I am on the telephone to my 20th patient of the morning (don’t worry I’m used to it). My patient is sure she has a kidney infection. I take a history, prescribe a strong antibiotic and firmly attempt to say goodbye. However, she reveals she has 3 other issues.
During the next few minutes I decide to cut things short and fix up to see her face to face. It’s easier that way. Of course, when I see her later that day, as well as checking her for her chest, her toe and her mole (you’d be surprised what people think I can do in 10 minutes) I take the opportunity to assess her properly for pyelonephritis. An examination reveals she has no loin pain, no temperature and a normal urine dip. I cancel the antibiotic.
I had taken a careful history over the phone, I was not that busy, I came to a reasoned conclusion and yet my telephone consultation diagnosing a kidney infection turned out to be a piece of rubbish.
This is not unusual according to the Medical Protection Society (MPS) (Doctors’ insurers) who have been advising clinicians about the pitfalls of telephone consultations for decades. Clinicians tend to miss important cues and signs on the telephone, there is a risk of taking patients at face value and relying too much on what they tell us without checking, we apparently often have a ‘wellness bias’ -underestimating the severity of an illness, we are more likely to leave out questions from the history and we are more likely to make premature decisions.
However convenient telephone consultations seem to be, they are not as good as face to face appointments. They take longer and doctors are more likely to make mistakes. We need to remember they have only been used during the pandemic because when covid numbers are high the balance of risks makes sense. Every consultation that has been done remotely during covid has been a compromise between examining the patient properly and avoiding the patient being in the waiting room spreading the virus.
If you had ever told me my goal as a doctor was going to be to avoid having patients in the waiting room I would have been baffled. However, now that covid numbers are gradually dropping and the number of those vaccinated increases, avoiding having patients in the surgery is not the right goal anymore.
Patients who say, ‘It was great, I didn’t have to sit and wait’ are forgetting that the point of seeing a doctor is not convenience but good medical care. (Ideally, of course, we would have perfect convenience as well as great care for everyone.) But there are other patients who know they need a hands on examination and who feel they are being fobbed off.
There is a place for remote consultations of course, for brief follow ups that don’t need an examination, in some chronic conditions or for test results. Even in normal times about 20% of patient appointments in General Practice are often on the telephone, GPs are used to this. Total triage worked well during the pandemic, you can get a surprisingly long way on the telephone. But its time to get back to safer ways of practicing.
Not everyone agrees with the goal of safer, face to face practicing and although the pandemic is receding there are those who seem to want to continue keeping patients at arms length indefinitely. In particular, NHS England’s 2021/22 Priorities and Operational Planning Guide published March 25th insists that all GPs should ‘increase significantly the use of online consultations, as part of embedding total triage.’ Presumably someone in government thinks that continuing total triage (that is all patients must speak to a clinician before being allowed a face to face appointment) although less safe, will solve the GP appointment crisis by saving GP time.
But this is not correct either. Most doctors and even the medical protection societies are aware that it often takes longer to consult remotely. Its harder to connect with patients and takes additional time to communicate effectively. Even a clear issue such as a lump is harder to describe than to simply look at. A long and usually baffling description over the telephone is usually followed by a further appointment having to be arranged for a proper examination. A complex issue takes even longer.
Following the demand to ’embed total triage’ there has been an outcry from medical bodies. Passionate and openly published letters have been written by the Royal Colleges and the BMA. In response NHS England has now done a sort of muddled about turn and advised GPs to, ‘Respect preferences for face-to-face care unless there are good clinical reasons to the contrary.’
This is a far cry from understanding the principle that remote consultations lead to increased errors. NHS England needs to realise that GPs have only been using them because of the pandemic, not because they are better. And it has been left to the Daily Express to track down a patient severely harmed by remote consultations leading to a delayed GP examination and subsequently a delayed cancer diagnosis.
The possibility of a missed or delayed diagnosis leading to serious consequences is always present and is exacerbated by remote consultations. Every doctor knows this. The MPS explains ‘The health professional who does not put himself in the best possible position to make a diagnosis is vulnerable to complaint and litigation if the patient suffers as a result of his negligence.’
Medical protection societies are clearly worried. ‘Already we have started to see a number of complaints and inquest cases that have raised issues and concerns around remote consultations.’
General practice is well on the way to returning to safer and better practice. Although facing a crippling demand for appointments, in general practice over 50% of consultations have gone back to face to face. In some practices patients like my ?kidney infection patient can even cut out the middleman and book a face to face appointment directly again. However, what about in the hospitals? Many outpatient clinics have put every GP referral into ‘telephone triage’ leaving patients in a deadly limbo where they never know when or how they will be contacted.
General practice is nimble and can respond literally the same day to a change in appointment policy. But there seems to be an inertia in the hospitals about returning to normal, safer practice. We should be worrying now about patients being kept at arms-length from their outpatient specialists. That’s where the hidden masses of unlooked after patients are lying.
Berenice Langdon is a London GP