Virtual Bedside Manner
Bedside manner. The GMC encourages UK medical courses to teach the importance of effective communication to ‘Tomorrow’s Doctors, including demonstrating how to break bad news, discuss sensitive issues or plan treatment with vulnerable patients.
Given 2020’s rapid transition to digital and remote consultations, I wonder if medical schools may now consider expanding these classes by adding new modules into the curriculum that cover how best to communicate with patients when conducting telephone or video consultations.
Clinical and administrative resource has been redistributed during the immediate response to Covid-19 and as the months pass, the NHS will be able to identify costs savings occurring as a result of severely reduced onsite outpatient clinics.
It seems inevitable that there will be a significant long-term shift to remote consultations, on a more permanent basis. At a local level, Trusts could begin to experience the actual cost benefits and the potential for bigger savings in terms of clinical administration (booking clinics, receptionists, ancillary support staff in clinics); from nursing staff required to support clinicians; from patients in clinics; and, if the virtual consultations are structured efficiently and effectively, from a more focussed and targeted use of clinician time, allowing consultants to deal with the more complex cases and junior doctors to manage the more routine.
The benefits to patients can also be great, not just in saving time by not having to take a whole morning or afternoon off work just to attend a 15 minute clinic appointment, the hassle and stress of getting to the clinic location, costs of transport (and parking!) and the general disruption to the day, but there is also the safety factor of not needing to go to a hospital, which, by its very purpose, is full of sick people! If possible, most people would prefer to avoid that risk, especially since CV-19.
But all these efficiencies presuppose and will only be realised if the actual process for setting up and running virtual clinics is efficient and not more time consuming and administratively burdensome for both admin and clinical teams, and, that the patient can be effectively and fully assessed. If this cannot be put in place then clinicians will have less time available to see patients, will experience increased frustration due to the increase in administrative overhead in preparing for clinics (sifting through notes and information), the NHS will see an increase in costs and, significantly, the quality of care potentially reduced. A bad situation from every angle.
So, if we assume the hospitals have efficient processes, then what about the consultation itself? If you ask any clinician who sees patients in a clinic, they will tell you that the questions they ask the patients, the physical examination and what the patient tells you is only part of the information they use to assess the patient in a face to face consultation. Non-verbal cues are often a very important part of the overall assessment.
The challenge then, is to figure out how to ensure the assessment of the patient is not compromised without those non-verbal and visual cues that a clinician might ordinarily use. Are there skills that can be learned when assessing patients over the phone or via a video call? Perhaps tone of voice, pauses in the response to questions or possibly even the questions that are asked might need to be different from the ones normally asked in a face to face clinic?
It may be possible to develop and learn these new skills, and in time, research studies may be published and student courses developed on best practice for virtual consultations. But technology also affords the clinician another effective means of supporting their virtual consultation, specifically with the use of Patient Reported Outcome Measures and other validated questionnaires that can assist an assessment by providing the clinician with another valuable element of quantifiable information, even where the responses to questions are subjective.
Some NHS clinics have already embraced the digital future and are already using PROMs and other questionnaires to successfully monitor patients, not just with chronic diseases but also to help prioritise the huge backlog of acute patients on waiting lists. This approach is allowing the clinical team to easily monitor patients remotely, assisting with decisions on treatment and priority. Surely this has to be a good thing and a better approach to treating patients based on time on a waiting list?
Without a doubt, well organised virtual clinics, with efficient processes and the right clinical information easily at hand, have huge potential value to the NHS and its’ patients, delivering cost savings, productivity enhancements, optimising use of clinicians’ time and a better service to patients. The question is, can this be effectively implemented across the whole of the NHS as a new standard? Only time will tell.
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