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Remote Safety Netting with Dr Roger Neighbour

In the second part of our interview, we discuss safety netting in regard to remote consultations and when it's not appropriate to consult with a patient over video.

In the second part of our interview with Dr Roger Neighbour (OBE MA DSc FRCP FRACGP FRCGP), we discuss safety netting in regard to remote consultations and when it's not appropriate to consult with a patient over video.

Produced by Arc Health in collaboration with

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35 mins

Dane: Hi there, Dane here from Arc Health. Welcome to Remote Consultation Masterclass series. Now before we get started, if you’ve not already listened to the first part of our podcast with Dr Roger Neighbour, do head over there first – so that’s episode 1. So this episode, episode 2, is the second and final part of our podcast with Dr Roger Neighbour. Now you can listen to us on Apple Podcasts, YouTube, Spotify or wherever you get your podcasts from. So I hope you enjoy the episode.

So moving that forward, I guess, based around your consultation model. What modifications do you think we need to make in terms of how we safety net patients when particularly we can't read their body language as easily or is you know, you can't give that paper information leaflet in the same way. Any advice around those points?

Roger: Yes. If I could be slightly immodest just for a moment, the whole thing about safety netting. It's one thing which I'm aware that I personally introduced or at least gave a name to that has stuck. I'm actually quite proud of that of you. I think that has made a difference. It makes me feel like it hasn't been totally in vain. That and Housekeeping's the other one, which I think is important and which you will probably talk about. There are some misunderstandings. I think about housekeeping. It's a mindset thing. In a way, there aren't any rules - that you must do this and you mustn't do that. And you should always say X, Y and Z. It isn't a question of technique. It's a mindset thing. If in your mind constantly is the idea that there is some risk here and part of what I need to do is to make sure that I don't expose the patient to unnecessary risk.

Roger: With that thought in the back of your mind, and particularly as you approach the end of the consultation, it comes to the front of your mind, then I think whatever is appropriate, that safety netting ought to flow naturally from that. So it's a safety netting isn't just something you tack on at the end of the consultation. It ought to be part of it, just kind of the background that kind of counterpoints to a lot of what we say in the consultation.

Roger: And that even started before the consultation. If there's one key thing to having a successful video consultation it's to make sure that the consultation you're having is suitable to be had on video. And that sounds obvious, but I think maybe because of the shift in popularity for all sorts of reasons. I think it's possible for us to overestimate the usefulness and the appropriateness of video. There are some consultations that are fantastic for videos. They could be timesaving and labour saving and all sorts of excellent things. But there are some that it's actually dangerous to do. And if you're having a consultation where finding physical signs is important, then that is not safe to do on video. So if you're aware that the consultation, either in advance is going to need proper physical examination, then it's not suitable for video. And I think you shouldn't really start a video consultation unless you've already got potential backup converting it, if necessary, to a face to face quite quickly to be able to say to the patient, "I'm sorry, I can't take this any further because I really actually do need to have a look at this rash. You'll need to come in." I know at the moment that the heat is on from COVID at the moment, but that will die down eventually. I think it's really important that we don't get seduced by the novelty of it or the fact that it's quite fun to be consulting from home. To lose track of that there are circumstances where it actually is unsafe and the time to safety net is before the consultation, not just tacked on it. Does that make sense?

Dane: Yeah, definitely. So this goes back to conversations we had before around triage- to make sure it's the right person as well as in the right format or mode.

Roger: Yes. I think just staying with the triaging, if I can. It's very tempting to delegate your triaging, either to a receptionist or, in my mind, a great deal worse to some kind of algorithm. I will ask a series of yes no questions. And that gives me the answers to who you've got to see. I think that is awful. It doesn't work for the phone up service anyway. For the 111 service, it doesn't work anyway. Most of those seem to end up with a load of pointless questions followed by "you need to see the doctor". On the other hand, I think the experience that we ought to take from this work that's been done in hospital A&E departments is to do effective triage, you put your very best person at the frontline. The person who really can make decisions and who can sniff out the ones where this doesn't quite fit. The ones where there's a bit of danger or the ones where it really is appropriate to say well you need to talk to somebody else about this. So I think there's a balance to be struck there. Obviously you can't have every doctor triaging every consultation. But neither should you have your junior receptionist or your committee designed algorithm.

Dane: Yeah. And I think that's a good point. I think a lot of people now over the next few months are now relooking at how do they move forward. You know, because this has been almost a baptism by fire. People have worked quickly to do what they've done.

Roger: Yes, and they've done a fantastic job I might say.

Dane: So I guess it's now for the key points for practices to consider really around what does triage look like to decide on. Is it telephone? Is it video? Is it face to face? Who does that and how? And also, I think the other point you made which is really important, which is if you start a video and you think it does need more, but also more importantly, that more is needed now, you know, how do you pop that into a face to face? Do we have the capacity? So that's all key. Planning questions, I guess, really, isn't it?

Roger: Yes, indeed. Yeah. I think…

Dane: No, go on Roger, yeah?

Roger: No, I was going to say, video at one point and telephone consultations, which are still actually slightly more common than video. Much applies to phone consultation as it does to video. The expectations seem to be that this will be timesaving. Yeah, it actually isn't. If anything, I think the experience that's coming in is that for the condition that it isn't obviously a quick in and out- video doesn't save time. It saves convenience for many people - in terms of not having to trek to the surgery or take time off work. But it doesn't save time.

Dane: Yeah.

Roger: And we shouldn't expect it to. And we shouldn't think that we're consulting badly if you can't consult faster on video.

Dane: Which leads on to probably my next point and question, really, which is, it's the age old ten minutes, isn't it? And I think there's a few different doctors who have been submitting questions, which is a part of this podcast. And I think some have been saying that for them there seems to be a pressure for them to do these video consultations in under, kind of 10 minutes, really. And they're finding that with the switch in consultation style, that these consultations are more comprehensive than a remote one would have been in the past. And they're kind of struggling to kind of manage. And a lot of them were asking what are your key messages around housekeeping in this context? What are your thoughts?

Roger: But when you say you people feel under pressure to stick to ten minutes at max and if anything, work faster. The adolescent in me wants to know, well, who on earth is making this stupid rule? There's no law, even before COVID, there's no law that says that a consultation must be 10 minutes. It's a purely arithmetical exercise. If you defy the demand by the number of times, by the number of doctor hours available, it comes to ten minutes. It's a purely administrative thing. There's no law that says that it must be ten minutes or ten minutes on average. There's no law that says what it gets to 11 minutes, you're working badly. There's no law that says patients will sue you if they're two minutes late because they don't. And I think one of the key messages, I think that's really what this is about. I think this is me now being a grumpy old fart. I want to say, to give to some of the younger generations, if somebody says, you know, that you ought to work to 10 minutes, tell them where to stick it. It's an issue of manpower and capacity in the system. I don't know many doctors in this country or in any others who think the ten minutes is ample time. It isn't. It used to be less than that, which is about the arithmetic, when I started practising. Six minutes was the norm. But 100 years ago, when I started in practice, you could cover the medical agenda in six minutes because it wasn't that complex. It's now much more complex. The nature of the problems the people bring to us, a much more complex, the number of options that we've got, for management and therapy and so forth, are much more wide-ranging with much more treatment options available. We can't do that necessarily in ten minutes.

Dane: Yeah. And we've got lots more allied health professionals also working in general practice now who potentially are seeing some of the quicker, possibly presentations, which means, as you point out, quite rightly, a lot of GPs say they are left with a more complex consultations at 10 minutes isn't it?

Roger: And in a way that's what it should be. I mean, we've had the training and the experience that enables us to do this. For God Sake, it's what we bang on about as being the strength in general practice, that we can handle complexity and uncertainty and comorbidity, and we can delve into the wider context that we boast about that.

Dane: Yeah.

Roger: So I think if somebody is saying, well, please do that in 10 minutes. The answer has to be we can't and don't you dare expect me to. Because this then I think this is really important because it ties with what you are saying about housekeeping. Housekeeping is about looking after yourself and protecting yourself. And there's a bit of an assumption these days in that, I mean obviously, far too many people in our profession are suffering from stress and burnout and wanting to take early retirement and are really succumbing to the pressure of the job. And there's a bit of a sense out there, it's seldom put into words, but it's a bit of a sense out there that if people can't stand the pressure, well that's a reflection on them and they ought to be more resilient. Resilience is a buzzword at the moment. We've got to have people to have resilience. I don't think resilience is the answer to a system that actually oppresses you. There's a danger of blaming the victim. There was a danger of saying to the doctors you ought to be able to work in 10 minutes and if you can't, it's because you're not up to it. That is bollocks. Sorry, it's a medical phrase, as I did a urology job once. I'm allowed to say that. But I do feel really strongly about that because the answer to time pressure is not to make more resilient doctors necessarily, it's to solve the time pressure. And that's the system and manpower. And that's politics. And it's about power. It's about colleges and government departments and committees- all that sort of stuff. But it needs to be seen for what it is. It isn't down to the individual doctor to solve a capacity problem in the system.

Dane: Yeah. Yeah.

Roger: That said to, as you know, my interest is in the consultation and quite a lot of teaching I was doing before COVID closed out a lot of stuff, was very much around the issue of time. Everyone feels time pressure, of course, you do. It goes with the territory. And people would quite often ask him how, how should we change the way we consult in order to get it done in ten minutes? Well, there's a limit to what you can do with consulting techniques. Because quite a lot of the things that you can do to relieve your own work time pressure aren't to do with how you consult at all. They're outside the concept of the consulting room. They're to do with have you got enough doctors? What's your policy on locums? Are you training the receptionist right? Are you using the nurses and nurse practitioners and the other disciplines, are using them right? Nothing to do with how you consult at all. This issue of time and 10 minutes. We have to think much more widely outside the box. Not just how do I run my consultation? There's a limit to what you could do in that time and there's a limit to what you should do at that time. End of rant.

Dane: No, valid point and I think many practices are doing it differently. So, for example, the practice I worked with in York and working in York, many have moved to 15 minute consultations and others. But I do know there are colleagues of mine in London who are still very much on 10 minutes that I'm aware of. But I guess the big question you raise here is what are the resources that you have, who is doing things and what are the systems in place? And it can't just all be solved by resilience. Yes. Completely. Because there's nothing worse than being stressed every appointment because you're trying to fit in 10 minutes.

Roger: You're right in. And one of the things which is nice about general practice is the degree of freedom we still have about how to organise our working days. And there's no law that says a surgery is 12, 10-minute appointments without a break. There's no law that says that. Yeah.

Dane: So everything's possible. And we need to relook at it.

Roger: I know. I know. It's not easy. You know, I'm not trying to lighten it of course, but I think we actually have to locate the problem where it really is. And it's incapacity. The problem is capacity.

Dane: Yeah. That's important. So kind of moving on from that point really to the more handing over part of your model in the past. I think a lot of doctors say at the moment, but there's a lot of health anxiety in some patients and I guess it's obviously understandable with COVID. And that they're worrying about where they can contact their doctor in a timely manner. And a lot of people are saying that their patients are struggling to take control of their health at this time because of those anxieties. And I guess a lot of GPs are now finding that these video consultations or even any remote consultation is becoming lengthier as they try to spend more time really encouraging people to take responsibility for their own health. So I wonder what your take is on the kind of language we could use or the tips we can get across to try and do that handover of health, particularly over a video consultation?

Roger: Yes. That's really hard, isn't it? Because I think we should - we sometimes overestimate the impact that we have on people, on patients lifestyles. I'm sure you have countless times said to somebody gently, politely and helpfully, etc., you know, you could really benefit from losing some weight. And they say, oh I know a doctor. Yes, you're absolutely right. And they go home and do absolutely nothing about it. And same thing with smoking advice and exercise. Oh, all the usual things. And I think that we have to acknowledge GPs or any kind of medical professional, are not necessarily the best people to be doing that. And there's a limit to the impact that we can have. And I think in terms of what's the alternative, then, I can't for a moment think that anything you could say in a 10-minute video consultation is going to persuade somebody to lose three stone in weight. I just don't, I think that hoping for the moon. On the other hand, you do know what your local resources are. You might have some nurse groups or you might have some patient-led support groups and so forth. I did a similar conversation with this thing through the college a couple weeks ago where there was the most interesting presentation by a guy called Alex Maxwell, who's a GP in London somewhere, who's organising video groups for patients with shared problems, overweight problems or diabetes or hypertensive or people recovering from strokes or whatever, with some enormous success about that. And I'm not the expert to go to, but make a note of the name Alex Maxwell and Google it and you'll find your way to some excellent advice about how to, how to take some of the responsibility from this off the GPs shoulders. I think it's in a way, one thing which doctors are addicted, which GPs in particular are addicted to are the idea that we are actually all things to all people. Most GPs suffer from or have a please love me syndrome. We like to be liked by our patients and thought well of and admired and so forth. And that's not necessarily a bad thing, but it is an undercurrent in many doctors psychology, my own included. And part of that can express itself by saying, you bring me a problem. Bring it on and I'll solve it for you. We don't have to be the experts on everything.

Dane: No, and obviously that's a challenge given the broad spectrum of things we cover. And sometimes I find it's the patient's expectation of us as well. Sometimes, yes. But behaviour change is difficult. And you're quite right to point out, I think, a brief intervention wise, my own interests is in more physical activity and getting people more active. There's a couple of good studies talking about brief intervention being if we give brief advice for every 12 patients or so that we give, that brief advice to one patient might change from an inactive person to active. I think smoking's much larger. I think the numbers are 50 plus. So there's some potential. But like you said, we have to partly join that network. We have to signpost the right person with the right skillset.

Roger: I think also being slightly more constructive about it. We tend to count our motivational advice in terms of health effects, you know, stop smoking or you'll get lung cancer, lose weight or you'll get a stroke. Well, for many people, health issues are not their primary motivators and with some individuals, it might be a case of stop smoking because actually your breath smells and I'm not surprised your girlfriend has gone off you. Or lose weight because if you get a stroke, they won't let you fly to Australia to see your grandchildren, not health issues. And I think I think most people are outside the medical profession who work in this field of lifestyle advice and lifestyle change will say the key thing is to tap into the individual's key motivators, not to assume that just because they're talking to a doctor that health issues are their key motivators. I think that is really important not to assume that it's a health issue. Trying to find out. Well, if you had a stroke, what would that stop you doing?

Dane: Yeah. Yeah. And I think I said there's a couple of points you made that hopefully listeners might want to go away and have a look but behaviour changes are so complex. Some of the stuff you're talking about is around understanding the patient enough to then understand their motivations. But also there's other things like capability and opportunity for them. You know, what can they do? Susan Meechie, UCL based, has got a behaviour change, will say is worth having a look at. Steven Rolnik has his motivational interviewing model as well, which has some value and people enjoy that. So all parts are worth looking at.

Roger: That's really useful. Really useful.

Dane: So moving on. One last thing on consultation. I want to finish off on some of the more kind of medical education bits. But considering the handover part of your model. We've just talked about that. So I think we've taken off some kind of key points there around what we need to talk about. But it is a challenge so do have a look at that and Alex Maxwell is someone that we should probably try and get on actually and talk about some of the things that-.

Roger: Yes, you should. He presents it well too.

Dane: So in terms of medical education and really to finish, in terms of medical education, what are your thoughts and advice for TPDs, trainers, doctors providing medical education? Particularly around how to teach consultation. Should any of this change in the way we teach this now to our registrars?

Roger: Yes, that's really interesting. At risk of going over some past history, the UK and the English speaking world in general, in most parts of the world where English is the vehicle for medical education, emphasis on the consultation has been quite a thing for many years and it dates, I think, probably back to the days of Barnard, which was 1950, no the 1960s -1950s and 60s. That original work and doctor-patient interaction. And most of the theoretical stuff. Most of the models and the teaching and the training in any systematic way worldwide is actually UK derived. And I don't know quite what that is apart from the accident history that took the violence from Hungary to London in the 1950s and 60s because they were actually pioneers in looking at communication and interaction. And I think also it probably does stem from the fact that in the NHS, right from its early days, there has been, regardless of what we were talking about earlier, there has been that pressure to do a lot in a short time. And unless you manage that interaction, you can't do it. And you can't in general practice, you know, you can't hope to do hospital medicine only faster. That's not enough. You can't do it that way. We have to catch it in an entirely different way, as you know, and most of the work that's been done and the books have been written and the models have been published and the advice and the training and so forth that's been done dates from the 1980s- 70s and 80s. It goes back to Bernard Long in 1976 and Pendleton's book came out in 1985. My own in 1986. Calgary Cambridge, which was the most recent and that's 1992, I think. But since then, there's been very little original, different stuff taught in terms of theory about the consultation. How the world has changed hugely since then, not least when MRC GP became mandatory in 2004 was it? On and around then. And there's been very little fresh thinking about the consultation since then. And I think in a way, I think those of us, well quite a lot of the people who have contributed, myself included, are still around on the block. And it's very tempting to peddle the same old messages and to think that it's possible to know to consult in 2020 in the same way that it was possible to consult in 1990. And I think we've actually made things in terms of the formal teaching about the consultation. I think we probably have over complicated it. I think we've made it more complicated than it is. Bernard Long with the original ones that had six phases didn't they? And then with the Pendleton, they have seven tasks. And I had 5 checkpoints. Calgary, Cambridge, at the last count, have 71 micro-skills.

Dane: Yeah.

Roger: But you can't handle that sort of stuff in real time, in real life, it's too complicated. Yeah, and I think the time is probably ripe for a rethink about how we have tried to teach the consultation, because certainly. It isn't enough just to hope that people can intuitively develop an effective consultation style. You can't just sit there in your consulting chair brimming with goodwill and medical knowledge and just hope that it works. You have to make it work. And I think we probably over complicated it. Which is why- can I get a plug in here?

Dane: Go on yeah, go for it.

Roger: Okay, I've got a new book coming out later in the year called Consulting In A Nutshell, which simplifies things beautifully. Aimed, particularly at S.G. 3s and people early in their careers- end of plug. And I defy you to edit that out of the edit. But seriously, as I said, I think that in our consultation, essentially the task of consultation is quite simple. Someone who comes in with a problem needs leave with a plan. It really is as simple as that. And the strategy for doing that is actually not that complicated- it's work out what the problem is and the key message is work out what the problem is first before you move on to the solution.

Dane: So from a training point of view, you're almost identifying that while there is lots of things in the past that still are current and workable, there is definitely an opportunity here with the way things are going. For someone to potentially to even put their own name on it. At this point in time. But I guess this is where I guess the next few years will really inform what the new models in a way will look like.

Roger: Yes, I think seriously, linking with, you know, with what's prompted this discussion in the first place, which is COVID and its impact. It's almost impossible during COVID not to consult in a more doctor centred way. We've had to impose some structure on the access process. We've had to impose certain forms of triage and certainly consulting by video, of course, it's not so easy to have the spontaneous ebb and flow between two people. Most video consultations are a bit more doctor centred. That's not necessarily a bad thing, but it does mean that the pressure at the moment is forced to revert to a way of consulting that I thought was on the retreat to some extent, which is up to us all was to run the show.

Dane: Yeah.

Roger: So I think in all this and all the forms of teaching, I mean, we've got a fantastic body of trainers and programme directors in this country. Second to none in the world. They are superb. I think it's really important, that particularly at this time, that those of us with any input into education, keep our eye on the ball and try to keep a sense of, well, actually, what are the core values here? The core values are delivering good, sound clinical medicine, of course, but also being alert to the wider context of the buried stuff and the and the hidden stuff and the stuff that takes a bit of insight and empathy and an understanding. We need to try to find ways of preserving that and there's no single way of doing it. But I just think that we mustn't in our enthusiasm for video and telescoped forms of consulting and under the pressure of a pandemic, let's not lose total sight when the pressure eases off a bit. Let's try to remember what actually are the core values here that we're actually trying to deliver something that revolves around the person opposite us. Not necessarily around the medical textbook or what the nice guidelines say. So that was good. That was the second rant.

Dane: Well, you're entitled to your opinion. One take I want to ask you about is the CSA and exams, in general, because I know you've had stuff to do with this.

Roger: Oh yes, right.

Dane: And you're still involved with this. I guess, firstly, if you're able to give us a quick overview on what's changed during COVID. How things are happening now and also then your take on CSA moving forward?

Roger: I ought to make clear that actually, I think in your introduction, you said I was an examiner. I mean I'm not now. I haven't been for many years. I stopped being an active examiner in 2003 because I was then college president. And one of the rules of the game are that the college president, the ultimate court of appeal, someone that appeals against an exam fail, there's a conflict of interest there. Having said that though, ever since then, and still to this day, I'm actively involved in teaching and preparing candidates for CSA preparation courses and so forth. So I still have my network of friends and connections within the exam. So I do know what's going on. As you know that the CSA is impossible to run under COVID social distancing rules. And so from, I think it was the end of April or thereabouts, the CSA is currently suspended. And has been replaced by something called the recorded consultation assessment. The technology of that is that people doing this - the MRCGP now will upload onto a website. Recordings are, I think 13 might maybe twelve. I think it's 13 of their own real-life consultations, which might be face to face. So they might be recording consultations themselves, but they upload real-life consultations and those then get looked at by examiners and assessed against the same criteria that the CSA was. So they could be the marking approach and things that are being looked for haven't changed at all. It's just that what the examiners are now looking at are recordings of your real consultations rather than simulated ones with the role player. It's also slightly cheaper, actually. It's a fair bit cheaper at the moment.

Dane: Oh that's good.

Roger: Well, people don't realise this. The exam is an act of college policy, is not profit-making. It never has been. It covers its costs. It doesn't actually make a profit, much to the disappointment of the Treasurer, but it doesn't. The CSA is labour intensive. You have to pay low players and you have to pay backfill locum cover for the examiners. That's why it's expensive for no other reason. Whereas with the RCA, all you're paying is a set amount of time for the examiners without having to pay roll-players and so forth. So it's actually cheaper to run. But in terms of what it's looking for, it's looking for nothing different. It's still looking for can you deliver safe medicine in a compassionate way?

Dane: Yeah,.

Roger: And it's assessed in the same way. So in terms of preparation for any people who might be listening or watching or watching this, there's no need to prepare for the RCA in any other - any radically different way from how you would have done for the CSA, except that with the RCA, the choice of cases is entirely in your- the candidates- hands. And so how you choose a portfolio, there is some skin in that.

Dane: Yeah.

Roger: If you send in 14 cases of people with a cold, 13 cases of cold because you can't go wrong there... On the other hand, you can't be seen to be any good either.

Dane: Yeah.

Roger: If, on the other hand, you send in 13 really difficult testing cases, you'll probably not do terribly well. How could you? You're only a young doctor. So there is some thought there. And if I can get another plugin, not myself this time, but the RCGP website has got some really good advice with some good clinical examples about the type of cases that are appropriate to submit. And quite a lot of questions that people ask about the exam and about RCA are answered. It's actually... the RCGP website is not the best in the world, but the exam section of it is.

Dane: Yeah, okay.

Roger: And it's full of really good stuff about. There were some practical examples and so forth, so do check it.

Dane: Yeah. So yeah. Have a look at the site.

Roger: The course, by the way just at the moment, is intending to revert to the CSA as soon as the social distancing rules allow.

Dane: So a question for you on that, the final question really, is... CSA wise, once it comes back into play, can you see a change in exam-style happening? And if so, what might be the case?

Roger: I would think so, wouldn't it? Because the CSA is intended to be a test of how you function in real life or real-ish life. And real life has changed. Real-life is now going after the CSA, after COVID rather. I'm sure we're not going to continue to do 90 per cent of our work remotely, but we probably will do 40 to 50 percent of our work remotely. And in that case, any kind of assessment of how you function in the real world needs to include some kind of assessment about how that gets translated into another format. I've no idea, I would expect that discussions like that are in hand as we speak. And the colleges already made it clear that it will always give six months notice of any change it makes. The regulations. People have time. That's really important because it's a high stakes exam. And contrary to popular belief, the college is not trying to play tricks on people and screw money out of them. It really isn't. Nobody ever believes examiners when they say that. But it's true.

Dane: No, perfect.

Roger: I think the answer is watch this space, but I expect it will change yeah.

Dane: My NCSA exam, I remember thinking it was a reasonable set of cases that I could have seen. It wasn't anything that was overly complex. I thought they were reasonable.

Roger: Why would you? I mean, there's no pleasure from an examiner to be gained by watching somebody repeat themselves and fall. That's not them. And nobody likes to see that.

Dane: No, perfect. Well, Roger firstly, thanks so much for your time today. And we've covered a lot of things and it's been fascinating. And I wanted to finish with one last thing for you, really, which is any kind of key final messages from your Top Tips before I close?

Roger: About video?

Dane: Video consultation yeah, mainly.

Roger: Yes, a couple. Think safety. Secondly, in terms of how you improve and manage it well and develop a style of doing it that you can be proud of and think that's OK. Take advantage of every opportunity you get to get some feedback on how you're doing. I think the very best way is actually just to watch recordings of yourself. I think virtually all the platforms allow a recording of you to be reviewable afterwards. Watch yourself. It's good advice for doctors anyways, isn't it? To put this most succinctly, try to become aware of the kind of doctor you come across as.

Dane: Yeah. And then it always looks different how you think it went when you're in the room, isn't it? Perfect. Well, thanks again, Roger. So thanks for joining us. Thank you guys for listening.

Dane: Hi there, you’ve been listening to the Remote Consultation Masterclass series. Now, in the next episode, we’ll be interviewing Dr Anthony Waring. He’s a consultant in Sports Medicine and also Musculoskeletal Medicine and he’s going to be talking to us about the rise in remote working and the challenges that this brings musculoskeletal presentations as always do keep in touch with us for future episodes by clicking the subscribe button on Apple Podcasts, YouTube or Spotify. See you on the next one.

00:00 Episode introduction

00:27 Modifications on how we safety net patients remotely

01:48 When you need to have a face-to-face consultation

03:10 Delegating your triaging

05:46 Key points around housekeeping and time-management

08:15 Time pressures with video consultations

11:45 Language to use to help patients take control of their health

14:16 Influencing behaviour changes

16:52 Changes in medical education

23:17 CSA and exam changes during COVID-19

28:50 Roger Neighbour’s top tips on video consultations

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