Remote consultations: striking the right balance for patient access

14 August 2020

I have previously mentioned how a computer algorithm would struggle to navigate the nuances of a truly patient focused consultation in general practice and this week, I provide another example.

Remote consultations

The consultation with Joan (not her real name) started in a most unusual way. I rang back the number given which was promptly answered by May, Joan’s second eldest daughter.

"Something’s not right with Mum, but you had better speak to Dawn, my older sister." I dutifully phoned Dawn - "Mum is not well, and she is very irritated. You know, like, down below. She’s a bit embarrassed to talk about it, but she likes you."

I was now onto the third phone call of this consult, with any notion of telephones improving efficiency completely gone. Joan answered the phone. I recognised her voice, but her daughters were right - she did sound hesitant and slow. "Doctor, I am so embarrassed. Would you mind taking a look?"

The easy answer would be to phone through some Canesten Hydrocortisone cream, but I have known Joan for many years. She is now 72 and has had a difficult time recently. She has mild Alzheimer’s disease and for the past eight years has been attending a gynaecologist with a failing mesh implant.

He deferred operating and had kept regular reviews instead. In between those reviews, she has suffered breast cancer, type 2 diabetes, two shoulder replacements, and now Alzheimer’s disease.

From the consultant’s point of view, watchful waiting was the correct management for Joan’s failing mesh, but I wondered if the mesh had anything to do with her current symptoms.

I remember one of my tutors in Hillsborough, Dr Chris Hall, advising me at the start of my training: "Patients will forgive you if you don’t make the correct diagnosis immediately; they will not, however, be so forgiving if you do not either examine them or offer to do so."

We all have witnessed cases where, after an innocuous sounding consultation, we put a hand on a tummy to reveal a mass or unexpected peritonism. We all dread clapping eyes on a child who is sicker than previously expected.

My current pattern of consulting has morphed into a familiar one for many of us - telephone consults in the morning and bringing patients in for examination in the afternoon.

Joan came in that afternoon with her husband. Her gait was slightly unbalanced, and she was evidently uncomfortable. I examined her in our treatment room where our nurse Dianne was kind and sensitive.

The examination didn’t take long and revealed a horrific vaginitis - an angry, dark purple coloured inflammatory rash extending across her vagina, groin and onto the top of her thighs. It looked extremely painful and, while it may not have been life-threatening, it could have led to an exacerbation of her dementia, putting strain on her already frail 74-year-old husband.

My uncle, Dr Richard Dorman, provided gynaecology services for his patients in Keady for over 30 years and he showed me through his example that male doctors can and should examine female patients when indicated.

It was simply a case of good patient communication and having the correct, up to date skills. Similarly, when I worked as a GP appraiser, many female appraisees would sigh when devising their CPD for the following year: "I suppose I have to do some family planning".

I would try and emphasise that just because a doctor was female, didn’t mean they had to be interested in family planning and gynaecology.

After COVID-19 has ended, I feel 2020 will be remembered as a year when general practice changed irrevocably.

A significant debate is occurring within RCGP nationally on how we can shape these changes while maintaining our unique skills of relationship-based medicine, generalism and continuity of care.

The College is trying to ascertain what is the right ratio of remote (or telephone) consultation versus face-to-face contact. Our Chair, Professor Martin Marshall, has postulated it could be 50:50, but has admitted he doesn’t know the exact answer.

It could vary depending on the population we serve - a younger, working population may prefer remote consults where an older cohort may need more face-to-face.

Adding to the complexity of this, have we adequately thought about potentially disadvantaged patients, such as those suffering digital poverty or poor internet access and those with language or cultural barriers?

I also wonder if we need to step back and ask a more fundamental question - should patients be allowed to book an appointment with a GP directly?

No triage or remote shifting. No barriers or pathways aiming to sort stuff remotely first.

We don’t allow people to book directly with hospital consultants, so should GPs, as expert patient generalists, be any different?

The premise is that you can sort at least 60% of issues over the phone, which I accept, but does this inadvertently reduce contact with our patients, preventing us to get to know them better and establishing what truly matters to them?

Education and training

I had a good chat with Dr Derval Dolan, who is a GP in Derry/Londonderry and a widely respected educator.

Derval is working hard, taking in patients for examination for teaching purposes to ensure our specialty trainees and medical students get as much experience as possible.

It will be difficult to answer this question fully during the pandemic, as infection control necessitates us to perform more remote working.

Academics are discussing it extensively and to me they often miss the nuances of our patient’s difficult and often unconventional lives.

These are existential questions for our profession, so please feed back to me your views and experiences.

It is vital we take control of this issue that will change our profession forever. Whatever the answer and however our service changes, our values of compassionate, whole patient-centred care must run through us like a stick of rock.

Pain management

Joan’s diagnosis of Alzheimer’s disease was the cumulation of a difficult process. She had ended up on a cocktail of analgesics over the years and weaning her off these took on a new importance and urgency.

It was not easy, but she benefitted from it with a clearer thought process and a brighter demeanour according to her family.

The National Institute for Health & Care Excellence has just published draft guidelines on chronic pain and they are worth reading. 

Our College nationally has formally responded to the guidance, but it would be good for NI to respond formally, so feed back to us your views.

Many GPs I have spoken to about this issue feel stuck. We don’t want to prescribe strong analgesia but frequently don’t have an alternative option.

Living with chronic pain is miserable for many people and a superb article on how doctors respond to chronic pain, giving good insight and links, was recently highlighted to me by Dr Louise Rusk. 

Accessing alternatives to medication, such talking therapies like cognitive behavioural therapy (CBT) and so on, are limited.

So, it will be important that if our chronic pain services are to change their offering, there must be better access to these services. 

The considerable time and resources required to wean patients off strong analgesia is beyond many of our practices’ capacity.

It is, however, very worthwhile to do and our Executive Member for Patients, Dr Rose McCullough, was involved in a very important piece of work on this topic which won a RCGP Bright Ideas award in 2018.

Her practice was able to put in place a multidisciplinary team, with pharmacist and psychologist involvement, offering good alternatives to prescribing.

Do you have an innovative way your practice manages chronic pain? Please get in touch if you have good practice we can share.

Urgent Care Centres

Work has commenced with an Interim Network to establish Urgent Care Centres.

We fully support the intended outcome of this work - a more streamlined way to ensure our patients receive the care they need when their condition needs escalation - but we cannot endorse GPs having to staff them. We simply do not have the workforce to do this.

There needs to be good communication between our five Health & Social Care Trusts (HSC) and general practice. Ensuring good communication about intended changes will ensure our concerns are heard and will help Trusts by informing us on how to engage best with these new services.

In the Southern Trust, my own local area, our acute medical director Dr Maria O’Kane will be hosting a Zoom meeting to engage with GPs and hear their views on 27 August at 1pm, and I feel this is a great way to hear locality views and understand from front line staff the local issues they are facing.

Again, I am very keen to hear your views on these significant new changes. Please feed back to me. It is very important that your voice is heard.

Leadership in general practice

It has been incredible to hear the outpouring of good wishes and joy for our new Professor of General Practice at Queen’s University Belfast, Nigel Hart.

Messages of support have come from doctors and health professionals across our entire HSC and it is testament to Nigel and his commitment to educating all doctors over the years.

Added to this, the medical school at Ulster University has confirmed they have passed the final General Medical Council requirements and are open for applications to start in September 2021 under their inaugural Dean, Professor Louise Dubras.

This shows that general practice in Northern Ireland is going from strength to strength. 

Our esteemed colleague Dr Louise Rusk has also been appointed to the Board of the Migraine Trust.

The Migraine Trust is a UK-wide body and has an excellent selection of resources on this debilitating condition which is worth checking out.

It is also worth remembering that headaches with visual symptoms are covered under the Northern Ireland Primary Eyecare Assessment and Referral Services.

Idiopathic Intracranial Hypertension is a difficult but important diagnosis, so examining a patient’s fundi either by ourselves, (another afternoon appointment) or by our skilled optometry colleagues, is vital.

Get involved

Just a quick reminder to get involved in our next 'click and chat' Zoom conversation on Friday 28 August at 1pm.

I am aiming to host member engagement sessions on the last Friday of every month over lunch, so please join in and share your thoughts and updates.

You can pop in for a few minutes, or stay for the whole half hour. Everyone is welcome.

Blog holiday

I am taking a week off next week and the blog will be taking a break for the summer, too.

Stay tuned for an upcoming blog from the wonderful Dr Miriam Dolan - a fantastic, dynamic GP in Maple practice Lisnaskea, Fermanagh.

Miriam has introduced remarkable services for her patients and as a teacher is widely revered for her inspiration to the next generation of GPs.

Post written by

Dr Laurence Dorman, Chair of RCGP Northern Ireland

Dr Laurence Dorman took office in November 2019 after three years as Deputy Chair of Policy for RCGPNI. A GP principal in Mourne Family Surgery, Kilkeel, Co Down, since 2007, he is the fourth generation of GPs in his family. He was also, until recently, the Chair of Newry and District GP Federation. 

Laurence has particular interests in new ways of working in primary care, cancer care, and inspiring the next generation of GPs. He set up the successful Dear Colleague initiative to improve the interface between primary and secondary care and has been a strategic advocate for interface and communication since September 2017.

During his time as Chair, he wants to support College members to ensure that the future of GP services is protected, supported and sustainable.

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