The tyranny of distance: Consults by phone deprive us of important clues

When our area recently went back up a COVID-19 alert level for another week, my practice encouraged phone consulta­tions wherever possible.

Most of my days were filled with phone consults, with some face-to-face slots for urgent patients. Unfortunately, I experienced some of the downsides of trying to help my patients via phone.

One of my first patients was a young man who had a new rash on his hands. He described it as itchy, sore and dry looking. He had never had rashes before, had no medical history and no regular medications.

I felt I could have provided much more emotional support if our discussion had been in person

Clearly, I needed to be able to see the rash to give him a diagnosis and plan. I decided to ask him to take a photo and email it to me. This worked well and the photo was of good quality – although it took him 15 minutes to send it, so I was then behind schedule.

The photo showed dermatitis and, on further discussion, it transpired he had been working from home and had taken the time to furiously clean the mould from his room (gloves not included). A script for some steroid cream was sent to the pharmacy, and I was rushing to call the next patient.

This was a young woman who announced to me she had taken five pregnancy tests yesterday. They were all positive. She then burst into tears.

I struggled for something to say. Generally, I feel communication is one of my strong suits, but how do you show support and empathy over the phone?

Eventually, we talked it out and made a plan that would work well for her; she was to see me in person in a few weeks’ time to follow up. But I was left feeling a bit hollow. I felt I could have provided much more emotional support if our discussion had been in person.

Another phone discussion, with a mother who was worried about her child’s rash. After a while, I learned it was a new-onset rash over his bottom. Mum said it was red and raw-looking, over both cheeks. He seemed to her to be otherwise well, but maybe a bit grizzlier than usual – definitely worse with nappy changes.

Here I faced a dilemma. I needed to see this rash. The photo trick had worked well in my earlier patient, but was it okay to ask a mum to send a photo of a child’s bottom to my email address? Should I bring them in for a quick look, knowing I was potentially exposing the child to anyone in the waiting room? After a discussion of the pros and cons, we decided to bring him in and, one nappy-rash diagnosis later, they were off home again.

The final thing I noticed about phone consults was how much I have come to rely on the “end-of-bed” assessment of patients.

Talking to a mum whose toddler has a cold, or to an elderly lady with a likely urinary tract infection, it was hard to figure out how sick they were.

I realised I was missing being able to just look at them and assess their condition – and some vital signs never go amiss either.

At the hospital, I always regarded as supernatural beings those older consultants who walk into the patient’s room and figure out how unwell they are. It’s funny how I have developed this skill as well, without realising it. I guess experience helps.

I admit I got the mum with the “coldy” toddler to come in (I saw them in the car park). I reasoned that they should get tested for COVID-19. As lines can be so long at the community-based assessment centres, I decided I might as well do it myself and have a squiz at the child at the same time.

As soon as I saw him, I knew he was okay. My concern went down, and his mum and I discussed supportive treatments and some safety-netting in case he got worse.

So I’m not a fan of the phone consult, even though it seems to make most consults shorter, and kept me on time. But I missed face-to-face interactions, because they help me relate to my patients and they make assessment and diagnosis much easier. I’m thankful we are back to level 1.

Dr Cat is a trainee GP working in a New Zealand general practice