Why Telephone Consultations with Doctors fail

Doctor on the phone

Last week I posted some incredibly powerful videos on how to conduct effective online consultations so this week I thought it fitting to review a qualitative analysis paper that looks at why telephone consults are failing. Written by Heather Hewitt, Joseph Gafaranga and Dr Brian McKinstry FRCGP from the General Practice Section at the University of Edinburgh and published in the May 2010 British Journal of General Practice the paper is titled “Comparison of face-to-face and telephone consultations in primary care”.

This paper is the first I’ve ever seen that compares the communicative practices of doctors and patients in face-to-face and telephone consultations in order to generate more understanding on the contrasts between the two consulting modes.

I’d thoroughly recommend it to anyone interested in consulting with patients remotely, and I’d be really keen to see the team take a look at the revolutionary potential for Interactive Patient History Taking tools to enhance these consultations (find out more about these by watching these educational videos from the Mayo Clinic’s John Bachman MD).

Here’s the key points (comment below to request a scan of the paper) or join the RCGP/BJGP discussion forum here:

“it was found that telephone consultations were typically shorter than face-to-face meetings, and included less disclosure by patients, less questioning by doctors, and less discussion of problems”

“(the findings) suggest that telephone consultations are typically treated by both doctors and patients as an appropriate medium for discussion of single non-complex problems, but casts doubt on the suitability of the telephone for discussion of new acute problems, since they are almost always referred on for discussion face-to-face”

“the study analysis… …raises questions about levels of attention when patients call to discuss self-diagnosed conditions or treatment concerns”

In the 72 telephone consultations that made up the study not a single patient “presented more than two problems”

“The most interesting aspect of the question use in the study sample is its low incidence when patients discuss self-diagnosed or treatment problmes over the telephone or raise new concerns opportunistically at the end of face-to-face consultations”

“low levels of elicitation of additional concerns in the telephone channel suggest that they (=Doctors) expect (telephone) consultations to be mono-topical”

“Patients also contribute to the shorter length of telephone consultations by treating them as mono-topical… …patients consulting by telephone do not introduce additional health-related topics or small talk”

The study also points to a published paper: Telephone Consulting in Primary Care: a triangulated qualitative study of patients and providers (Br J Gen Pract 2009;59(563):e209-e218) by Dr Brian McKinstry that is worth a more detailed analysis as it also shows “that both Doctors and Patients consulting by telephone expect to pursue limited agendas”

“there was evidence that Doctors carried out only cursory verbal examination when patients consulted by telephone about self-diagnosed conditions or treatment problems”

My conclusion:

If we want to do anything with phone call consultations with Doctors that is more than “mono topic” or “refer to a physical meeting” we need to empower patients and their doctors with history gathering tools.

In 2005 it was from this appreciation that we decided to integrate the Instant Medical History Questionnaire tools (from Primetime Medical) into the 3G Doctor consulting process.

In 2010, we have an internet awash with high quality rich video content and communities of patients educating one another, I fail to see any other cost effective way of serving the varied, multi topic Doctor advice needs of the informed patient.

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4 Responses to Why Telephone Consultations with Doctors fail

  1. Allen Wenner says:

    In the US we are replacing telephone calls with the internet because the incomplete history is inadequate for diagnosis and risks liability. In case reviews for a malpractice insurance company, I have recommended settling (the doctor loses) in every case in which the interaction was a telephone call. The doctor will never win the “he said, she said” argument and telephone care is usually very brief, opening significant doubt for the jury.

    Using the telephone as an internet device to gather the patient history opens the full spectrum of care. At least 20% of face-to-face visits can be replaced with an expert interview system, Instant Medical History, with confidence in patient safety. The opportunity for increasing efficiency using this technology will be presented by Dr. John Bachman of Mayo Clinic on September 21 in London at the Royal College of Medicine.

    Disclosure: I am System Designer for Instant Medical History (IMH).

    Allen R. Wenner, M.D.

  2. Very interesting post and comment above by Dr. Wenner. I agree that the problem with telephone consultations is the lack of complete disclosure over voice conversations. As you pointed out Internet consultations open the door for much more comprehensive disclosure of medical history, not to mention cataloguing the consult ensuring nothing is missed if there were to be a problem down the line. Another way to conduct these short consultations, or supplement telephone conversations, is through the use of text messaging technology. At Globaltel Media we’ve customized our SMS messaging platforms to handle the wide variety of uses for SMS in healthcare, from appointment reminders, to mobile diagnostics and general health alerts, all of which are 100 percent HIPAA compliant. Hopefully this trend of using secure communications to facilitate patient care continues to grow, thanks for the post!

  3. Pingback: Doctors are using unsecure email communications with 9 million US patients, but rarely getting paid « 3G Doctor Blog

  4. Allen Wenner says:

    SMS messaging it absolutely a great opportunity to bring patients and doctors closer together. It will be good for follow up and coordinating care. SMS messaging has the same pitfalls of telephone medicine without the 3GDoctor approach. If you read Bachman’s article carefully, you will note that he identifies structured data as paramount to the success of e-visits. Using Instant Medical History, he reduced the “back and forth” communication previously seen with e-mail consultations and made the e-visits very productive, replacing face-to-face visits 80% of the time.

    3GDoctor takes this to the next step by changing the form factor to a mobile device. This is the future of medicine.

    I visited UK practices recently where I saw doctors call patients back for telephone consultations only to find the PATIENT WAS NOT AT THE TELEPHONE number given. Is playing phone tag with patients a good use of a doctor’s time when an e-visit affords more information in 1/5 of the time? I heard doctors tell patients the same thing four (4) times on telephone conversations. Are verbal instructions on the telephone a good use of a doctor’s time when written e-mail instructions are quicker and better.

    Bachman’s successful e-visit article removes all doubt the internet is better for doctors and patients. 3GDoctor simply makes it better. When will UK doctors realize they could see 20% more efficient or go home at 3PM every day using this approach?

    The Bachman abstract and pdf are at: http://www.mayoclinicproceedings.com/content/early/2010/06/01/mcp.2010.0145.abstract it covers his experience with 2500 online consults
    A video of Prof. Bachman talking about the article is at http://www.mayoclinicproceedings.com/site/misc/Multimedia.xhtml

    When patients discover that they do not need to go to the Surgery for many complaints, they will demand this service of their providers.

    Disclosure: System Designer for Instant Medical History (IMH)

    Allen Wenner, M.D.

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