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Dealing with Remote Consultation Challenges with Dr Adam Abbs

Dane catches up with Dr Adam Abbs, author of the ‘Remote Consultations Handbook’.

Dane catches up with Dr Adam Abbs, a GP and author of the RCGP accredited ‘Remote Consultations Handbook’. They discuss the challenges of remote consultations, the inability of performing face-to-face examinations, how to assess body language remotely and tips on how to deal with medico-legal concerns during a remote consultation. 

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Produced by Arc Health in collaboration with Doctors.net.uk.

Explore more educational resources for remote consultations at archealth.io/education.

Arc Health helps clinicians save time with remote consultations. Our technology is used in hundreds of NHS GP surgeries, care homes, hospitals and pharmacies. Find out more at archealth.io.

Episode
8
32 mins

Episode preview clip: “Previously, a remote consultation was a stop gap between a real consultation and another real consultation. The telephone was just a way of tiding you by until the actual consultation. But now the remote consultation is the real consultation. So, there's a change in mindset that's required from both the clinician and the patient, and the consultation needs to be slowed down. And it's no longer just a transactional consultation. This is, it’s all the things that you've been taught in your undergraduate curriculum and post-graduate curriculum related to how to undertake a consultation, applies online as well and applies on video or telephone as well”.

Dr Dane Vishnubala:

Hi there, Dane here from Arc Health. Welcome to Remote Consultation Masterclass. This is a podcast where we catch up with leading health care professionals to discuss tips and tricks for carrying out remote consultations, as well as bringing you key nuggets of information for your CPD. Now you can listen to us on Apple Podcasts, YouTube, Spotify or wherever you get your podcasts from. Hope you enjoy the episode.

Dr Dane Vishnubala:

Hi there. Welcome to Remote Consultation Masterclass series. Our series of podcasts is aimed to dive into the mind of experts in the field on a range of medically related topics. My name's Dane, I'm a GP and a sport and exercise medicine consultant based in Yorkshire. In this episode, we're going to base our podcast around a poll that was run by doctors.net.uk, asking doctors what their main challenges were around remote consultation. To do this, I'm joined by Dr. Adam Abbs, a GP and the author of the RCGP accredited, The Remote Consultation Handbook. Hi Adam. You all right?

Dr Adam Abbs:

Hi there. Hi, thanks for having me today.

Dr Dane Vishnubala:

Cool. As we talked about before, obviously we're going to discuss some of the themes and topics that were picked out from this poll and kind of look at them in a bit more detail, but just before we jump in, I guess it would be really useful to know, Adam, a little bit more about you and kind of also how you ended up authoring this guide.

Dr Adam Abbs:

Well, I've been doing remote consultations for over two years now and I was involved in remote consultation education when COVID hit us, I was asked by some colleagues in Italy to do a presentation to them on how to undertake a remote consultation because they had no experience of it and suddenly they had to do this with no education whatsoever. I did this and in order to communicate with them, because sadly I don't speak Italian. I wrote everything down and a friend translated it into Italian for me and it was the worst ever presentation because it was all written down in English and written down in Italian and then I spoke over it for the audience. But the result was a lot of text about how to undertake a remote consultation. Cut a long story short, from that I then produced a handbook, which was the edition one of The Remote Consultation Handbook.

Dr Adam Abbs:

Then following feedback and following some really positive feedback from people actually and it was very well taken up in Italy and also in the UK. I decided to do the Remote Consultation handbook, edition two, with a lot of my information in, with expanded chapters, with some new chapters and also with a lot of referencing to make it a little bit more respectable, if you will, a little bit more evidence based. This was then accredited by the RCGP. And since then, things have continued to expand and the Arc Health education hub has expanded and I've been doing a lot of remote consultation education over the last year, including for GPVTs and also foundation year doctors.

Dr Dane Vishnubala:

Perfect. No, sounds good. And for the guys that you haven't seen the Arc Health education hub, there's lots of good resources on there, which includes a handbook. Do check it out and we'll make sure we put the links again at the bottom of the podcast. Again, do you have a look.

Dr Dane Vishnubala:

Oh perfect. Obviously you're the right man to be here to do this and the questions that have come up are really relevant. I'm using that, I guess, we'll kind of move on. Actually one of the first things picked up by this poll then was that 56% of the doctors had concerns about their, and the quote was, "Inability to perform a face-to-face examination if needed." Clearly for a lot of us pre-COVID, if we ever did anything remote, there was always this well it's okay, because they're either going to come down if I need them to and I can get them down face-to-face. And clearly, because of a range of reasons that might not always be an option now or doesn't seem to be for a lot of people. What do you make of that kind of statement? And what are your thoughts or tips around that?

Dr Adam Abbs:

Well, I think it's an interesting statement to make, because obviously I'm a huge fan of remote consultations and I think they're a really important part of the mix of consultation modalities that we have, but they are part of a mix. I have some hesitation there in that question, because there should always be the opportunity to convert a telephone or video consultation into a face-to-face consultation. I think what we need to do is be bold enough to do what we can on telephone and video, but also be safe enough to know what we can't do. And those boundaries are different depending on not only your abilities, but also your confidence with remote consultations. But the GMC guidelines are very strict and very clear that throughout any remote consultation, there needs to be constant assessment as to the appropriateness of the consultation.

Dr Adam Abbs:

I think we should do as much as we can, but we have to recognise the limits. When we are doing any kind of consultation as well, we do need to consider what the next step is. If we are having a telephone or video consultation and we say, "This isn't enough. Doing nothing. Isn't an option." But also we need to consider bringing them in the next day is an option because sometimes that's too late. Bringing them into us later that day may also be too late. Trying to do as much as we can in remote consultations would also allow us to sometimes send a patient directly to urgent care, A&E or hospital specialty, because a remote consultation is still a medical consultation between a GP and a patient so we need to recognise that the validity of a remote consultation as well.

Dr Dane Vishnubala:

Yeah, that makes sense. I guess it's even if clinicians aren't going to see that person themselves, it's kind of where is the most appropriate place next, depending on their differentials and the time in which this person needs to be seen as well.

Dr Adam Abbs:

Exactly. If you've got a 20 year old with severe abdominal pain that started, essentially is moved to the right or left fossa and they've got diarrhea and they have a fever, telling that patient to wait four hours and come back and see me in the afternoon is not appropriate. You know that that patient needs to go to hospital. And that sometimes will cause an awkward conversation with the specialty you're referring to, but you have to do, you're the advocate of your patient and you have to do what's right for them. And having them wait for you is not always the right option.

Dr Dane Vishnubala:

Yeah. Perfect. It's like you said, already really understanding the limitations of that consultation mode and knowing when to change. No. Perfect.

Dr Adam Abbs:

Because nobody can tell me on the telephone that that patient I've just described to you shouldn't go to hospital. It's a surgical abdomen. They need to be seen. I have done my medical consultation, even though I've not actually touched the patient.

Dr Dane Vishnubala:

Yeah. No, that makes sense. And I think that that kind of leads on really nicely to concerns a lot of people have, which, and again, in this poll, it showed 43% of people are concerned about eliciting clinical signs in a remote consultation. There were a couple of other things that were also picked up. Nearly half were also concerned about difficulty of picking up body language on a remote consultation, other things that are around medical legal concerns with remote consultation. And finally, one of the other big ones picked up was 27% people were worried about kind of the patient's confidence of using appropriate devices as well. We kind of picked them in turn and start with eliciting clinical signs. Obviously this is a big concern to many clinicians, is that what if I missed something? And how do I best do this? What's kind of been your advice? And what do you teach around this kind of area?

Dr Adam Abbs:

The first thing is, again, like I said before, do what you can. Do basic and general observations. Record how the patient looks, the respiratory rates, are there any obvious signs that you can tell simply by looking or listening, looking at a patient or listening to them? Ask the patient if they have any equipment at home is also useful. Many patients these days have monitors, increasingly people are getting pulse oximeters at home and many also have blood pressure machines as well. And some patients with certain conditions will have things like the glucose meters or peak flow meters at home. If they have them, then use them. The more information you can gather round, the better. But also try to be structured with the patient, with the assessment of them. There are certain tools you can use. Don't know if you've seen the Healthy Together website, Royal College of Paediatrics and Child Health have produced an amazing website with some clinical pathways for remote assessment for paediatrics.

Dr Adam Abbs:

And they're really useful at giving you a structured approach to do an assessment of a child with different presentations. But also make sure that you examine the patient fully. Ask the patient to put the phone on the side and to step back or if it's the laptops, simply step back from the laptop, move backwards, see them moving. And you can ask the patient to examine themselves as well. Patients can put their hand forward if they've got shoulder injury, they can ask them to put the hand forward, press down, turn the hand over, press down and demonstrate to the patient what you'd like them to do. Or you can ask a family member to help as well. There's a lot that you can do remotely if you have some imagination. I think we're going to cover that in more detail at a later date, but they're the general principles.

Dr Dane Vishnubala:

Yeah, exactly. No, no, definitely. And I think, we could almost spend quite a lot of time in just that and kind of the nuances of how you do that. And I think one of the points you really pick up on is that self examination. And at the moment you kind of say imagination versus I guess if you think about how we traditionally practice medicine, a lot of these things aren't left down to imagination and we don't need to problem solve because we've just been taught how to do it and we do face-to-face. Whereas now we're trying to come up with ways to do something that actually there isn't a tutor above us that has taught us before.

Dr Dane Vishnubala:

But again, you've picked up lots of exits in the handbook and we'll definitely talk about this in more detail. But for me, I think it was nearly a year ago now that I came and observed you doing some remote consultation as well, a time where I was trying to do a bit more. And yeah, that was definitely an area that most of the ways you could coach those points. Yeah, I think that'll be a really good podcast. I'm looking forward to doing that one with you. Coming back to that. We talked about examining self. The other thing you mentioned, which I think is really, really important was that kind of wide view seeing the whole patient and not being afraid to ask them to get their setup right so you can do your job.

Dr Adam Abbs:

Yeah, absolutely. To take the time to do that. Be firm at the start. Look, this is a medical consultation with your GP and we need to do this properly. Please take a moment to do this for me.

Dr Dane Vishnubala:

Yeah. And then the paediatric assessments that you talked about, the tools, we'll make sure that they're popped in the at the bottom of the podcast so if you guys do want to have a look at what Adam has been talking about in more detail, do check out the links below. Okay, perfect. If we move on kind of from clinical signs, but there's definitely a whole podcast in itself, and we will come back to it. The second kind of point really picked up was the difficulty in picking up on body language and missing those kind of keys that we might be better at doing automatically. Given the skills of doctors I guess, over years of doing that, how do you kind of pick up on that given it is a challenge, I guess isn't it?

Dr Adam Abbs:

And it's a huge challenge, but just like we as GPs, especially we're used to overcoming all sorts of challenges that in every single consultation that we have pretty much, we overcome them remotely as well. A few things that we need to do. One is slow down the consultation. Previously a remote consultation was a stop gap between a real consultation and another real consultation. The telephone was just a way of tiding you by until the actual consultation. But now the remote consultation is the real consultation. There's a change in mindset that's required from both the clinician and the patient and the consultation needs to be slowed down. And it's no longer just a transactional consultation. This is, it's all the things that you've been taught in your undergraduate curriculum and post-graduate curriculum related to how to undertake a consultation, applies online as well and applies on video or telephone as well.

Dr Adam Abbs:

We shouldn't just rush through to get to the endpoint in a remote consultation. Slowing the patient down will allow you to assess their body language, whether that's through the speech on the telephone or whether that's through looking at them on the video. Second of all, show your body language. As I'm talking with a patient, as I'm talking now, I'll show my upper arms so they can see my arms moving. They'll see something of my hands. When they can't see my hands, and then let's say whilst I remember is if you are typing, when you're speaking to a patient, they might be able to hear that. Let them know that you're typing. But they can still see some movement and they can see your face nice and clearly, if you've got good lighting, which you should do.

Dr Adam Abbs:

But also, and it's more so on the telephone, be explicit with your empathy so that the patient, maybe they lose some body language, but they hear in your tone of voice and in the words that you're using, that you are empathising with them and you are with them. Just like we've been taught previously, say to the patients, "This must be really difficult for you. I can understand how that would be stressful and that must have been distressing." Saying these things might seem a little too much because normally our face we'll say it, but we need to be a bit more explicit when that's not so obvious.

Dr Adam Abbs:

Finally, ask the patient to move back so you can see more of them. Like we were saying before, we ask them to put the phone down or on one side or move the laptop back. On the phone, you can get an idea of body language still. You can talk about, so in the notes, you talk about how the patient sounds well, they're calm, they're happy, they're chatting about their day. It's not body language as such, but you're getting a picture of the patient. They walked upstairs to get the thermometer. When they came back, they weren't out of breath. They didn't sound in pain when I asked them to put their hands over their head or when they were moving around the house, because I asked them to. And the patient stated that and sounded like that they were happy with the plan at the end of the consultation. Again, that's trying to get a full assessment of the patient when there is the sort of loss of body language, if you will.

Dr Dane Vishnubala:

Yeah. That's really interesting, isn't it? Because you're talking about, it's not just what they're saying to you, it's all the things they're not saying that you're picking up. And sometimes, particularly when we were doing remote consultation, generally in GP training and other places, like you said, because they ended up being stop gaps we maybe didn't colour or write down some of those observations because it was a, right they're now coming in or not. But then when we look back at the notes, the information you're talking about, it's actually really critical to deciding how well was this patient.

Dr Adam Abbs:

Yes, yes, absolutely. And heaven forbid you're in court one day, that would be what you'd hope you'd written that you'd done a full assessment.

Dr Dane Vishnubala:

Yeah, no, that's really useful. Yeah.

Dr Adam Abbs:

On that note of patient safety as well. If you are worried from a point of view of a patient's social situation, if you will, or home situation, one of the advantages of a telephone is you can ask them to say yes or no to questions. You can ask them if they're safe, ask them if they're there or something. Ask them if they need extra help. If you do pick up on something in the tone of voice, when you're speaking to them, naturally you want to bring those patients in. But just a bit of a tip is to just switch to yes no questions where appropriate.

Dr Dane Vishnubala:

Yeah, okay. No, that's really useful. I think there, there are definitely things for us to take away. And I think many of us who are doing telephone or remote consultations, maybe not for as long, you think it's always good to, when we audit our own notes and look back at them, to maybe have a look at a couple and go, now that we're looking back at this set of notes a week or two weeks later, does it colour it? Can you visualise yourself being there? Is all the information there? And I think there's some great tips there in terms of picking that up.

Dr Adam Abbs:

That's a good phrase. Does it colour it. I'll use that one.

Dr Dane Vishnubala:

I'll give you that one for free. Moving on from body language really, the next one was really more about and I think you've already touched upon this is kind of medical legal concerns were another ones that was brought up in that poll, which obviously, I think for many people, some of it's also the unknown, the lack of experience in an area that they then perceive their risk to be higher as well. What general advice have you been giving around the kind of alleviating kind of the medical legal concerns, I guess?

Dr Adam Abbs:

Again, a huge subject, but some key points are, as I said before, use of colouring in what you can. Just because you can't get it 100%, it doesn't mean that 80% isn't useful. But document, document, document. Document everything. There'll be some things that will be assumed in a face-to-face consultation that you need to be a bit more explicit about when you're making the notes in a remote consultation. And also use scoring systems. To help check your own practice, but also defend your actions. Using scoring systems is useful. The central criteria and Liverpool peritonsillar abscess score is particularly useful. They've both been modified for remote consultations. And using simple pain scores, a patient who's reporting pain of two out of 10 is very different for patient reporting pain out of eight out of 10.

Dr Adam Abbs:

Some of us as time progresses, we forget to use these simple pain scores, but they are useful for trying to, as you say, colour in the notes a little bit. I would also say my experience of colleagues who've had problems with remote consultations is that the patients who've been seen or spoken to on the telephone or seen on the video, two, three, four, five, six, seven, eight, nine times, and then something's come to light. And the doctor who helps that patient is a doctor who has finally brought them in. Everyone will have their own number. My rule is three strikes and you're in. If a patient is coming back with this problem that hasn't been improving or that we're still uncertain about, after three times, that third appointment needs to be a face-to-face appointment. There's something not quite right. There's something we're not understanding. Continuing to do it over the telephone or video is not always appropriate.

Dr Adam Abbs:

And also something else which is useful for both us and the patient is to safety net to the extreme with remote consultations. Be really explicit. What should prompt them to act? When should they act? Where should they go if something should happen? And how they should get there. And also check, just make sure you check understanding because on a remote consultation, as we've talked about, the body language and the feedback are a little bit less, so you need to just double check that what you said has been understood by the patient.

Dr Adam Abbs:

And then one final thing from a medical legal point of view is with most systems that we have, we have improved communication with the patient via text or via email. Send them patient advice leaflets. Patient.co.uk has some fantastic advice leaflets. And again, the Healthy Together website with the Royal College of Pediatrics and Child Health have got some fantastic patient information for parents. Use those, send them to the parents, send them to the patients and the patient's in safe hands, even after you've ended the consultation.

Dr Dane Vishnubala:

And I noticed that with you, the time that I came to observe you doing it, you were every consultation effectively got that patient leaflet and it was done electronically. And that was quite nice because it was kind of the confirmation and kind of repeating what you've already said, but they got it in another resource. And definitely, probably sometimes we don't do that enough in practice because we assume we've got most information across.

Dr Adam Abbs:

Yes. Yeah. And who knows how much the patient remembers tomorrow. Or later on when they're unwell.

Dr Dane Vishnubala:

Yeah, no, definitely. Perfect. Yeah, quite a few components there on the medical legal, but you kind of talked about your three strikes out a policy, which I think is I definitely want to keep an eye on because there is people that keep coming back don't they? That we haven't seen. That strong safety net and then particularly I think things like the documentation and that patient leaflet. Perfect. Again, there is a good podcast we did with Andrew Latham, who is a medical legal kind of solicitor and that was podcast 4, off the top of my head. It's definitely worth a look at that if you guys are interested. And I know it's an area that I believe has come up time and time again from the listeners so far. We are hoping to do a little bit more around medical legal elements, remote consultation. Look out for that. And then the final point that was made in this poll was concerns that in kind of was the patient confident with remote consultation themselves? What were your kind of thoughts around that concern?

Dr Adam Abbs:

Again, a lot of what we're trying to do here is trying to change the mindset of both clinicians and patients to be more open to remote consultations. And as the GP, it's your responsibility to do that conversion and to face that skepticism and acknowledge it for the patients. You could always say to the patient, "Look, I understand that this isn't the type of consultation that you're used to, but please, let's try a telephone or try a video consultation. And if you're not happy by the end of it, I promise I will see you tomorrow," for example. It's one way of trying to recognise a patient's skepticism, but also recognising the need to at least try this new modality of consultation. And then it's your job within that consultation to convert them, to do such a good job, to pay so much attention to the patient doctor relationship, to really let them know that they've been assessed thoroughly and that they've been listened to so by the end of the consultation, they're perfectly happy and they don't need to see you face-to-face, if naturally that's clinically appropriate.

Dr Dane Vishnubala:

Yeah, and it is difficult because I find that the ones I do, there are some patients that will always just say, "I just want to see face-to-face." Even though you know that it doesn't sound like it needs to go there. And then there are things that you say to reassure them kind of beyond what you've just said now to kind of get that across that it's okay.

Dr Adam Abbs:

All I can do is offer them the consultation to show them that the consultation is valuable. And a lot of what we're saying at the start about not being transactional in the consultation is the patient will often see their remote consultation as that stop gap, as the cheaper version of a GP or GP light. But what you need to do is engage with the patient, listen to them, use your body language, express your empathy. And actually you'll find a lot of patients by the end of it, will say, "Wow, I've actually had a doctor listen to me more than I have for the last 20 years." And many patients will like it. Some won't and that's the nature of human beings. But the vast majority, if you work hard enough, just as you work hard in a real face-to-face consultation, you can convert them.

Dr Dane Vishnubala:

Yeah, I guess, for a new patient who isn't up for it yet, it's kind of that there is a little bit of sales in terms of getting them around and showing them that you can achieve what you're looking to achieve this way. And like you said, emphasising some of the points that maybe they might be less clear about.

Dr Adam Abbs:

Yeah. And not by telling them, "You have to do this." Saying to them, "Let's try it and I'll show you." And I expect most patients will be happy.

Dr Dane Vishnubala:

Yeah, no. Sounds good. Try before you buy. I guess, so I think that was a quick roundup of some of the key points that were brought up. The key things were around concerns around kind of the ability to have a face-to-face examination if needed, which we talked about. We've talked about eliciting clinical signs and the challenges there, body language, picking it up and then kind of medical legal and patient confidence. But to kind of put you on the spot a little bit, I was hoping you might give us a quick summary of what you think the kind of key take home points are from some of the things we've discussed.

Dr Adam Abbs:

We've discussed a lot, haven't we? Mainly just to do as much as you can, as thoroughly as you can, but know the limits. And also don't forget, you're still the patient's doctor. You're still their GP. You're still the clinician, you're still the person that they put faith in. Not only are you clinically responsible for them, but you're not a telephone operative. You are there to listen to them, to recognise their feelings, to appreciate their feelings and to attend the patient doctor relationship. It's even more important remotely than it is normally. Please, let's not forget everything we've learned in under and postgraduate medical education, when it comes to remote consultations. We need to do even more of it. And then we can have real fruitful, meaningful remote consultations.

Dr Dane Vishnubala:

Perfect. And I have been typing away under the guise of the camera, so I don't know how obvious it was, but I wrote down a few bits just thinking about the key points you made.

Dr Adam Abbs:

You weren't typing emails then.

Dr Dane Vishnubala:

No, I promise you I wasn't on my emails, no. For me, the main ones were kind of remembering that remote consultations are no longer just the stop gap and potentially could be the consultation. I think you mentioned the ability to self-examine. There's some things we could coach and tell the patient to do that will give us valuable information that may let us make a decision or decide what needs to happen next. That view, so you get a good view of them and not being afraid to let them see that view. You've mentioned quite a few tools, but I think the main was the paediatric ones. That's one we're going to talk about, but obviously there's the handbook as well for the guys to have a look at, but hopefully we'll start to pick apart some of the details from the handbook in more detail moving forwards.

Dr Dane Vishnubala:

I liked the three strikes and you're out, but obviously if you feel that there's two strikes and you're already worried, then obviously you can do that but three strikes is a nice way to look at it. Kind of colouring that kind of consultation notes with some of the information that isn't what they say, which you talked about such as, did they come downstairs were they out of breath? What did you make them do? I thought it was good. And then I think the final point, it's a point you made very early on, which is knowing the limitations of your tools and knowing at what point this cannot be remote and not being afraid of that, I guess, as well.

Dr Adam Abbs:

There's the remote roundup as well is another resource that we do. There's new resources coming out every day feels like but probably every week. And the Remote Roundup is a newsletter that we're doing that puts all that together. We search the internet to find out the latest resources and guides and we put that in there. If you want to check out on the Arc Health website, you'll be able to sign up and receive that. It's just once a month.

Dr Dane Vishnubala:

And that's still on the education hub.

Dr Adam Abbs:

Yes, exactly.

Dr Dane Vishnubala:

Perfect. Okay. Lots of things on the education hub to have a look at. Definitely have a delve around when you've got time. Yeah, finally, a big thank you for joining us, Adam. Do appreciate it. And I'm hoping you guys found that useful. What I'm hoping to do moving forward is based on kind of feedback and polls, there's lots of interesting bits about Adam said that we can expand on. Hopefully we'll come back and look at some of those points in more detail as well. Anyway, I hope you found it useful. Lots and lots of interesting topics to come up soon. Hopefully we'll see you on the next podcast. And remember, you can find our podcast on Apple Podcasts and also on Spotify. See you on the next one.

Dr Dane Vishnubala:

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.

(01:07) Episode introduction 

(01:38) Introduction to Dr Adam Abbs

(04:08) Doctors’ concerns about their inability to perform face-to-face examinations  

(08:01) How to manage concerns about eliciting clinical signs during a remote consultation

(12:42) How to assess body language during a remote consultation   

(18:32) Advice on how to alleviate medico-legal concerns  

(23:52) How to encourage patient confidence with remote consultations  

(27:21) Summary of the main points on how to deal with the challenges of remote consultations


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