Telephone consultations are ideally conducted hands-free by clinicians to allow easy access to the clinical record. A poor line, particularly to mobile phones, risks misinterpretation or loss of important information and struggling on in such circumstances may lead to a less comprehensive history. It is a reason to hang up and try again or to move to face-to-face. 

For video consulting it is important to establish in advance that the patient has satisfactory equipment with adequate bandwidth and that they are aware there may be potential costs to using it. Previous patient use of Skype or Zoom would suggest that clinical software is likely to work. Ideally, equipment could be checked by an administrative assistant for the first such call. Patients should be advised that Wi-Fi is usually more reliable than 3G or 4G (there is little experience with 5G). However, given how bandwidth can vary at different times of day, a back-up telephone number is essential.

Ideally, but not essentially, good quality headsets should be used by both parties. It is important that any communication platform is secure. Web-based communications should ideally be encrypted. 

With remote consultations it is important to establish where the patient is currently located. Your licence to practice and medical indemnity may not cover you in other countries. Consider asking such patients to consider consulting a local doctor.

The consultation should take place for both parties in a quiet, secure location, as in the consulting room, with doors shut. When calling a patient the clinician should ensure they are speaking to the correct person. Ensure that the patient is in a position to be able to speak freely and, if on a speaker, that there are no other people in the room (unless specifically agreed). If the patient is outside, or in a public place, consider deferring the consultation. Providing a specific time window when the call will be made facilitates this. In general, be careful about revealing the contents of the medical record unnecessarily.

Third party consultations are particularly challenging remotely. In the consulting room co-attendance is usually taken as consent for discussion, but may not be. It is not always clear, for example, if a daughter, speaking on the phone on behalf of her elderly father, has his full permission to do so and that he has capacity to provide this. The General Medical Council states that it is important to assess capacity and if in doubt consider if a remote consultation is appropriate.¹

A similar quandary arises in consultations with teenagers, particularly when sensitive topics are being discussed. As with face-to-face consultations, in general, video and telephone consultations with children are usually better conducted with a responsible adult present. However, if it is assessed as being in the child’s best interests, they may be conducted alone. The circumstances in which this may be appropriate are clearly outlined by the General Medical Council.²

If video consulting, clinicians should be aware of their background, particularly if consulting from home. Images which are perfectly acceptable in some societies can cause offence in others. Clinicians may wish to consider their dress, which has been shown to affect confidence in the clinician.³

Lastly, when video consulting, it is possible to make use of the Internet to demonstrate online resources or share a screen, for example an X-ray or a lab report. Practicing with the software prior to consulting is valuable in learning how to do this smoothly. 

Notes

1. The General Medical Council. Remote Consultations. https://www.gmc-uk.org/ethical-guidance/ethical-hub/remote-consultations 
2. The General Medical Council. 0-18 years: guidance for all doctors.  https://www.gmc-uk.org/outcomes-legislation 
3. McKinstry B, Wang JX. Putting on the style: what patients think of the way their doctor dresses. Br J Gen Pract. 1991 Jul;41(348):270, 275-8. PMID: 1747264; PMCID: PMC1371685.