Setting up

From the clinician's perspective, a telephone consultation is qualitatively identical to a face-to-face consultation: seated at the clinic desk, the patient's notes to hand and the computer on, with access to relevant results and scans, etc (figure 1). There is no need for open neck, short sleeves and removal of watch, and coffee can be left on the desk. I prefer the phone on loudspeaker, to maintain hands free, but also so that others in the room, such as students (first introduced to the patient) can hear the conversation.

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Figure 1

Consulting using hands-free loudspeaker, with notes and imaging to hand.

Our clinic list typically places telephone consultations first on the list, since early appointments can allow patients still to go to work or college as normal. However, some enjoy a lie in before their consultation and specifically request a later appointment.

Preparatory contact

Much clinician time can be wasted through trying various telephone numbers, not connecting to patients, or getting through to patients or family members who were not expecting or indeed wanting the call. Patients who receive a courtesy call beforehand (eg, from a secretary) can be reassured that the consultation will happen (even if late) and also reassures the clinician that the patient's correct and preferred phone number is to hand.

The opening statement

As in a face-to-face consultation,2 there is no best way to open a telephone consultation. My usual opening words might be, “Hello, this is Dr Smith from the clinic: we had an appointment this morning for a chat on the phone. Is this a good time to speak?” After introducing other people in the room (students, etc), I would then ask and record in the notes who else is listening in at the patient's end (relatives and carers).

The consultation itself

Inevitably, the style of consultation differs to that when a face-to-face. For example, prolonged silences, so valuable when the patient is in the room, need some filling (‘uh huh’, ‘yes’), not least to reassure the listener that the audio connection is maintained. The clinician and patient also lose the mutual advantage of seeing or perceiving one other's body language. Furthermore, it is not possible to show patients their scan results (valuable and informative for patients, even when normal) or to hand over a prescription or information sheet.

Patients worry if the call is late

Patients waiting by their phone at home become understandably concerned if their phone stays silent a few minutes after the appointment time. Again, a courtesy call beforehand from a secretary or administrator can help to settle their anxieties.

Clinicians can phone early

An advantage of the telephone arrangement is that, when the clinic runs ahead of time, the consultation can begin early, rather than awaiting patient arrival. However, we need to be aware that some patients may not be fully prepared early, or may not yet be joined by the accompanying person whom they would like to be there.

Take each patient in turn

Even when some patients arrive in person and are seated in the waiting room, they do not take precedence over phone patients whose appointments are due: patients for telephone consultation have equal priority on the list.

Difficult to provide written information

Patients who need prescription changes require urgent letters (or email) to their general practitioners. Similarly, if patients need written information sheets, for example, medication information or shared decision aids, these need to be emailed or sent urgently.

Ending the call

Patients can misinterpret the mindset of a clinician who ends a consultation too abruptly; it seems better for the patient to hang up first. Some clinicians advise patients to hang up when they are ready; however, it seems sufficient just to wait a few extra seconds at the end before ending the call.

Not picking up

It is sometimes unclear whether a patient's failing to answer a planned phone call directly equates to ‘Did Not Attend’. Mostly, it probably does (some deliberately switch off their phones before the appointed time). Nevertheless, when we cannot make telephone contact, our service tends to be less strict (compared to face-to-face) in offering an opportunity to re-consult.

Not suited to all

Although some patients love telephone consultations—no time off work, no need for long journeys or waiting for ambulances for a 10-min appointment—and most can see some merit, they clearly need to be appropriately targeted. Some people prefer to visit in person and will turn up anyway, perhaps ‘misunderstanding’ the written arrangement for a telephone consultation.

Sometimes challenging

Some consultations are challenging by telephone, particularly where the problem is very complex; for example, a patient with psychogenic non-epileptic seizures who continues to have frequent episodes and whose understandably anxious family is assembled around the phone expecting answers. In such cases, I might have to end the call early and set the date for an urgent face-to-face visit. Other patients feel shortchanged, not having had a ‘proper consultation’, unless they have visited in person (perhaps with justification).

Shorter consultations

Telephone consultations are undoubtedly shorter than those performed face-to-face. When a patient comes to clinic—having awaited their turn on the list and in the waiting room, and having entered, removed their coat and sat down—even when there is no new information to impart, both sides sense an obligation to ensure that the consultation lasts for at least a few minutes. A consultation covering the same situation by telephone can much more easily end after a brief and focused chat.

Deceptively quiet clinic

A busy clinic usually means a busy waiting room; it is obvious to everyone that the clinician is working hard. Coffee, biscuits and sympathy appear as a matter of course. By contrast, a full telephone list, equally hard work and stressful for the clinician, has an empty waiting room and a feeling of calm in the clinic. Staff may need reminding that refreshments would be just as welcome!