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Views And Reviews Primary Colour

Helen Salisbury: Teleconsultations for all

BMJ 2020; 370 doi: https://doi.org/10.1136/bmj.m3211 (Published 18 August 2020) Cite this as: BMJ 2020;370:m3211

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  1. Helen Salisbury, GP
  1. Oxford
  1. helen.salisbury{at}phc.ox.ac.uk
    Follow Helen on Twitter: @HelenRSalisbury

England’s health and social care secretary, Matt Hancock, announced in a speech to the Royal College of Physicians that all future GP consultations should be done remotely by phone or video, unless there’s a compelling clinical reason not to.1 I wonder what he considers to be “compelling clinical reasons”?

Since mid-March we’ve been talking to all of our patients by phone, before seeing some of them face to face. There have been some increases in efficiency, and it’s helpful for patients with a simple problem or request to discuss it without having to spend time in our waiting room. But to suggest that because 70% of appointments have been remote there’s no reason to go back to majority in-person consultations is to leave out important questions about quality, choice, and relationships.

The problem with remote consulting is one of unknown unknowns—you don’t always know what you’re not seeing. Many of the clinical examinations I do are normal or confirm what I already suspect from the history, but I’m sometimes surprised by an unexpected finding. Some of the most interesting parts of my job are when the chest exam that I thought would be normal reveals pneumonia, or when I detect fast atrial fibrillation in the patient who just feels a little tired.

I’ve done my best during lockdown, particularly when patients were very fearful of attending the surgery, but I’m acutely conscious that the restrictions have led me to practise substandard, second best medicine. My antibiotic stewardship has deteriorated: when I have no examination findings to aid my decision making it alters the balance of risk and leads me to err on the side of caution. I’ve seen patients who have waited too long to receive the right diagnosis because of an incomplete, remote assessment—something put right only when they’re finally seen in person.

Any success in my remote consulting has relied on my pre-existing relationship with patients. When you’ve been looking after a family for many years you’ve banked a lot of knowledge and trust, which you can call on to see you through the current difficulties. Developing new therapeutic relationships from scratch over the phone is possible, but it’s harder to achieve when you can’t see the person and read nuances of expression and body language.

As restrictions ease I’m seeing more patients face to face and doing a better, safer job as a result. I predict a shift towards remote consultation as some patients choose to continue to access their GP in this way, especially for simple or minor problems. But much of what we do is not simple: patients have new problems on top of longstanding ones, complicated medicine regimens, and struggles coping with life and illness. For many, a phone call won’t adequately replace the traditional doctor’s appointment.

I’d be delighted to welcome Hancock to my surgery and explain to him what we do in general practice—and why I won’t be making the change he suggests.

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References

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