South Bristol Trainers Workshop Saunton Sands 1.4.11.
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Transcript of South Bristol Trainers Workshop Saunton Sands 1.4.11.
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South Bristol Trainers WorkshopSaunton Sands1.4.11
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Broad aims of phone consultation:Make accurate assessment of clinical problem
Provide appropriate advice or offer consultation (where?)
Ensure patient safety (safety-netting++)
Caller (may or may not be pt) satisfied with outcome
Dr satisfied
Appropriate use of resources
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PHONE CONSULTATIONS...
Easy or tricky?
What makes them challenging?
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Some of the challenge of phone consultations...Effective communication without the non-verbal
cues
Obviously makes assessment of physical condition harder (diagnosis & just how sick) but also...
Relative anonymity: psychological distance (lack of social cues) on phone...greater likelihood of expressing anger & anxiety, & potential for miscommunication, so...
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Harder to make accurate diagnosis & appropriate Rx decisions than face to face
Harder to know if caller truly satisfied as can’t see them
Weighing up if face to face needed & if so where (matching pt’s ‘needs’, not necessarily ‘wants’, with appropriate resources)
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One thing is on our side...
80% of diagnosis comes from the history
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But...55% of communication relies on
observation of body language & facial expression...
8% comes from the actual words themselves and 37% from vocalisation (phrasing, emphasis, tone, pauses etc)
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Survey of GPs’ concerns & confidence in phone consultations...(BJGP 1999)
4 most frequently mentioned ‘difficult calls’:
Difference of opinion on need for home visit Parental anxiety about children (& GP anxiety)Chronic conditions (symptoms suggesting something new
or part of continuing problem?)Mental health problems
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Confidence levels in these same GPs...Far greater in own practice than OOH
Sense of risk & uncertainty worse OOH
Lack of info re pt’s medical & social history OOH
Different working relationships with colleagues OOH – less able to discuss tricky encounters than in own practice
Conflict twixt doing best for pt & duty to co-op – felt pressure to be quick& efficient & resist visits if possible
Not knowing outcome of phone advice given OOH
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How can we as trainers help our registrars develop safe and effective telephone skills ?
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Patient-centred models...Cambridge-Calgary consultation guide can help us,
applied with even greater depth & intensity to phone consulting:
InitiationGathering informationBuilding the relationshipStructuring the interviewExplanation & planningClosure
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• exploration of the patient’s problems to discover the: biomedical perspective; the patient’s perspective ; background information - context
• providing the correct type and amount of information
• aiding accurate recall and understanding
• achieving a shared understanding: incorporating the patient’s illness framework
• planning: shared decision making
Initiating the session
Gathering information
Physical examination
Explanation and planning
Closing the session
Providing structure
Building the relationship
• preparation• establishing initial rapport• identifying the reasons for the consultation
making organisation overtattending to flow
using appropriate non-verbal behaviourdeveloping rapportinvolving the patient
• ensuring appropriate point of closure• forward planning
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Top Tips...Even before picking up phone:
- check what’s known about pt- but avoid assumptions
Introduce yourself, Dr .... Calling from ....
How you start is really important...+ve attitude, make pt feel you’ll do all you can to help
If possible speak with actual patient (if 3rd party remember confidentiality issues)
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Attentive listening: - note words used, tone of voice, emotion, pauses- encourage pt contribution (silence, “uh huh”, “I see”, “anything else you feel I should know” etc)- echoing, paraphrasing (checking your understanding)- cues
PMH, drugs
ICE (incs pt health beliefs)
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Top Tips...Speak to listen rather than listen to speak...
Mental clipboard
Use of C-C techniques: periodically summarising, chunking & checking, signposting
You can’t examine...use caller’s senses to help you
Avoid ‘rigid hypothesising’ (or ‘mind snapping shut’)
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Share your understanding of problem & negotiate management plan (without being unduly influenced by pressure of workload)
Matching pt need (not necessarilywant) with medical provision
If visit seems inevitable – offer early in consultation – reduces potential for conflict
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And finally...If needs to be seen: PCC or visit? (quicker seen at PCC
& better facilities for assessing...?)
Safety netting – hugely important with phone consultations:
- specific instructions (“worse”?)- possible unexpected outcomes- how to seek help- check understanding
DOCUMENTATION (remember the 3 major failures...)
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Potential pitfalls:Inadequate history taking
Incorrect assessment
Premature decision-making (mind snapping shut)
Conflict (eg over necessity for not for visit)
Failure to visit
Fear or anxiety can make pt seem uncompromising & antagonistic, need to recognise these emotions
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In fact you could hit all 3 big potential failures in a phone consultation...Misdiagnosis
Failure to visit (when it was actually warranted)
Failure to refer
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Ethical considerations of phone consultations?
Possible teaching opportunity?
BENEFICIENCE
NON-MALEFICIENCE
AUTONOMY
JUSTICE
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Does the literature help?BJGP 1999 one of 1st articles
Everything between 1999-2007 pretty much summed up in RCGP Book “Telephone Consultations in Primary Care”
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Most useful bits for jobbing GPs:
Negotiation more difficult than face to face
Different style of interviewing...more Qs (?signposting so doesn’t seem interrogation)
Suggested skills lists and approaches from phone skills courses & articles (handouts)
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Specific skills to be encouraged:
cues from tone of voice, emotion, pauses, as well as words
overt expressions of empathy
Using pt or carer’s eyes & other senses to supplement history
Give info in small chunks & check understanding, reinforce by repetition
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Common errors...In info gathering:
- inadequate drug & allergy history- absence of key questions
In relationship building:- clinician anger & frustration psychosoc probs- pt anger at unmet expectations
In decision-making:- Premature decision-making, absent diagnosis, wellness bias
In explanation & planning:- unclear communication of instructions & Rxs
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Literature 2007-2010?
Not a lot...
15.2.08: Cochrane Review: Telephone consultation & triage: effects on healthcare use
& patient satisfaction – looked at 9 studies...50% calls handled by phone only (no need for face to face)Appeared to reduce visits to Drs & not increase those to A&EAppears safePts just as satisfied as seeing face to face
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