Dr Dave Triska argues that remote consulting is a useful tool to improve patient care
In her column last week, Dr Katie Musgrave wrote about the potential negative impact of remote consulting on health outcomes and the patient-doctor relationship.
As a GP with experience in remote consulting, I disagree with this perspective and argue that the mode of consultation has no bearing on whether or not that consultation is good or bad. The key element of a good consultation is the quality of the communication. Whether it is done in-person or remotely can be achieved through the careful planning of systems, training of staff and coaching in these new ways of working.
Remote consulting, in my opinion, is a very useful tool for improving patient care. It allows patients – who might have mobility issues or live far from the clinic – to access healthcare services more easily and conveniently. It also enables doctors to provide more flexible and responsive care, which can be especially beneficial in the case of follow-up consultations.
We are all familiar with the use of remote consulting to help reduce the spread of infections in clinic, which is essential in the context of the current global pandemic.
When properly implemented, remote consulting can also be used as an augmentation to face-to-face consultations. A remote-first approach, with senior clinical input and careful, nuanced and structured history taking by a human – not a chatbot or algorithm – can be productive. Human-initiated structured histories specific to the presenting complaint can not only improve safety but also improve the patient’s face-to-face consultation. This is far from ‘double handling’ and is getting the right information from the patient to the clinician who can prepare appropriately for their in-person consultation.
Dr Musgrave suggests that remote consultations may weaken the continuity and personal relationships between patients and doctors. I would argue that remote consultations, when done correctly, can be just as effective as face-to-face consultations in building trust and rapport with patients. It’s all about the quality of the communication. Video consultations, for example, can enable patients to see and hear their doctor, which can help create a sense of connection and familiarity.
I have had warm, longstanding relationships with patients who I rarely see or I have never met in person. These patients prefer to consult with me from home or work for a variety of reasons, including serious mental health issues, work constraints, and abusive relationships (which we subsequently helped them escape).
It’s all about understanding the modality. As a GP with significant experience in remote consulting (over 100,000 consultations at the time of writing), I do not experience the problems described, but have seen them frequently when these new methods are shoehorned into current models and staff have neither the time nor the infrastructure to support them in implementation.
I can remember a case recently where a patient had been dutifully assessed over 10 times by their previous caring and competent practice face to face. No doubt due to the pressures of time, mode and manner of consultation, the pattern of illness and investigations that demonstrated their rare, treatable and life-threatening condition wasn’t spotted. The patient and I put the pieces together over a couple of text exchanges, and having the time to properly review the notes meant the eureka moment came during those moments of reflection. They’re now being treated and doing well, and come to see me in practice when needed.
Remote consulting is not the cause of GP’s current woes and can be a useful tool for improving patient care if implemented properly. It’s essential to support GPs in learning new ways of consulting to provide caring and clinically safe care for our patients. As the world of GP continues to shift beyond our recognition, those who adapt and augment their traditional practice will thrive, but those without the desire or means to do so will continue to struggle.
Remote consultations are not just the current trend, they are the future of healthcare delivery. It’s essential to adapt to them with a positive and open mind.
Dr Dave Triska is a GP partner in Surrey
Leeds Coroner probably doesn’t agree following a mastoiditis death?
As ever devil is in detail to ensure are “safe” & acceptable to elderly population?
Yes, it’s the future..
https://bjgplife.com/futurism-gp-2031-the-stocktake-antimatter-part-1/
https://bjgplife.com/futurism-gp-2031-the-stocktake-antimatter-part-2/
https://bjgplife.com/futurism-gp-2031-the-stocktake-antimatter-part-3/
It’s an excellent and persuasive article but I am not convinced – not sure the general public are either !
Hey Iain, I work in one of the longest lived localities in the UK (was 1sr at one point). Digital inequality is absolutely not the aim, we treat every mode of contact the same and looks after the non-digitally enabled patients just the same (with the time we get back).
The mastoiditis case was a convincing case for my argument that mode doesn’t matter – that’s a history not an exam finding that takes some to w (IIRC from the case). As an example, all our ear symptom patients get a Florey with mastoiditis flags in it. Each time, every time (phone equivalent for those who
Can’t).
Liam – thanks, and agree. It’s something in infancy at the moment, been done badly in parts and been worse for
some (?many- maybe).
Done well, with support and planning could be a massive positive.
Fair enough David – let’s see where it goes – I still like the energy of two human beings sitting in a room !
An augmentation of face to face or a replacement?
Unfortunately it’s the latter in many cases.
At a request from Twitter, if anyone hasn’t read my bio I consult for Accurx on this particular topic (ie how to consult well remotely). The query was, is this a paid-for-product advert as a result?
Nope, I’m product agnostic and deliberately so in the article as this is a discussion about *consulting* not online GP service providers. You can happily achieve whatever you need to, for you, with whatever product you like. That may be your own website, it may be one of the various online service providers. Up to you, as I’ve mentioned in previous output you need to find whatever suits your practice. For some people, that isn’t this model – clearly on *that* I do have an opinion, but as far as the tools anyone uses entirely up to them.
Cheers,
Dave
Excellent article. Well done Dave.
And it reflects my experience of rural care as well, where perhaps we are more experienced in remote management by telephone triage as to where and when to see patients F2F, and redirecting those who need to be somewhere else more efficiently (and not just ‘go to nearest A&E’ as often that would be wrong A&E).
Remote history taking and remote result giving can augment substantially the F2F contacts that are necessary in wholistic and ‘continuing’ care, and free up time for Doctor and Patient, and also reduce the infection risk – we just do not have the ability to guarantee safety of the luxury of ‘the energy of 2 people in a room’ passing the time of day, and should consider the adverse effects this may have on the patients as well as continuity of the service.
Thank you for a good and stimulating article, Dave.
Remote consulting has of course been around for many, many years – in the form of the telephone.
The offer of video consultations and improvements in GP technology haven’t driven recent increases in patient uptake – necessity (due to Covid), the increasing patient desire for convenience, and the ubiquity of the mobile phone have been responsible for this.
The problem is, it’s fine for some things and really not very good for others.
– it is not as safe as face to face
– it doesn’t build the relationship as effectively as face to face does – and trust and goodwill is very important in continuity of care
– it increases both clinical risk and workload – because the GP has to work harder and be more directive to exclude sinister illness (despite people seeming to think it is ‘an easier option’)
– it significantly reduces the possibilities for opportunistic care to be delivered – check a BP, check a pulse rate/rhythm, notice the new limp, weight loss or increasing frailty etc etc
– encourages over-investigation (e.g. the person with abdominal discomfort that gets remotely triaged then sent for extensive bloods, calprotectin, FIT tests etc then is reviewed face to face and found within 30 seconds to have a hernia)
– it also gives commissioners the incorrect, unhelpful and over-simplistic impression that almost all general practice could be delivered this way – perhaps by untrained people working from algorithms in call centres
Some patients like it – but only as an additional occasional option rather than as a replacement for face to face – hence the furore over returning to face to face after Covid.
Patients also generally don’t want video consultations – over the three years we have been offering this not one patient has requested it – and they are generally seen as a poor substitute.
So, it’s actually not safer, better, cheaper – or even terribly popular.
It will obviously continue to have a role in some patients at some times, mostly as a convenient way to deliver simple interventions, and so is part of the future just like it has been part of our past.
But it’s not *the* future – unless we accept the belief of some ignorant commissioners that the future of NHS general practice is a cheap unsafe system of call centres manned by untrained staff working off algorithms.
The future? Another nail in the coffin
Remote consultation only works in systems run for the benefit of the providers where patients have no real choice – such as the NHS.
Absolutely agreed with Dr. Triska
Having done my CCT during the pandemic and having had to adapt to rapidly changing working environment, taking an important exam (RCA) with reliance only remote consultations, I believe there is a huge benefit in having a balance of Remote consultations with a F2F, specially where capacity and access is an issue. The system is unsustainable as people still do not feel empowered to manage their self-limiting illnesses, and “seeing a doctor” remains ingrained in people’s minds, even with all the self-help resources we have been rolling out. Outbreaks like Scarlet Fever destroy the whole functionality of the system within days. If it weren’t for remote consultations, Out of Hours would not be able work. I have rarely seen a situation where a clinician did a remote consultation and the outcome was very different from a face to face review when seen depends on who does it. In the end, it is about how each clinician feels comfortable in their own respect, but we can not undermine the importance of remote consulting, and a hybrid way of working, no matter how we feel about it, is the way forward.
Is it helpful to talk about “remote consulting” as a single concept?
I can think of at least 3 different types of “remote consulting”, with different strengths and weaknesses
1. Telephone. Great for mental health and for follow up conversations. No use for initial assessment of anything requiring examination.
2. Text. Great for sending information to patients, great for receiving pictures of visible conditions. Quick and easy for the clinician. Not good for complex discussions.
3. Video. I find video to be of limited value – the audio (including stability of connection) is often worse than telephone, making conversation harder; and in my experience the video is rarely good enough to help make a diagnosis.
Face to face remains my own “gold standard”
I find them high risk.
This technology makes examination so last century. I go to my GP to be told all Snellen charts removed as eyes go to optician (practice of 17,000 enough to run a slit lamp at least or OCP…doing stuff for patients is no longer regarded as useful or interesting). I cannot get on the couch at first, as it was used as a storage table, and they then go searching for a patella hammer.
The telephone consult has crept into the consulting room for face to face. Patients are now shocked to be examined, and many tell me they have been have not been for decades.
Touching. examining, getting a history face to face shows you CARE, and that is what stops complaints and getting sued. This has worked for me over the last 45 years. There is a role for teleconsults, but it is minor. A third perhaps.
Wife’s friend aged 82 was asked to cough down the phone by her GP “I can tell by that you do not need antibiotics” But my hand a week later on a social visit at her wrist showed she must have slipped into AF.
Can’t agree. Remotes are by nature less safe and inefficient. You are often forced to double-handle the case by also seeing them later. And the perceived value of the “consultation” to the patient is diminished, with commensurate high “DNA” rates. Also, the lowering of the access bar (i.e. the reduced “bother” to the patient) stokes demand, as a King’s Fund review accurately identified. The remote is a sop to fix the shortage of appointments which actually makes it worse.
A future very unpopular with patients then.
GP Principal for 34 years, now work in a hospice.
I am sad to say, many delayed diagnoses due to patients being managed at arms length end up with us.
Main reason I left practice was the dissatisfaction of patients with ‘new/novel ways of working’
A classic NHS bureaucrat; he knows what’s best, the patients get no choice, and he still gets paid regardless of how rubbish the service is.
The sooner this Stalinist bureaucracy collapses the better.
I’m disturbed by colleagues’ assertions that remote consults are safe/effective. There is no substitute from having the patient in the room with you. Colleagues are undervaluing their skills if they think otherwise. Remotes consults have been foisted on us by ignorant politicos thinking they are quick and a way of dealing “flexibly” with demand. Bullshit.
A worrying number of my GP colleagues saw the first 2020 lockdown as a golden opportunity to dramatically reduce energy-sapping lengthy F2F surgeries by replacing them with relaxed remote consultations, done at the GP’s convenience and speed, frequently in dressing gown and slippers accompanied by frequent coffee breaks, school runs and brisk walks.
At last, we could cast off the crushing stress of increasing demand and decreasing GPs by regaining the whip hand of control over our patients.
So alluring has this great reset been that doctors across the board have been remarkably stubborn in returning to the horrors of “normal “.
But they are now crashing into reality.
The overwhelming majority of patients DETEST remote consultations, and the adherence of many GPs has seen a sudden and vertiginous collapse in our popularity, something we clung on to throughout a decade of decay and erosion despite daily vilification from a hostile press.
Now that public opinion chimes with the Mail’s , it’s no surprise they’re sticking the boot in.
We’re learning the hard way that we are running a service for the patients, not ourselves……recently, a locum walked out when he realised his surgery was mainly F2F…….good grief!
Personally I cannot stand remote consultations, and moved back to full F2F ASAP, but many local practices are running unpopular hybrid models,
Ironically, many surgeries clinging to remote consultations are drowning in daily emails as patients realise this is the hassle-free contact method, thus driving workload even higher as the barriers to access collapse, meaning that even if practices want to they can’t go back to full F2F as they could never meet the demand.