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Top Tips for Telephone Consulting

Top tips for GP telephone consulting

Before we get started….

It’s not about rationing access…

Please remember that this system is NOT about restricting access to GPs. The telephone call IS the consultation; it’s NOT a triage call. It’s about offering the most appropriate style of consultation and response for the patient – making best use of their time as well as your own.

The great thing for patients is that access is not artificially filtered by availability; everyone who needs to, WILL get to speak to a Doctor THAT DAY. Face to face appointments are given to those who actually REALLY need them. It’s fairer and less stressful for everyone.

If you have the detailed history already produced by the patient through askmyGP, the advice below applies in the same way but you have a head start on what further questions you need to ask.  To illustrate, please see a selection of actual patient histories.

Is it safe?

Patient safety is paramount. Call in the patient if you decide a face to face consultation is necessary OR it is the clear and strong preference of the patient. Always OFFER TODAY for an appointment – you will find 80% will happily take that option, but if they want to book another day, fine, don’t push them to come today.

The key thing is to make your decision about calling in for a face to face consultation QUICKLY.  No need to keep talking or sending them back to the receptionist, just book them in! What’s more, you can book them in for a consultation of an appropriate length of time, not a one-size-doesn’t-fit-all 10 minutes.

Doesn’t this mean more work for me?

The experience of over 50 practices using the GP Access method show that roughly:

  • 60% of patient issues are resolved in the telephone call (average time on calls approx.  5 minutes)
  • 30% of patient issues require a face to face consultation (median = 10 to 11 minutes, as is standard)
  • 10% of patient issues result in a referral to a practice nurse

So you’re certainly NOT working any harder – but you ARE dealing with more patients – you are meeting the true, underlying demand NOT simply filling your available time.

These figures are remarkably robust and representative of the full range of practices in terms of size and patient demographics – you CAN trust them!

When should I call patients back? What about fitting in face-to-face consultations?

For the great majority of patients, being able to speak to a Doctor (or a Doctor of their choice) WITHIN AN HOUR – or when they ask for a return call – is EXTEMELY REASSURING, and is actually preferable to booking an appointment. The quicker you are in responding, the better the system works.

Do expect to do most of your calls in the morning and your face-to-face consultations in the afternoon, but if you need to see someone urgently – or they can only come in the morning – then that’s fine.

How the GP Access method can help improve continuity of care?

PROVIDING YOU GET YOUR NAME UP IN LIGHTS  –that is, making sure that you use every available opportunity and location – physical and virtual – to let your patients know when you’re available, you will quickly find that your patients will call when you’re there – improving continuity and cutting down on wasted phone calls. Remember, it’s those patients for whom continuity is really important who are those you’ll deal with most often, so there’s a real efficiency premium to be gained here, for everyone.

Making the call

Much of what you’ll find below you’ll already know from your training and experience in face to face consultation. It’s just that to begin with when using the telephone, it’s important to make a little bit more conscious effort to ensure that the patient knows that you are fully engaged with them. Similarly, you need to listen very closely when they speak to pick up information that is diagnostically useful as you don’t have access to non-verbal signs and cues.

The 6 fundamentals of expert telephone consultation

There are 6 fundamentals of expert telephone consultation. Practice these precepts and you will flying in no time.

  1. Be prepared – double check the information about the call the receptionist has gathered and check against the patient’s record before making the call. The chances are you’ll have a very good idea about what needs to happen next even before you have spoken to the patient.
  2. Take your time. Just as with a face to face consultation, take your time. If you are rushed, or even (as you may think) simply briskly professional in your tone of voice and pace of speech, you are likely to unsettle the patient and unconsciously they will feel the need to hurry as well. This can easily lead to an unsatisfactory consultation and almost inevitably, more unnecessary work down the line. You have more time than you think!
  3. Be clear, calm, friendly, interested & empathetic throughout the call. Don’t be flat, mechanistic and formal, try to modulate your tone of voice. They need to know you are on their side and your voice is the only tool you have to demonstrate your interest and your empathy, so please use it as best you can.
  4. Give the patient time to talk – let them know you’re here to listen and give them up to two minutes without interruptionto tell you their story.
  5. Always Be Checking you have understood what they have said to you, and what you have said them has been understood.

and finally

  1. Good record-keeping. As with any face to face consultation, it’s essential that you accurately record the conversation, its outcomes and agreed further actions, if any. Contemporaneous notes are hugely important in successful – and safe – telephone triage and consultation.

 

Safety-netting

Ensuring safety will of course be your prime consideration. As has been said, if you are in any doubt at all, or if they report standard clinical red flag symptoms, bring your patient in for a face-to-face consultation – don’t waste time on the phone. Employ the same protocols that you currently do to identify patients who need immediate attention, but beyond those who need to be seen that day, you’ll still want to ensure that if a patients symptoms don’t improve or worsen, you will know about it ASAP.

So, it is vital to always prepare a safety net and give the caller permission to ring back if things get significantly worse, e.g. “please do feel free to call if he gets worse”. Also, give concrete examples of worrying signs and symptoms. Explain what to do if your plan is not working, including when and how to seek help.

Give clear, specific, follow up instructions e.g. “If the pain/temperature has not settled in an hour please call back” If necessary, re-check patient understanding and acceptance of your plan. Remember that a face to face appointment with you doesn’t have to be the next step. You can ask them to come and see the nurse if you think that is appropriate, or ask them to come in and have some tests done if that is likely to be needed, or perhaps visit their pharmacist.

Just as a clear management plan is essential for those looking after patients, it is vital for patient confidence that they share an understanding of the plan. The aggressive and usually anxious patient can make life a misery if badly handled. Even these calls can lead to a rewarding consultation if appropriately completed. A confident assertive clinician delivering good advice makes everyone feel better! With clear understanding of the patients’ agenda and assertive triage, comes less stress, fewer complaints and a more pleasant working environment for everyone. Ending the call well is so important to successful telephone consultation – not only for that particular instance, but for building confidence in the long term, so please don’t leave the call if you feel the patient is still unhappy!

A safety net that works for the caller/patient will often depend on you having clearly identified the “caller’s agenda”. Sometimes the caller/patient’s ideas, concerns and feelings – beyond the reporting of symptoms – are really clear, but at other times you will have to ask, e.g. “Tell me, have you any worries about what might be going to happen” or “have you had any bad experiences with these sort of symptoms before?”  Then, the fear of the throat closing up, the ear drum perforating or meningitis developing will be out in the open. This is particularly important where you are dealing with parents of sick children.

Finally, in completing the safety net, remember you may need one too! If possible, allow some time for reflection and if not entirely happy with any element of the triage, never be afraid to phone the patient again.

Telephone consultation and vulnerable patients

Frail and elderly people

Consultation over the phone can be tricky as they may want a visit or to come and see you for reasons other than clinical. So it’s really vital with this group that you get the message across that you are not saying NO to a face to face consultation, just establishing the best course of action. Of course, if the usual red flags are there, or if they are very distressed, or simply unable to have a productive conversation because of poor hearing/language ability, it’s best to bring them in or arrange a home visit straight away, and not waste time on the phone. But where you can have a conversation, we suggest you try and proceed as you would for any patient. However, before you call, make sure you are fully aware of what their current care package is, if they have one, and if you know they have recently been in hospital, check up on the discharge notes. It may well be that there will be several healthcare professionals involved in this persons care – e.g. district nurse, social services as well as you and the local hospital, and a face to face consultation with you is not necessarily the best response in any event. Taking time to gather all the salient information and arranging for a visit by another healthcare professional, and/or a modification of the care package might be a far better option. This can be a time consuming call, but in the short to medium term, well worth the effort.

Children

Naturally, this will involve concerned or anxious parents, a small number whom may be angry or exasperated at the call back system, if it’s their first experience. So again, it’s really vital that you get the message across straight away, that you are not saying NO to a face to face consultation, just establishing the best course of action. Of course, if the standard clinical red flags are there, or of you have any uncertainty, it’s best to bring them in or arrange a home visit straight away, and not waste time on the phone. But children can fall ill and recover very quickly, and most parents will know that, so the chances are, if the red flags aren’t there, then the problem will resolve itself within a day or two. In this case, most parents will be happy with advice and reassurance coupled with a clear safety-netting plan (see above).

Make sure you get information about what the child is doing at the moment of the consultation – if the child is, for example, running around, they are probably OK. If the child is old enough, ask to speak to them – they might give better information than the parent, or you can assess useful information directly such as breathlessness, and the strength of their voice.

If you’re not bringing them in it’s important to express confidence in your diagnosis and your suggested course of action. You also need to make it clear that you are very happy for them to call back if the situation is not improving within a given timeframe. Make sure that they are happy also with the plan – ask them directly how they feel about it. Whilst you are not restricting access, it’s important not to reinforce coming-in-too-soon behaviour.

Patients with mental health issues

Clearly if this is a new presentation, you need to be sure they are safe and not likely to harm themselves or others, so if you have any concerns at all, bring them in. If the patient has a history, then make sure you have read the notes and proceed as you would with any other patient, if that is possible. If they are too upset, or again if you have any concerns about self-harm or harm to others, bring them in.

Angry Patients

Stay calm, speak in a low tone and slowly. Reassure them – they probably will have a face to face appointment, but it’s hard to diagnose with a lot of anger present – make sure they understand you are NOT saying NO.

Using ‘I’ Statements allows a person to ‘own’ their thoughts feelings and opinions rather than using ‘you’ Statements, which may implicitly blame the other person. These also disclose your feelings in a professional manner and help to create empathy:

“I understand that you are angry”

“I am sorry that….” Can be an expression of sympathy only and does not have to imply that anything was your fault

“I am concerned that”

At the end of the call, make sure that repeat back what they want and explicitly agree to the course of action.

Information gathering – useful questions and approaches

What if a patient is not really being very clear about what their concern is? If you find you need to gather more detailed and specific information, DO USE the five ‘W’s:

  • What is the problem?
  • Where does the problem occur?
  • When did the problem start?
  • What makes the problem better or worse?
  • When does the problem happen/is most troubling?

DO NOT ask lengthy complex questions – KEEP IT SIMPLE

DO NOT do ask quick-fire multiple choice questions – “Have you tried x, y, z….?)

DO NOT use medical/NHS jargon

In general always try to use OPEN rather than closed questions.

Using “I” Phrases to build rapport and confidence

“I” Phrases can make repeated or sensitive questions or statements less threatening. They also involve the patient in the process of diagnosis, which is a great builder of rapport and confidence. Examples include:

“I am wondering….”

“I get the feeling that…”

“I have a sense of…”

After a discussion led by these questions and their responses, you should find it a lot easier to get the patient to feel that they have proper ownership of the care plan – that it’s not something simply imposed upon them.

The patient isn’t listening!

All consultations are a form of negotiation. Sometimes this might break down because the patient is angry, anxious or has unreasonable expectations. Most likely they will cease to listen at this point; how do you tackle the situation?

You may need to use the ‘Broken Record’ approach before you can move on

The Goal:

To be very clear about what you want to say – or what information you need – and to make this known without getting angry, uncomfortably irritated or loud.

When it’s Useful:

In conflict situations, when refusing unreasonable requests, when saying no, when asking questions for clarification, when being taken advantage of and when expressing requests especially when the other person isn’t listening.

What you do:

You speak as if you were a broken record. You need to be persistent, to stick to the point of what you want to sa ay, and just keep saying what you want to say over and over again. It is very important to ignore all the side issues. Do not be deterred by or respond to anything, which is off the point you are trying to make. Just keep saying in a calm, low and repetitive voice what you want to say until the other person hears what you are saying. Broken records eventually get heard. It is uncomfortable to listen for too long!

Talking through the action plan

Always share your thinking with the caller, i.e. “this sounds highly likely to be a nasty virus” or “if it was something that I need to see immediately, such and such would be happening”. When giving advice, as with asking questions, be assertive but not aggressive.  E.g.: “It would be good to give paracetamol on a four hourly basis because…” rather than “I told you before, tepid bathing went out years ago!”

Always check that there is agreement and understanding of what you propose. This is important. It might also be necessary to emphasise your confidence in your own advice e.g. “yes, I’m sure this is medically sensible and safe, could we try it for a while”. “Are you happy with that?” etc.

Being able to help is wonderful but it is important to stress, where necessary, what you are unable to do so that the caller does not have unrealistic expectations. E.g. “I cannot arrange an outpatient appointment any more quickly than your own clinician but I am happy to listen and see if there is anything I can offer….”

References – our practising GPs, Telephone Consulting Mastery eProgramme, and the useful gp-training.net site, also with further advice.