face-to-face consultation be needed?
Set up a face-to-face consultation or home visit if:
There are technical difficulties with communication, such as the line cutting out
There are communication difficulties such as the patient not able to hear or understand due to hearing, linguistic, or cognitive problems
You or the patient/carer become uncertain whether a telephone consultation is safe, such as if you cannot be sure about the diagnosis22
An in-person examination may be needed.
Approaching challenges in telephone consultations
Punctuality—Patients are often not contacted at the arranged time, and doctors may not be able to communicate if a scheduled appointment is delayed. Give a specific window in which you will call the patient back and assess if these are safe, workable, and appropriate for the patient, especially in acute settings
Time constraints—Telephone consultations are often done “in between jobs,” and less time is available to speak of other (seemingly less relevant, social) issues, other comorbidities than the reason for the call, to build up a rapport, and patient education and prevention.23 Schedule time slots for your telephone consultations and take these as seriously as face-to-face consultations1
Expectations of a face-to-face consultation—An early discussion about the patient’s expectations of a face-to-face appointment or home visit instead of a telephone consultation will help facilitate the right mode of consultation
Escalating emotions—Pick these up by listening to the emotion in the caller’s voice. Try to remain calm and empathic and emphasise what you can do rather than what you cannot. Use the individual’s name to calm them.1 Avoid pre-empting what your caller is going to say. Recap what emotions you have heard by using statements such as, “It sounds as though you are worried about having….” When you detect hostility, defuse it with an apology (such as “I am very sorry to have kept you waiting”)
Prescribing medication—Make sure that any instructions such as about administration, side effects, or monitoring are understood. If the caller requesting medication is not your patient, prescribe the smallest quantity possible.1 Prompt the patient to read the medication information leaflet before taking the medicine
Talking to an intoxicated patient—Realise that the caller may not always be in control. This can be heard in an inability to present a problem, contradiction, and lengthy and unstructured descriptions. Firstly, evaluate and act on medical life threats, suicidal ideation, injuries, and any other medical complaints (anxiety or depression).16 If these are negative, invite the patient for a face-to-face consultation
Myths about telephone consultations
Myth—Clinicians are more likely to be sued when consulting via telephone rather than face-to-face
Fact—The potential for both medical and legal consequences can be minimised by awareness of common risks such as inadequate documentation, by training, and by analysing the quality and safety of telephone consultations (similar to face-to-face ones) as outlined in guidelines (such as from the Medical Defence Union and HIPAA) and textbooks71516182425
Myth—Only younger patients favour telephone consultations
Fact—Telephone consultations are a common means of communication between patients and health professionals irrespective of age. Older people often use them and are not disadvantaged by consulting through telephone26
Myth—Telephone consultations are only relevant to primary care
Myth—Telephone consultations cannot be conducted between countries
Fact—With appropriate medical indemnity and in accordance with standards of practice, telephone consultations can be an invaluable avenue to increase access to care by the patient’s usual doctor (who has also full access to the patient’s medical records) for a patient who is overseas27
Education into practice
How do you or your organisation use telephone calls in clinical practice?
Did you learn anything reading this article, which you could use to alter the way you carry out phone calls?
Do you have an introduction sheet on telephone policy as part of the new patient package?
How patients were involved in the creation of this article
Patient advice was sought at the planning stage. We consulted patients to incorporate their experience in telephone consultations. In response to this feedback, we stressed the importance of organisational issues and policies relating to telephone consultations, safety-netting, and the necessary conditions for a telephone consultation (such as checking the patient can speak freely, no background noises, etc).
Patients endorsed the importance of structured telephone consultation and the need for reassurance.
Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.
Transparency: J Car, guarantor of the manuscript, affirms that the manuscript is honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned have been explained.
Provenance and peer review: Commissioned; externally peer reviewed.