Helen Salisbury: Teleconsultations for all
BMJ 2020; 370 doi: https://doi.org/10.1136/bmj.m3211 (Published 18 August 2020) Cite this as: BMJ 2020;370:m3211Read our latest coverage of the coronavirus outbreak
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Dear Editor
It was so refreshing to read this article cutting through the current hype on teleconsultations.
In recent weeks I have diagnosed cases of diabetes and of goitre in which thorough telephone consultations had failed to make a correct diagnosis but which was apparent within minutes of seeing the patient.
I am concerned about the number of conditions being misdiagnosed in the rush to embrace the 'new normal'. A further re-calibration is already overdue.
Competing interests: No competing interests
Dear Editor,
Remote consultations were introduced widely within community mental health services at the initial peak of the COVID-19 pandemic.(1) Helen Salisbury explains why teleconsultations are sub-optimal for many patients in primary care.(2) In an era of social distancing, psychiatrists and other mental health practitioners have to be inventive to provide good clinical care, whilst balancing out the risks of aerosol infection and communication problems when performing assessments with mental health patients.(3) Walking and talking with a patient outdoors may be an appropriate setting for conducting assessments in situations where a teleconsultation (by video or telephone) is not possible or the risk of aerosol transmission too high for an indoor consultation, or because a patient cannot sit still and/or does not want to wear a face mask.
The outdoor walking and talking mental health assessment, was introduced by Sigmund Freud on 26 August 1910. Freud walked through the Dutch city of Leiden whilst talking to the composer and conductor Gustav Mahler for more than four hours. Mahler was famous for his creative restlessness and may have suffered from ADHD throughout his life.(4) He asked Freud for a consultation when he was going through a marital crisis and Freud’s assessment and brief intervention seemed to have a healing effect on the marriage of Gustav and Alma Mahler.(5) My suggestion is simply for colleagues to also consider outdoor settings for performing mental health assessments.
(1) Anjana Rao Kavoor, Kripa Chakravarthy & Thomas John: Remote consultations in the era of COVID-19 pandemic: Preliminary experience in a regional Australian public acute mental health care setting. Asian J Psychiatry 2020;51:102074
(2) Helen Salisbury: Teleconsultations for all. BMJ 2020;370:m3211
(3) Barnet, Enfield and Haringey Mental Health NHS Trust: Guidance on using remote patient consultations in community services. London 2020
(4) Ulrich Müller-Sedgwick: In lockdown with Mahler. In: The Wayfarer [Newsletter of The Gustav Mahler Society UK] 2020
(5) Stuart Feder: Gustav Mahler: A Life in Crisis. Yale University Press, New Haven & London, 2004.
Competing interests: No competing interests
Dear Editor
Brave article stating the truth. Thank you.
Added to this are the 'moans' I hear in my social circle about the difficulty in getting access to see their doctor and at work trying to find the time for face to face care when the whole day is pre-booked with telephone assessment with or without video. Yes, it's great for many things, but can we think about moving to using non-clinical triaging so reception staff can use their skills and allow direct contact without the steps of telephone triage and e-consult if the 'patient' does not want this?
The huge drop in the cancer and heart referrals over the last 5 months suggest that the new model has the potential to miss serious problems before we move into the training and job satisfaction problems it may cause.
Competing interests: No competing interests
Dear Editor,
The pendulum has swung too far: pre-Covid there was perhaps too great an emphasis on the face-to-face consultation, but Matt Hancock's assertion, as quoted, fundamentally misunderstands the primary care presentation. Helen Salisbury states that it misses 'vital questions about quality, choice and relationships'. I would go further, and suggest that patient safety, the acquisition and maintenance of clinical examination skills, as well as professional satisfaction are all compromised.
The mutually trusting pre-existing (patient-doctor) relationship is vital to the success of remote consulting: this can uniquely be established by personal continuity of care, now only available if it is deliberately and carefully built into appointment systems taking into account sessional working. A succession of random clinical 'snapshots' incurs greater clinical risk and reduced professional satisfaction relative to 'clips of cine films'.
Stressed GPs counterbalance their pressure with job satisfaction: reduce the latter and more will depart their profession: perhaps it is fortuitous that Medical Schools will increase their intakes this autumn.
Competing interests: No competing interests
Dear Editor,
I was glad on reading this article (and the many twitter conversations it sparked) to see that there are many GPs and other community workers who are uneasy with a blanket switch to remote consultation as default. However, I have also been intrigued that these conversations have largely taken place around the issue of clinical safety and the 'unknown unknowns', rather than barriers to healthcare.
For many GP trainees such as myself, part of the appeal of General Practice is the opportunity to be part of the solution to health disparities. As one of the few remaining areas of the NHS that are truly open access and free at the point of use, GP surgeries have been the place where many of the marginalised and unseen people in society can be seen and receive care.
The switch to remote consulting first, for many will remove this safe place. It goes without saying that people who can't afford a mobile telephone, don't have internet access, and particularly those who can't speak English, will have difficulty navigating the myriad remote entry points to GP consultation.
The difficulty accessing primary care services for migrants, and particularly asylum seekers and refugees, is well documented (1); though as yet there isn't a large body of writing about this with regard to remote consultations. During the first wave of the pandemic, Doctors of the World conducted a Rapid Needs Assessment for excluded people in the UK, and titled their report "An Unsafe Distance" (2). This report repeatedly uses the term 'digital exclusion' to describe some of the barriers outlined above. The plan for digital appointments being the default threatens that this exclusion will extend beyond the end of this pandemic and well into the future.
Far from the hope of of a bright technological future for general practice, Matt Hancock's announcement was yet another occasion when these 'unseen unknowns' were pushed even further away from accessible healthcare.
References
1. Kang, C., Tomkow, L., &; Farrington, R. (2019). Access to primary health care for asylum seekers and refugees: A qualitative study of service user experiences in the UK. British Journal of General Practice, 69(685). doi:10.3399/bjgp19x701309
2. Doctors of the World (2020) An Unsafe Distance: The Impact of the Covid-19 Pandemic on Excluded People in England.
Available: https://www.doctorsoftheworld.org.uk/wp-content/uploads/2020/05/covid19-...
Competing interests: No competing interests
Dear Editor,
I would like to thank the author for raising raise this important topic worldwide. I would argue for as much teleconsultation as possible and for safety. In many cases, teleconsultations are quick, convenient, and safe. When supported by future platforms for collecting information from the patient and history taking, that is usually time-consuming for doctors might spare a lot of time for both parties. Patients can comfortably recall and collect all the needed information and prepare it for the doctor. Physicians have more time for analysis and conversation. Obviously, in many cases personal contact and examination are necessary.
The challenge is to define when it is not and try to continue developing the system of teleconsultations for these cases. Why not use some tests as home monitoring for patients? What about technologies based on artificial intelligence (AI) already developed and ready to be used? They are already available. The use of these new technologies depends on us and regulators. The UK was the first country worldwide to introduce a national diabetic screening program based on telemedicine, and this helped to save the sight of many patients. The system is, however, very expensive, which limited its use in many other countries. Now it can be supported by AI and made much cheaper.
Sometimes doctors are reluctant to use these new technologies and they can easily limit their use. I worry that after COVID problems pass away doctors will forget about tele-technologies, and regulators will not be interested in supporting this field to such an extent anymore. I perceive it as a chance for health care to move to the new organizational system: more convenient and effective, although still safe. Let's discuss the future hybrid system: taking the best from personal and teleconsultations.
Competing interests: No competing interests
Dear Editor
F Scott Fitzgerald said “ The test of a first-rate intelligence is the ability to hold two opposed ideas in mind at the same time and still retain the ability to function.”
I would suggest that the idea that teleconsultations are essential to General Practice and the idea that face to face consultations are essential are not in fact opposed ideas.
Six years of teleconsultations in a phone first model in my own practice have enabled a huge increase in access with an increase in time spent face to face.
I would hesitate to base any decisions about the future of General Practice on experience solely based on the Covid pandemic, that hesitation would include suggesting that teleconsultations are second best when for many patients they are the best access they have ever had to General Practice.
Competing interests: No competing interests
Could not have put it better! I wonder if Hatt Mancock has ever actually spent time in a busy GP surgery seeing the breadth and complexity of what we do? Our job is nuanced, that is the art of it, and why 'being clever' is not enough. My working relationship with my patients is what has given me so much pleasure and job satisfaction over the years. Physical, social, psychological, spiritual. Some love us, some can't stand us, the feeling is mutual and it can evolve over the years in ways that can surprise and move us. We are more than an app or an algorithm. I've recently retired after 30y as a partner (in three practices - UK, NZ, UK) and am now locuming for colleagues at my practice till the magic 60y comes - then it will be NZ again. No way could I practise the way we are expected to do now, safely, with patients I don't know, for all the reasons Helen presents. I know many of our patients feel the same, and value the familiarity of a voice of someone who knows them and their story. We undervalue the doctor / patient relationship at our peril. 'We don't know what we don't know' applies to teleconsultations as much as it does in so many other areas of medicine.
Competing interests: No competing interests
Re: Helen Salisbury: Teleconsultations for all
Dear Editor,
Well done to Dr Salisbury for her commonsense and wise words. A 'virtual' consultation is a poor substitute for a face-to-face clinical encounter: even if no examination is performed, the clinician benefits from nuances and subtleties that would be otherwise be missed but which are essential to the algorithm instrumental to accurate diagnosis and thence good care.
Dr Michael Barrie
Competing interests: No competing interests