We read this paper and the associated commentary with considerable interest. It certainly raises some timely and valuable issues on patient-doctor communication over the phone. However, we found that certain key points are not adequately – even wrongly - addressed. Specifically:
How does the physician compensate for the loss of face-to-face connection? Certainly voice and intonation can play a role, but how can you adequately alleviate a patient’s health concerns without giving them access to your professional personality? What about the “magic -almost therapeutic- power” that this face-to-face connection has?
How can you ensure that there is no significant “between the lines” loss of information over the phone cables?
How can you reliably decide on a modification of the diagnostic or therapeutic intervention dictated by presence or absence of disease signs and symptoms?
Are all physicians regardless of their level of clinical experience and expertise and their type of voice (“persuasive or adequate”) able to handle diagnostic and treatment over the phone? If not, who then would be able to evaluate the type of physician that can successfully handle a phone consultation? Can we really afford medical “trial and error” methods on a health consult?
What legal guidelines would apply for a phone consultation (that varies across countries) and what is the physician’s legal liability in such a setting?
Of note, the tips presented by authors are quite useful, but they apply only to a limited subset of patients/diseases.
We do agree that such consultations may apply to the management of long term conditions, such as diabetes or depression (of an already known patient), or for communicating the results of investigations, or even for providing preventive healthcare advices, we oppose the notion that acute conditions can be safely managed by telephone calls. Safety-net criteria cannot be really “safe” when they are used only by patients. Patients have neither the knowledge nor the skills to adequately recognize a medical emergency. It would be more prudent if safety net criteria could be used by medical personnel, but again this is not an easy target to be accomplished by and over the phone. As the authors mentioned patients in many cases do not even know the name and location of body parts. This is why the authors mention twice in their manuscript the need for safety netting provision to the patients.
The authors acknowledge that telephone consultations do not reduce the workload of clinicians in most of the cases. Not to mention that a doctor can trust the report of a non-medical patient who conducted self-examination, or examined their child and rely his/her a diagnosis based on that. The Cochrane review showed that there is a lack of training in phone consultation. This is true, as this practice is not taught in any medical school worldwide, probably because it is considered as not practical and unsafe for both patients and doctors alike.
In conclusion: Let’s not make haste to put aside elementary rules of patient diagnosis and treatment in the name of innovation or convenience. Granted, flexibility in approaching and evaluating a patient health concern is essential, but in the interest of maintaining a reasonable risk-to-benefit ratio for our patients, a phone consultation should remain strictly complementary to the office visit that precedes it.
Competing interests:
No competing interests
20 May 2018
Charalampos S Siristatidis
MD, PhD
Gagari Eleni,Oral Medicine Clinic, A. Syggros Hospital of Dermatologic and Venereal Diseases, Department of Dermatology, University of Athens School of Medicine, Athens, Greece and Daskalakis George,First Department of Obstetrics and Gynaecology, Alexandra Hospital, Medical School, National and Kapodistrian University of Athens
Assisted Reproduction Unit, 3rd Department of Obstetrics and Gynecology, “Attikon Hospital”, Medical School, National and Kapodistrian University of Athens
Rapid Response:
Re: Telephone consultations: issues to revise
We read this paper and the associated commentary with considerable interest. It certainly raises some timely and valuable issues on patient-doctor communication over the phone. However, we found that certain key points are not adequately – even wrongly - addressed. Specifically:
How does the physician compensate for the loss of face-to-face connection? Certainly voice and intonation can play a role, but how can you adequately alleviate a patient’s health concerns without giving them access to your professional personality? What about the “magic -almost therapeutic- power” that this face-to-face connection has?
How can you ensure that there is no significant “between the lines” loss of information over the phone cables?
How can you reliably decide on a modification of the diagnostic or therapeutic intervention dictated by presence or absence of disease signs and symptoms?
Are all physicians regardless of their level of clinical experience and expertise and their type of voice (“persuasive or adequate”) able to handle diagnostic and treatment over the phone? If not, who then would be able to evaluate the type of physician that can successfully handle a phone consultation? Can we really afford medical “trial and error” methods on a health consult?
What legal guidelines would apply for a phone consultation (that varies across countries) and what is the physician’s legal liability in such a setting?
Of note, the tips presented by authors are quite useful, but they apply only to a limited subset of patients/diseases.
We do agree that such consultations may apply to the management of long term conditions, such as diabetes or depression (of an already known patient), or for communicating the results of investigations, or even for providing preventive healthcare advices, we oppose the notion that acute conditions can be safely managed by telephone calls. Safety-net criteria cannot be really “safe” when they are used only by patients. Patients have neither the knowledge nor the skills to adequately recognize a medical emergency. It would be more prudent if safety net criteria could be used by medical personnel, but again this is not an easy target to be accomplished by and over the phone. As the authors mentioned patients in many cases do not even know the name and location of body parts. This is why the authors mention twice in their manuscript the need for safety netting provision to the patients.
The authors acknowledge that telephone consultations do not reduce the workload of clinicians in most of the cases. Not to mention that a doctor can trust the report of a non-medical patient who conducted self-examination, or examined their child and rely his/her a diagnosis based on that. The Cochrane review showed that there is a lack of training in phone consultation. This is true, as this practice is not taught in any medical school worldwide, probably because it is considered as not practical and unsafe for both patients and doctors alike.
In conclusion: Let’s not make haste to put aside elementary rules of patient diagnosis and treatment in the name of innovation or convenience. Granted, flexibility in approaching and evaluating a patient health concern is essential, but in the interest of maintaining a reasonable risk-to-benefit ratio for our patients, a phone consultation should remain strictly complementary to the office visit that precedes it.
Competing interests: No competing interests