It is important to be fully up to date
with the current General Medical Council (GMC) regulation for the use of
RC. The GMC has set out 10 key high-level principles for good practice
in remote consultations and prescribing that have been supported by 13
other regulatory bodies in England, Scotland, Wales, and Northern
Ireland
5. These principles are
not new guidance, rather the existing standards adapted to the current
pandemic situation.
The GMC emphasises in its guidance that in
the current situation at times doctors may need to apply their
professional judgment to use the resources available for
consultation.
5,6,7 The Royal
Colleges, British Medical Association, and other relevant organisation
have provided guidance and updates on RC. We would advise familiarising
yourself with the most recent guidance from your respective College and
regulatory body.
It is vital to also consider the
medicolegal implications, inherent risks, and limitations of virtual
consultation.
8 Familiarising
oneself with the available guidance and updates from medical indemnity
organisation is essential for safe and defensible practice.
The NHS Information Governance team's
advice is that it is acceptable to use Skype, WhatsApp, Facetime, and
other commercially available products as a short-term measure during a
pandemic.
9 We would advise that
wherever possible, clinicians should consider using NHS approved
platform for RC.
TECHNOLOGY AND PLATFORMS
The ideal technology for remote
consultations is an NHS approved General Data Protection Regulations
(GDPR) compliant tool, that has both the audio and visual
components. The question one should ask when choosing a fully
compliant platform is how urgent and important the consultation is
keeping in mind considerations around safety, confidentiality, and
data protection.
There are multiple platforms available
both paid and free. It will also depend on your organisation that
may have an approved specified consultation platform. For a
high-quality experience of remote consultation, the clinician
requires correct equipment with good webcam, audio, and video
system. Internet connectivity for both the patient and the clinician
is vital for effective consultation.
PREPARATION
If one is not used to RC, it can be
a learning curve and requires a period of adaptation. Allowing us to
be curious and explore opportunities and experimenting with new ways
of working is important. There is evidence that once clinicians get
used to using certain platforms, the RC becomes less stressful, more
efficient, directed, and focused.
4,10
It is sometimes helpful to create a
template that may allow for triage of patients who can be safely seen by
RC. It may be helpful to send focussed questionnaires or information
sheets to the patient who could return it via secure email. Such
directed and focussed consultation can add significant value and save
time. Some platforms have the facility for multiple participants to join
the consultations for example another healthcare professional that is
involved in the care or an interpreter.
Developing flowcharts based on evidence
and for the most common scenarios can come handy at times when a lot of
clinical decision-making will be based on observation and reports.
Knowing when to avoid remote consultations is also important and having
a list of scenarios and criteria to guide you may be important.
11
EXAMINATION
In some specialities, RC can feel
inadequate, as it is not possible to examine a patient. Given the
extraordinary times with the pandemic, some creative and out of the
box thinking is needed.
12 Patients
can be advised to monitor their vital parameters by the use of
mobile applications or medical devices such as blood pressure
machines and glucose tests that are widely available for home use.
For instance, in a virtual ADHD clinic, patients monitor their heart
rate and blood pressure and send information through the application
to inform their clinician. The patient receives some brief training
on how to monitor their vital signs. In some cases, following a
remote consultation, the patient may need to be seen face to face
for the safe delivery of care. The likelihood of such an outcome
should be discussed in advance with the patient.
Table 1: Documentation of
ethnicity of respondents
| Location of both clinician and patient |
| Technology/platform used along with limitations
discussed |
| Clarifying reasons for remote consultation |
| Discussing circumstances to use face to face
consultation |
| Crisis or medical emergency management plan |
| Clinic letter to the referrer, other providers and
patient |
PATIENT PERSPECTIVE
It is important to ensure that
patients and their carers are comfortable with remote consultation
and allow them time to get used to it especially if it is their
first experience. Feedback suggests that patients and carers are
generally accepting of RC, can manage technical problems, understand
limitations, and are generally grateful for the virtual clinical
input and intervention. The other observation is that patients are
honest and able to express the emotions better as there is still
some distance between the clinician and patient. This is
particularly important in mental health conditions.
4,12,13
RC will require special consideration and more skill especially when
faced with challenging communication for instance in cases where bad
news has to be delivered.
10
THERAPEUTIC RELATIONSHIP
At the core of every good clinical
interaction is a robust therapeutic relationship, one that seeks to
elicit information and allows for difficult discussions to take
place. Clinicians consider the therapeutic alliance as the most
important factor for a successful outcome.
14 A sound clinician-patient relationship also
helps to improve engagement in the treatment plan and reduces the
risk of miscommunication and complaints.
RC can make it challenging to
establish a meaningful therapeutic relationship and clinicians may
need to work harder. The rapid rollout of remote consultation during
the COVID-19 pandemic has given clinicians little time to translate
their therapeutic skills from their consultation rooms to their
computer screens. However, clinicians are generally used to working
in constantly evolving clinical environments and most would have the
flexibility to adapt to this new world.
Evidence suggests that the key
principles of therapeutic interpersonal relationships include
therapeutic listening, responding to patient emotions and unmet
needs, and patient-centeredness.
15
Using technology can be a challenge to developing rapport. Every
interaction has the potential to elicit a countertransference
reaction in the clinician and care has to be taken that this is
appropriately managed so that it does not disrupt treatment.
16
Patients who are used to everyday
video conferencing and other technological advances will find the
transition to remote consultations easy. However, clinical
consultations are different from peer meetings and they might find
the clinician on a screen quite distant and harder to relate to. Any
barriers in language and culture can magnify this for the patient
and make the process dissatisfying. Worse still, difficult
transference feelings and lack of confidence might impact on their
ability to take the clinical advice on board.
TRAINEE PERSPECTIVE
The wide use of RC can have huge
benefits for trainees. In providing follow up care, virtual
Respiratory clinics can be set up to follow up COVID-19 positive
patients after discharge. Trainees with minimal consultant
supervision can manage this safely. This offers continuity of care
for patients and improves their level of satisfaction. It also helps
the hospital-based staff to focus on patients admitted and use
resources more appropriately including Personal Protection
Equipment. In a geographically widespread deanery, trainees who are
located in other locations can also be recruited, thereby making
better use of the manpower available.
Admission to hospital with COVID-19 is
a traumatic experience for patients and they prefer being able to
speak to their team from their homes after they have been
discharged. In addition to reducing further exposure, RCs are
proving useful in allaying anxiety in patients and improving the
doctor-patient relationship.
We have observed a positive
transformation in the inpatient referral process as well with the
system becoming more efficient. The use of e-mails to send
information and invitations securely in combination with RCs works
well.
Additionally, ‘COVID-19 Webinars’ have
been organised by different departments (Respiratory, Cardiology,
Gastroenterology, Renal, etc.) bringing together a rich training
experience and specialist focus on the latest information about
COVID-19 including clinical updates, treatment protocols and the
evidence base which appears to be growing steadily. This enhanced
learning experience for trainees can be safely accessed from the
comfort of our homes.
The provision of mentoring for new
trainees by senior trainees is an additional feature and this can
again be safely delivered by remote technology. Overall, the trainee
experience of RC is positive and has opened new channels of
education and continuing patient care.
ADVANTAGES
The biggest advantage of RC is the
ease of access to treatment. Patients do not have to rely on
transport or support from others to attend appointments. Once they
get used to the format and process, they can manage the appointments
with high degree of autonomy. Reduced reliance on family and friends
can mean that they take more charge and responsibility for their
care; this can improve concordance and health outcomes.
Patients can see their clinician from
the comfort of their homes. Those who don’t drive will not be
disadvantaged. They have greater flexibility in terms of appointment
times, as transit times will no longer need to be considered. RC
also allow multi-disciplinary approach and it becomes lot easier to
involve several specialists who may be located geographically
distant from one another to convene and provide their clinical
expertise to enhance the treatment plan.
11,12,13
There are financial incentives in terms
of not having to bear travel and parking costs and not having to
take time off work. Patients will also benefit from the time saved.
They would not have to wait unnecessarily in case clinics run over
and will save time by avoiding travelling especially to regional
centres and places with poor transport links. In the current
COVID-19 situation, RC is the near-perfect solution to maintaining
social distancing and minimising virus transmission. RC contributes
to reducing the carbon footprint and can help in creating
sustainable healthcare models that are environmentally friendly and
greener.
17
LIMITATIONS
There are complex reasons that can
make RC difficult to integrate and sustain within a healthcare
system including cost, logistics, and adverse impacts on
professionals.
18 Clinicians
and patients need good and uninterrupted access to the internet and
power source along with a device that supports the consultation
software. They might need specialist support to troubleshoot
technical difficulties.
The GMC recognises that there could be
potential safety risks and recommends considering if face-to-face
appointment is needed on a case-by-case basis.
6 Defence unions also advise about being aware of
inherent risks with remote consultations.
19
It is not possible to perform a
clinical examination apart from observation and inspection. Although
mobile applications can assist in the recording and monitoring of
vital parameters like pulse rate and blood pressure, more detailed
and complex examination remains out of bounds. It can also be
difficult to get a full and accurate picture of a patient’s mental
state. However, in several areas of clinical practice e.g.
dermatology, dentistry, and physiotherapy to name a few, clinicians
are adapting and able to use technology to complete a full
consultation. There are also issues with patient consent and
autonomy. Patients may find it harder to decline appointments and
may be coerced into seeing the clinician by family. It can also be
difficult to fully ensure confidentiality as unbeknown to the
patient, family member or friend might be in the vicinity. This can
be challenging for clinician in assessing risk and potential
safeguarding issues.
Patients with learning, speech, visual,
and hearing impairments may require additional adjustments and
support with these consultations. For certain vulnerable individuals
who are socially isolated, face-to-face appointments provide some
opportunity to leave their homes and meet with others. There is a
risk this group who are often marginalised may become further
withdrawn and lonely.
Clinicians need to be aware that
patients may record the consultation. THIs is not necessarily a
disadvantage when clinician is aware and ground rules considered.
Table 2: Important
Considerations for RCs of ethnicity of respondents
| Obtain valid consent |
Assume consent and confidentiality |
| Ensure confidentiality |
Be late |
| Explain limitations of consultation |
Be ambiguous with the management plan |
| Check communication needs, use verbal and non-verbal
cues |
Assume no one is recording |
| Have a template to introduce the session |
Use non-approved platforms or apps |
| Ensure good, clear and accurate documentation |
Continue the RC if you have any concerns about patient
identity or confidentiality |
| Remain up to date with current regulation and
organisational policy |
Rely solely on a single platform for RC, have telephone
option as a backup |
| Ensure medical indemnity cover |
Use RC where physical examination is essential |
| Have an alternative if technical problems |
Record without prior consent |
| Review the caseload to consider where RC is possible |
|
| Maintain professionalism – dress code and background |
|
CONCLUSION
We have made significant
progress and strides in the uptake and use of technology in all
aspects of our lives from consumerism to banking and beyond. In
healthcare, despite the limitations and barriers that over time
through research, professional experience, and patient feedback
have been refined and improved, the use of RCs in clinical
practice will remain. For healthcare professionals across all
levels of service including primary, secondary, and tertiary
care, the recent Covid outbreak has accelerated its uptake.
The regulatory, indemnity, and
health care organisations have supported the swift transition to
using RCs to facilitate social distancing whilst continuing to
provide health care. The experiences during this time will add
to streamlining the use of RCs in the long-term including
advances in hybrid models, risk stratification, contingency
planning, and governance structures.
Following the pandemic, it is
envisaged that the convenience, cost-effectiveness, and benefits
in a variety of scenarios and situations will lead to the use of
RCs being embedded in pathways of care. Medical schools and
universities may have to look to prepare future generations to
embed this way of working.
Conflict of interest
No conflict of interest declared by
the authors.
Author’s Contributions
All authors contributed to the
article and editing.
