Remote consultations are suddenly a part of everyday practice. The Covid-19 pandemic has made it necessary to limit physical contact between clinicians and patients. In April 2019, 80%¹ of GP consultations in the UK were face-to-face. Only one year later, at the start of the Covid-10 pandemic in April 2020, only 30%² were face-to-face.
Today’s medical students and doctors receive many hours of training over and over again, for years in how to undertake a face-to-face consultation. The sudden introduction in remote consultations has left the majority of clinicians unprepared for this new way of seeing patients. I hope that the information and advice in this handbook will help to not only educate, but also reduce anxiety.
The doctor-patient relationship is even more important to maintain when the patient isn’t physically sitting in front of the doctor. Therefore, I have endeavoured to thread this throughout the document.
Whilst the majority of primary care consultations can safely be undertaken remotely, the General Medical Council (GMC) recommends a constant assessment of the appropriateness of consulting each patient remotely. Maximise the opportunities of remote consultations whilst ensuring the safety of your patients.
Remote consultations are new, and some patients may not have the same deference for a doctor who they see in person. It is important to introduce yourself and make it clear who they are seeing.
When a patient attends a hospital or GP surgery they are greeted with a professional building, there is a clear sign outside, a clean waiting room, a professional receptionist, and you are sat in an official office, maybe with your name on the door. All this conveys professionalism and credibility to the patient, so you will need to present yourself in such a professional manner so as to make up for absence of these. Your setting, clothing and approach to the patient will be essential for them to feel that you are someone who they can trust and confide in.
Take the time to position your computer and mouse to allow you not only present a professional image, but also to allow you to be comfortable whilst you work.
If you are working on camera frequently, it is worth paying attention to your lighting as it makes a big difference to the image the patient sees.
The background is hugely important and patient perception of you will be heavily influenced by this.
Try to find somewhere quiet, background noise can sound unprofessional.
The remote consultation should have the same basic qualities of a face-to-face consultation, with a patient having confidence that the doctor will assess all their needs. There are some techniques that you can use to enhance the patient experience and improve the outcomes of each consultation.
With remote consultations your ability to see non-verbal cues is reduced, so it is important that you can look at the patient’s face throughout the consultation to read their facial expressions.⁶
We use our hands for a large proportion of our non-verbal communication, so consider how to include your hands in a video call.
Stopping to ask the patient how the consultation is going once or twice will not only check that the patient is okay but will also demonstrate your consideration for their wellbeing.⁸
This technology is new to the patient, so reassure them that they are doing okay; a patient who is comfortable and calm will give you a more complete and coherent history.
A strong and confident yet calm start will set the tone for the rest of the consultation. Before starting the consultation ensure that you are ready to give it 100% of your attention.
In a face-to-face consultation the patient sees you sitting in an office, having waited in a waiting room and been ushered in by a receptionist or voice over the speaker. There is some structure and formality, and with that an expectation and recognition that you are a professional. Without this you need a firm, professional start to the consultation,
With a remote consultation there are some additional checks required at the start of each consultation:
It may be useful to have a separate document open to copy and paste some key phrases from. This will act as a time saver, and a prompt to ensure you don’t miss anything. Some to consider include:
As per GMC guidance a capacity assessment is essential at the start of all consultations, including those undertaken remotely.⁹
In remote consultations you don’t have the same control over who is in the consultation, like you do in a face-to-face appointment.
We need to ensure that the consultation has the privacy and focus that you would expect if you were to see the patient face-to-face.
Try not to lose the pace of the consultation. It may be difficult to control the consultation in the same way as a face-to-face, but constant attention to the focus and pace will give to you and the patient a more satisfying consultation.
As remote consultations become the norm rather than the exception in primary care, it is important not to let health promotion be forgotten.
In a face-to-face consultation multitasking is a useful time-saving skill. This doesn’t work as well remotely
Exploring Ideas, Concerns and Expectations is also important in remote consultations. What's more, asking the patient why they presented now can be helpful in assessing for decline in the patient’s condition. Patients may initially feel that they can't talk in the same way as a face-to-face consultation, so asking these sorts of questions allows them to talk more openly. Try to identify a timeline, so you know when the symptoms started.
A well-structured end to the consultation will not only affect the outcomes of this consultation, but also set the tone for future consultations with that patient.
Even more so than in face-to-face appointments, where it is easier to assess understanding, effective safety netting is absolutely essential.11 Effective safety netting ensures that the patient knows confidently the what, when, where and how:
WHAT should prompt them to act? “If your temperature is still above 38 degrees”“If your temperature is still above 38 degrees”
WHEN does your advice apply? “In 48 hours from now”
WHERE should they go? “Go to the emergency department”
HOW they should get there? “Via ambulance”
CHECK understanding “Can you repeat that plan back to me”
There are key differences between patients arriving at a face-to-face appointment and patient arriving at a remote consultation. Patients attending a remote consultation may be in the very early stages of an illness, when they may appear less unwell, and their symptoms may be more vague, making it more difficult to give a definitive diagnosis. The risk inherent in this is that the clinician gains false reassurance from a well-looking patient, and the patient then worsens following the consultation. As such, thorough history taking, examination, and clear safety netting is even more important in remote consultations. Reasons for earlier presentations for remote consultations include:
Patients with very mild symptoms might not see the value in taking the time and energy to travel to a face-to-face consultation, but a remote consultation can be done from their own home, so they might ask for a remote consultation appointment sooner.
Finding a suitable face-to-face appointment time in a busy schedule can be difficult and can take time, but remote consultations are often available earlier and don’t require any travel time, so it is easier to attend remote consultations.
The ability to email, WhatsApp or SMS patients is a powerful communication tool.
Arranging follow up gives both the patient and the clinician reassurance. It is particularly useful in certain scenarios. This may be a follow up with you or another health professional; don’t forget community paediatric nurses and health visitors.
It can feel awkward at the end of a video or telephone consultation, so just like the start of the consultation needs to be clearly defined, the end does too.
A remote consultation should not be an incomplete consultation. Extra care must be taken to ensure the safety of the child, this includes taking a full social history.
The importance of the patient-doctor relationship is not something that is in any doubt, so we mustn’t forget this in remote consultations.13 Patient compliance with management plans and their subsequent health outcomes are dependent on this relationship.14 Clinicians must endeavour to overcome the actual distance of a remote consultation with some strategies outlined below. As many patients will potentially benefit from greater access to medical care due to the convenience of home consultations, such as reduced travel time, we need to work to maximise the value of these patient interactions.
Remote consultations add a physical distance that needs to be overcome to maintain the patient-doctor relationship.
The majority of patients are satisfied with video consultations, but you may face initial scepticism.
There may be challenges with the technology, the internet connection, the sound or the patient themselves, so your patience will be tested.
Not feeling listened to is a major source of patient dissatisfaction.¹⁵
By definition your patient is not with you, they may be alone, they’re probably ill and may well be nervous. They may feel vulnerable and they are trusting you with their physical and mental health, so be aware of this throughout the consultation.
Don’t forget the biopsychosocial model. As remote consultations are new, both patients and doctors may risk being too matter of fact, sticking to the basic medical information to get the consultation completed in a timely manner. But if this is the only contact the patient is having with their doctor, it is important that all their needs, including psychological and social, are attended to. Patients might not expect this from a remote consultation, so don’t forget to prompt them “how is this affecting you?”.
The advice given above about taking time to take a full history and complete a full examination applies to paediatrics especially. Be aware of your local policies as some organisations have age limits for consulting online. The physiology of children allows them to compensate, but when these mechanisms fail, they can decline rapidly. A low threshold for referral to a face-to-face assessment, or to secondary care, is essential in children.
The history, examination and management advice for paediatric patients are entirely reliant on the parents of the child. You need to be confident that the parents:
If you cannot be certain of any one of these, refer for a face-to-face assessment.
You should ask for the name and relationship to the child of any adult present in any paediatric consultation. In video consultations it is preferable to also see some form of photo identification, such as passport or driving licence. If the child presents with an adult that is not their parent or legal guardian it is important to establish the reason why.
When a child attends a face-to-face appointment you automatically assess their overall appearance and rapport with their parents. With video consultations you may have the advantage of seeing their home environment, make use of this, ask the parent to sweep the room with the camera.
You may not know the family and you may have limited information about them, so an extra degree of curiosity is required in order not to miss a child at risk. Asking the parents to undress the child if it is appropriate to do so, will reveal any marks on the child, and will allow you to assess the parental response. This is an additional opportunity to see the rapport between parent and child.
If you have any questions about a child’s safety, physical or social, you must have a low threshold for referring them for a face-to-face assessment. Trust your instinct.
Each organisation will have different guidelines, but caution needs to be taken in assessing injuries in children remotely. Aside from the risk of missing a physical injury, a greater concern would be if you were to miss a non-accidental injury.
Ask the parent to bring the child into the view of the camera whilst they’re giving you the history to allow you to undertake a general examination of the child.
Consider referring for a face-to-face assessment children of any age presenting with any of the following features:
At the time of writing this, in June 2020, there are reports of a Kawasaki disease-like inflammatory condition in children, possibly related to Covid-19.¹⁷
Other than observations (such as blood pressure and pulse rate), the majority of the general examination of a patient can be undertaken via video. There are some adaptations required though as maybe you won’t see the patient as well; however, you do get to see their environment, which can be very revealing.
All examinations start with an assessment of ABC. Where the patient is remote, and they don’t have any examination equipment, a modified assessment can be carried out:
Look at where the patient is. Are they where you would expect them to be at that time of day? A patient who is in bed at 4pm is likely much more unwell than a patient sitting in the lounge watching television with the family at 10pm.
Another way to assess the severity of illness is the attention the patient has given to their own appearance. Naturally this is considered within the context of the individual. It is reassuring if someone who has taken the time and energy to dress smartly, wash and style their hair, and put on make-up or shave. Conversely, the absence of these may point towards difficulties in carrying out activities of daily living.
Look for the presence of family members and if you can see if the environment the patient lives in is clean and tidy? You may be able to see signs of neglect, particularly in patients who are vulnerable due to age or comorbidities. Do you think this patient, or their family members, will seek help when appropriate as per your safety netting advice?
Is the patient alert and engaging or distant and incoherent? If the patient is anything other than alert it is probably not suitable to assess them remotely.
As well as asking them about pain, assess for objective signs of pain or discomfort. Engaging them in distracting conversation will reveal a lot about the pain, such as if it’s worse on breathing, moving or looking at light. Don’t forget to ask their view of the pain; at the very least a pain score will allow the next clinician to know if the pain is improving or worsening. As you may not be able to see their whole body it can be difficult to assess this and may need more direct questioning. In a consultation in the surgery you will probably have seen them make their way to their seat, and learnt a lot about them before they even sit down. It is likely that you won't have had the benefit of this in a remote consultation and so you will have to be more vigilant due to this.
Does the patient have any examination tools at home? Some patients will have some equipment that will allow you to measure some basic observations. Ask about a sphygmomanometer, pulse oximeter, thermometer, blood glucose meter or peak flow meter. Smart phones and watches sometimes have some of these capabilities too. Do take into consideration that these are rarely validated, and so some degree of caution is required in interpreting the results. If patients are unsure how to use the equipment, bring your own into view and demonstrate good technique to them.
Even where the patient doesn't have a sphygmomanometer, an assessment of hypovolaemia can still be carried out.
Very severe Mottled skin, cool peripheries
Severe Dizzy all the time
Moderate Dizzy when standing up from the bed
Mild-moderate Dizzy when standing up from the chair
In the same way as a general practitioner is aware of the limitations of assessing and managing a patient in the community, away from specialists and access to investigations, the clinician acting remotely must do the same. The GMC has clear guidance on this in its ethical hub.18 Always consider if a remote consultation is appropriate for this person, with this condition, in this situation. Examples of potentially inappropriate consultations include:
Without the ability to look in the ear or the throat, you may feel unable to undertake an ENT examination, but this is not true. There are techniques you can employ to ensure you make a safe assessment. What’s more, following the Covid-19 pandemic, there has been a reassessment of the need to examine the throat.
Ask the patient to palpate their own cervical lymph nodes. They will certainly be able to identify tenderness even if they aren’t certain about any increase in size. They may have to put their phone down to do this. Ask them to prop the phone up so you can see where they are identifying tenderness. Don’t forget to assess for tenderness overlying the mastoid bone, around the temporal arteries and close to roots of the teeth. Don't be afraid to demonstrate on yourself where the patient should press.
The patient or a family member may be able to use the phone in a video consultation to provide you with a view of the back of the oropharynx. This can be one of the most challenging areas for patients to show you remotely without a tongue depressor. It is important to explain clearly how to do it and be patient with them. Most people get the hang of it in the end with a clear explanation. If this fails to work, ask the patient to take a photo of the back of their throat using a smartphone with a good light; often patients have done this already. They can then send this to you. If this fails you will then need to decide the next course of action, your options are:
This scoring system provides some confidence in assessing the need for antibiotics in a patient with possible bacterial (streptococcal) tonsillitis. The Royal College of Paediatrics and Child Health has recommended a pragmatic approach when it is not possible to examine the oropharynx, by starting with a baseline score of 2.²⁰
Give one point for each of the following:
A quinsy commonly follows an episode of tonsillitis, and it has the potential to be very serious as it may progress posteriorly and obstruct the airway. To help differentiate between tonsillitis and quinsy, a scoring system has been developed. This has been adapted following the Covid-19 pandemic to remove the need for examination of the oropharynx.²²,²³
The Liverpool Peritonsillar Abscess Score is as follows:
Unilateral sore throat 3
Trismus 2 (Inability to open mouth more than 3cm)
Male gender 1
Pharyngeal voice change 1 (“hot potato” voice)
*Uvular deviation 1 *Requires examination capability
Without examination of the oropharynx the threshold for urgent ENT referral has been reduced to a score of 4+. The positive predictive value of this is only 60% but the seriousness of a missed quinsy justifies referring these patients. However, if you are able to view the oropharynx adequately, the threshold for referral is 6, and this has a PPV of 80%. Patients scoring a 4 or above in a remote examination should not have their ENT referral delayed by a further review in a face-to-face primary care appointment, as the need for a referral will not change.
Public Health England (PHE) reported a dramatic increase in cases of Mumps recently²⁴, at 5,042 in 2019 compared to 1,066 in 2018, thought to be due to the poor uptake of the MMR vaccine in the late 90s and early 2000s. Consider this in any patient with unilateral or bilateral facial swelling. Clinical features include:²⁵
Treatment is supportive but it is important to notify PHE and warn the patient to monitor for signs and symptoms of encephalitis or meningitis and orchitis.
To assess patients presenting with ear/hearing symptoms, the Hum test can form a useful part of the remote clinical assessment. Asking the patient to reproduce a high-pitched tone and tell you which side was louder has a sensitivity of 93% and specificity of 100% for conductive hearing loss in the louder side.
Patients presenting with ENT symptoms can cause anxiety due to the risk of serious complications. Some specific things to think of and safety net for are:
Consider early referral in children presenting with ENT symptoms and any of the following:
Do a general assessment. Are they able to give you a history? If not, they are likely too unwell to be assessed remotely (unless that is normal for them).
This can be done on video but not on the telephone.²⁷ Whilst current research doesn’t demonstrate a change in respiratory rate when the patient is aware of being observed,²⁸ you may still wish to tell the patient you need them to rest and not talk for 1 minute because after that you want to do a test of their breathing. Ask them to put their hand on their chest to help you to see the rise and fall of the chest more clearly.²⁹ Whilst they are waiting for this test, you will be counting their respiratory rate. Asking a family member to do this for them may be useful in a telephone consultation.
Some mobile phones and smart watches may be able to report heart rate and oxygen saturations but bear in mind that these aren’t validated. They should be disregarded if the results don’t match the clinical picture. Some patients, especially those with COPD or other long-term respiratory conditions, will have their own pulse oximeter.
Whilst demonstrating (if on camera), ask the patient to put two fingers on their opposite thumb and then slide those two fingers down to where their wrist strap normally is. If they can’t feel the pulse after a few seconds, ask them to take some time to feel for a pulse around that area. Once they have found it, ask them to say “tap” each time they feel the pulse. That is all they do; you will both count the number of “taps” and keep track of the time. If the patient fails to find their pulse, try the same on the inside of the elbow.
To assess exertion-induced oxygen desaturation, the 1-minute sit-to-stand test can be performed.³⁰
Consider using the NHS symptom checker:³¹
Include assessing for decline (this is more concerning than stable breathlessness):
Assess the level of breathlessness.
Take a moment to look at the patient more generally. This may require you to ask the patient to move away from the phone/camera, to allow for a wider view.
You may need to explain to the patient why you need to do it, but don’t forget to look at the peripheries such as the hands and feet, where appropriate.
Have a low threshold for referring paediatric patients with respiratory symptoms for further assessment as they may decline rapidly.³²
Consider referring children presenting with respiratory symptoms and any of the following:³³
One of the few observations that you can reliably take in paediatrics, over video and without examination equipment, is the respiratory rate. As such, it is essential to assess this in children presenting with an illness. It is important that the child is relaxed and not crying while you carry this assessment out in order to get a reliable result. Encourage the accompanying adult to distract them and reassure them in order to manage this. The following are the respiratory rates that would prompt an urgent referral to secondary care:³³
<1 year >50 breaths/minute
1–5 years >40 breaths/minute
6–11 >25 breaths/minute
≥12 years >20 breaths/minute
Patients presenting with abdominal symptoms don’t always require a face-to-face assessment. Those with symptoms typical of a simple UTI or mild gastroenteritis can safely be managed with a thorough remote assessment. However, as with all other symptoms, if you’re not comfortable, refer for a face-to-face assessment.
Peritonism is a late sign in abdominal pathologies, so you would hope not to be assessing patients with peritonitis. However, it is important to rule this out on all patients with abdominal symptoms.
Ask the patient to localise abdominal pain by pointing with a single finger to the centre of the pain; this will be more accurate if done when they are stood up.³⁵ Patients can also palpate their own abdomen, this time lying flat, splitting the abdomen into 6 zones, top, middle and bottom, left and right. If they are actively avoiding tender areas, be concerned, this is the self-palpation equivalent of guarding. The renal angle can also be palpated by the patient. They should palpate it whilst lying down but get them to show you where they have palpated afterwards.
Many patients will describe bloating, it’s a common symptom that occurs in many pathologies.
NICE guidance allows for appropriate antimicrobial treatment without urine microscopy in non-pregnant females under the age of 65 for the first presentation with a urinary tract infection.³⁷ But a clinical assessment is required to ensure there are no systemic features suggestive of pyelonephritis.
Safety netting has additional importance for patients with abdominal pain. Many intra-abdominal pathologies start with vague symptoms and become more localised and severe with time. Consider that any patient with abdominal pain in a remote consultation could be a patient at the very early stages of a severe pathology. Give specific safety netting, warning the patient what should prompt them to seek further help. Consider which conditions could develop?
Managing paediatric patients with abdominal symptoms remotely can be very challenging. Where symptoms are very mild, or chronic, it may be appropriate to manage them online with rigorous safety netting. Where a referral for further care is required the decision will be whether this will be to primary or secondary care.
Consider an urgent referral for children presenting with abdominal symptoms and any of the following:
Asking the paediatric patient to do a star jump, with their hands being lifted towards the ceiling, and assessing their facial expression, can give you an indication of peritoneal irritation. If they can do this they are unlikely to be suffering from peritoneal inflammation.³⁸
Most dermatological conditions can safely be assessed remotely if a patient can adequately show you the lesion and tell you the things that you can’t assess on camera, such as dryness and texture. Below are some techniques you can use to ensure you maximise the opportunities to assess the skin of your patients.
You are trying to assess the skin in detail so it’s important that the skin is well lit. Natural light from windows is better than artificial light, so simple things such as asking the patient to move closer to the window may help.
It can be helpful to check with the patient if the picture they can see on the screen looks the same as the rash in person. This will either give you reassurance that you are getting an adequate view, or prompt you to obtain a more representative view.
It is difficult to assess the size of something using a webcam, so you will need to use something as a reference. Ask if the patient has a ruler to place alongside any lesions. If they don’t have a ruler you can use any reproducible object such as a £1 coin (23mm).
Don’t be shy in asking a patient to remove clothing (other than underwear) to expose other areas of the body in a widespread rash.
Try to get an appreciation of any lesion in all 3 dimensions. Take the time to ask for views of the lesion, both from above and from the side, so you can assess the projection/height of the lesion. When directing the patient to move the camera, try using landmarks rather than directions, i.e. “move towards your elbow” rather than “move further up”.
Ask the patient to brush a hand over any lesion. Most patients will be able to clearly recount any of the following characteristics:
Non-blanching rashes are a red flag in any examination, face-to-face or remote.
Consider referring children presenting with a rash with any of the following features:
Whilst you can’t do a complete neurological examination remotely, there are adjustments that you can make to existing techniques to identify gross deficits.
Most cranial nerves can still be examined online, you just need to modify the examination a little.
1 - Olfactory nerve
2 - Optic nerve
3,4,5 - Oculomotor, Trochlear and Abducens nerves
6 - Trigeminal nerve
7 - Facial nerve
8 - Vestibulocochlear nerve
9, 10, 12 - Glossopharyngeal, Vagus and Hypoglossal nerves
11 - Accessory nerve
Patients can use an object such as a piece of twisted tissue paper to assess light touch. Certainly, it would not be appropriate for them to use their own finger.
Gross loss of power can be assessed online with a few movements:
Squat down and stand again L3/4
Stand on their heels L4/5
Stand on their toes S1/2⁴²
The finger to nose test can be used to assess upper limb coordination by asking the patient to:
You should be able to identify any hesitation. In particular you will be looking for sudden changes in direction, suggesting dysmetria, which would indicate a possible cerebellar pathology.
You can ask the patient to walk to the furthest end of the room and back heel to toe, demonstrating this with your hands. They may need to move furniture and set the camera so that you can view them walking. This will assess lower limb coordination and proprioception.
Where appropriate ask the patient to remove some items of clothing to assess for muscle asymmetry and any fasciculations.
Don’t forget to assess for any signs or symptoms of cauda equina in patients with lower back pain or lower limb symptoms.
The main elements of the musculoskeletal examination are applicable in a remote consultation: look, feel, move. If there are any concerns about a possible bony injury or non-accidental injury, a referral to face-to-face is essential.
To look at affected body parts, ask the patient to use their phone or camera to give you a close-up view.
To feel affected body parts, ask the patient to put the phone on the side so that they have both hands free.
To move the affected body parts, ask the patient to stand back from the camera so that you can see both left and right to identify any asymmetry.
Any child presenting with an injury, as opposed to illness, will need to be referred for face-to-face assessment. Fractures are easily missed and harder to assess in children, and non-accidental injuries may not be identified in a remote consultation.
It is estimated that 40 percent of all primary care consultations are related to mental health conditions.⁴³ As the examination of these patients is usually entirely non tactile, a remote consultation can be as thorough as a face-to-face assessment, in fact systematic reviews have demonstrated the efficacy of remote consultations for mental health conditions.⁴⁴ As with the physical examinations above, the information below is focussed on how to adapt your existing examination skills online.
If you are undertaking a full consultation, rather than triaging a patient, ensure that an appropriate amount of time is set aside. If this is the first time you are meeting the patient, or the first time they are presenting with a mental health problem, 10 minutes is unlikely to be sufficient. If you are unable to undertake an adequate consultation, due to time restraints, it may be preferable to ensure the patient is safe and make another appointment with time an appropriate time allocation.
It may be that some patients prefer video consultations to face-to-face appointments. Research has highlighted that some younger patients feel more able to talk openly when the clinician isn’t physically sat in front of them.⁵³ Assessing the patient perception of online consultations will enable you to adjust your approach accordingly
Mental health patients may be sceptical about the efficacy and privacy of a consultation undertaken remotely.
When a patient attends with a mental health problem, they have taken a leap of faith, and this is a potentially unique opportunity to help a patient who may be vulnerable or at risk. This opportunity must be treasured.
The consultation techniques discussed earlier in this document need some adjustment when patients are presenting with mental health problems.
Adjusting body language when a patient appears upset or is talking about something sensitive is something that we do almost instinctively, but when the patient isn’t sitting in the same room as you, this doesn’t come so automatically.
Assessing the environment of the patient is an important part of your assessment to ensure patient safety.
Patients often reveal details of suicidal thoughts only when asked. So, it is important that you ask every mental health patient about this, assess the extent of the thoughts and enquire about ongoing thoughts. Finding the right terminology can be difficult, but options include:
The wellbeing and safety of patients is always the primary concern of any medical professional. Ensuring this remotely necessitates additional care being taken in the history taking. Don’t forget to ask about the following, even if they don’t seem applicable to that patient, you don’t know until you ask.⁴⁶
Most treatments that you would give in a face-to-face appointment can also be delivered in a remote assessment, with the exception of some prescription medication, according to your local guidelines.
With remote consultations there is often the opportunity to send the patient an email with links to websites. There are lots of useful resources on the internet, including:
Royal College of Psychiatrists
Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
In medicine we encounter new situations and challenges every day and dealing with these are the key qualities of any doctor. But it is useful to think about some special situations that you may come across.
As care homes and nursing homes work to prevent transmission of diseases such as Covid-19, remote assessments are becoming more common. New technology presents some great opportunities here, but there are some potential challenges too. The GMC has issued related guidance, some of which is detailed below.⁴⁹
Now that patients have online access to their doctors, they may initiate consultations whilst they are overseas. Whilst they are your patients, they are in a different environment. There are a few things to consider, as discussed by the GMC.⁵⁰
If you have a safeguarding concern you will need to report it to the appropriate body based on the location of the patient, not you. Not reporting, or asking someone else to report it on your behalf, would not be appropriate.
Hopefully you there won’t be too many emergency situations in your remote consultations, but just as it happens in face-to-face consultations, it may happen in any consultation.
A patient with poor hearing or vision should not have their access to medical care disadvantaged because of this. This does not mean making all their appointments face-to-face, as some adjustments to a remote consultation may be all that is needed.
Requests for repeat medication in remote consultations are no different to those done in person. The general consensus is that extra care should be taken when prescribing potential drugs of abuse, observe local guidance and restrictions.⁵²
Angry patients are a challenge in all types of consultations; there are some considerations for how to manage these in a remote consultation. Check the local guidelines where you work.
Adam is a GP who has worked in numerous hospital specialties including neurosurgery, neurology, respiratory and accident & emergency in addition to his career in primary care. After qualifying as a GP Adam used his experience of working in the emergency department to set up a highly successful GP-led same-day care facility in Manchester, England.
More recently Adam has developed an interest in the innovative field of remote medicine, and has seen thousands of patients online, building up a wealth of knowledge on how to safely assess patients in often imaginative ways. Adam strives to overcome the challenges of remote consultations whilst also maintaining the immensely important patient-doctor relationship.
Dr Abby Hyams grew up in Manchester and did her medical training in Bristol. She has been a GP for over ten years, many of them as a partner in an NHS practice in Hemel Hempstead. Dr Abby Hyams is an early-adopter of remote consultations and has seen thousands of patients using Arc technology.
Dr Zubair Ahmed is a GP and the Co-founder and CEO of Arc and Medicspot. He is passionate about improving the quality of online healthcare.
After obtaining his medical degree from University of Aberdeen, he worked across a wide array of specialities including cardiology, accident and emergency, and geriatrics before focusing his energies on becoming a General Practitioner. Dr Ahmed is very excited about how technology can help both doctors and patients alike.