Doing Telephone Consultations In My Socks

On Saturday 21 March 2020 the Royal New Zealand College of General Practitioners requested all general practitioners (GPs) switch to telephone and video consultations by Monday. On Sunday the country reported 40 new cases of Covid-19. By the time the country went into lockdown at midnight Wednesday, New Zealand GPs had made a remarkable transition to 70% virtual consultations.

I am at the kitchen table doing telephone consultations in my socks.

On my first day consulting from home I dressed in my work clothes. No one could see me but it felt right. By the end of week one I was down to active wear and manky slippers. The second week I pulled a few weeds between patients and finished my telephone consults with dirty fingernails. Yesterday morning I went to a Zoom meeting in my pyjamas with a work jacket on top. I feel terrible confessing this - maybe I had flaky professionalism all along? But there’s a bit of me wondering if all that power dressing is about power? Maybe I am a better doctor in my humble socks?

Some GPs are uncomfortable with phone consultations; it’s un-nerving not having the room, with framed degrees and our chair that is always a little grander than the patient’s. If we can’t see the patient, perhaps we will miss something. I was taught that 80% of the diagnosis is in the history, so I figure the phone should cover it, mostly. And there are creative ways of examining people remotely: photos of rashes, teaching people to take their own pulse or to move their pinna up and down to see if their ear pain is caused by otitis externa. One man did his oxygen sats on his cell phone. I did try a video consult to look at a child’s rash but it was an unsatisfactory and vertiginous experience having the father’s cell phone rove up, down, and around, unfocused, on a moving toddler.

Days of phone consultations seem more intense because there are no micro-pauses, you don’t get off your seat for hours on end. Suddenly it is lunchtime and I am so stiff I can barely stand. I think I need to move between patients, perhaps a little mime of walking to the waiting room dropping off the last patient and greeting the next.

Phone consultations are efficient, but not quick. There’s no examination, no time spent getting in and out of the room, up and down off the bed, taking clothes on and off. The patient can’t see me so it’s easy to simultaneously listen and be looking on the computer, writing the script or checking the recalls. I have two circuitously loquacious patients who are challenging face to face but are a breeze on the phone: they can talk away while I ponder their complex medical puzzles.

I learned a lot about telephone consults from 20 years of rural general practice. After hours the patients were directed straight to our cell phone and as I lived 18 km out of town I never wanted to drive in and review people face-to-face unnecessarily. But there is a trick to this: phone assessment takes time, a very detailed nuanced history, an accurate exploration of the patient’s view of things and an agreed plan, with what ifs, and reassurance that I have considered the thing fully and am backing my judgement. These, I think, are the hallmarks of successful telephone consults.

It only works with relationship building, empathy and small doses of practical help, like how to get the medicine into the screaming child. These days I might add something about coronavirus and social distancing, and I might hear back about how they miss the grandkids. The telephone needs warmth.

There can be a strange intimacy, as if there is a safety in being unseen. It surprises me how often patients download their life in all its messiness, to me, an invisible stranger.

I am working as a locum so I have not met any of the patients in person. On the phone they can’t see my dirty fingernails, and of course I can’t see them. I find myself creating a mental picture of what they look like. I wonder if it will be surprising to meet them face to face but then again, they might be surprised to see me in the flesh too.

The mental picture I form of patients based on their voice reveals an internalized bias I’d prefer not to have. A lovely man who was having terrible panic attacks told me he had finally got himself out for a walk at 9 pm. He’d gone late so he wouldn’t run into anyone but the police had stopped him and interrogated him. I said, ‘Oh no, you didn’t need that’ (picturing my patient with clear white skin, a full set of teeth and Gap jeans). ‘They probably stopped me because I’m covered in tattoos and piercings’, he replied.

Then there was the lovely young women telling me she had taught herself to sing during lockdown. It was a heart-warming image. It didn’t quite fit my picture when she later lamented she couldn’t do sex-work in lock-down.

If the conversation is getting a bit overwhelming and complex, I can just stop the consult after a few minutes and say, ‘Look I’m going to look into this and call you back.’ That takes off a lot of pressure. In the face-to-face scenario you feel like you have to resolve everything in 15 min because bringing people back costs them money, and it’s really inconvenient coming back to the doctor; finding an appointment, parking the car, taking time out of one’s day.

In the past I hesitated to ring patients at all because they got a free consultation out of me. Now I find myself doing more follow-up calls, and charging for them. A phone call is easy for both of us and boy the patients appreciate the follow-up. I get many more thank-yous at the end of a phone consult than I do face to face.

I don’t think the telephone should be seen as the poor relation to the real consultation. I am giving my full attention so I am happy charging for my time. The question is can we charge for telephone consults initiated by GPs? I think so. If my complex patient is discharged from hospital it’s a simple text suggesting a phone consult to discuss ongoing care.

The Health Care Homes initiative has tried to improve practice workflow by phone triaging same day appointments. Do we need all patients assessed by phone first? Currently we have a bizarre system where we have no idea why a patient is coming, everyone gets 15 minutes regardless of need and suddenly they have a list, there is pressure of time and no staff to help. If we had started on the phone we could have planned ahead, ‘You need bloods before we see you, and then you will need a long nurse appointment for ECG and diabetic check and I will see you for a double appointment to look at your knee and your rash.’ So much more efficient and better care.

This pandemic has changed general practice forever and that’s a good thing. Challenges create innovation. Patients were starting to vote with their feet anyway, looking for more convenient ways to access health care. I’m an ageing boomer but when I heard a talk by Babylon Health at a recent conference, I wanted to sign up as a patient straight away.

The move to telephone consults has created a financial challenge - how do we get paid for digital health work? This question has been hovering over us for several years but now we need an answer. Do we just get over ourselves, value ourselves and charge for each interaction? Or maybe we start a membership system where patients pay an annual or weekly fee for all our services?

I am still at the kitchen table as I ponder this. I am very proud of general practice for our adaptability. I feel lucky that after a month of lockdown Covid 19 is nearly eliminated in New Zealand. I feel for GPs toiling in Covid hotspots around the world. I’m sure they would probably rather be at home in their socks.