Doctor numbers and dissatisfaction with working hours are foremost in the minds of clinicians and health politicians these days. We’re in short supply of the former and burdened with the latter, which may explain the resurfacing of non face-to-face (F2F) clinician/patient initiatives.
The CHAT program, an initiative of a team of Australian anesthetists, is one example of an effective strategy in a clearly defined situation that utilises the good old fashioned telephone (with the modern push-buttons) to conduct a preventive pre-surgery anaesthetic check up with low risk patients.
More sophisticated non F2F consultations like telemedicine, texting, videoconferencing, and electronic triage have a checkered history: the supporting research is equivocal and some is too old to be relevant (telemedicine was in vogue 15 years ago). However, where prior F2F contact has been made, such as follow-up and chronic disease management, some progress has been made for example in the home management of congestive cardiac failure.
Cold calling can be an advantage for areas of medicine that are neglected in the normal diagnosis-to-treatment consultation.
In immediate and first contact circumstances the evidence is not as compelling. A recent Italian study reviewed non F2F consultations for four straightforward problems that could be managed without seeing a clinician: an adult with a nosebleed, an adult with fever, a child with fever and a child with vomiting.
The results were disappointing. Insufficient questioning occurred in approximately half the consultations, which meant that clinical decisions were made on inadequate evidence. The average length of a call was just under four minutes (excluding waiting time), and less than 10 percent of patients were referred for a second opinion.
Even more disappointing is the image of doctors working in a regular bank or a teleco style call centre where the customer answers the organisation’s set questions and never gets an opportunity to explain the problem.
That said an improved call centre model could herald a new medical advance that takes advantage of the global move to flexible working environments where doctors might even welcome (!) extended hours in a less pressured way.
For any such change to be successful, a major reworking of the doctor/telephone or doctor/internet relationship is required. Using the traditional diagnosis-to-treatment or problem management model won’t work because our current clinical practice works best in a F2F environment of physical contact and opportunistic interviewing. And this doesn’t translate well into the call centre environment of customer service and information access systems in real time.
However, certain areas of medicine can lend themselves to less physical contact. For example, cold calling can be an advantage for areas of medicine that are neglected in the normal diagnosis-to-treatment consultation. Often in consultations there is little time to cover health issues such as Immunization, routine check ups, medication review and opportunistic depression assessment, and a non F2F interaction can be a bonus.
There are also emerging non clinical areas where patients might need advice that does not require an in-person interaction, for example, where and how to obtain the most effective treatment at an acceptable cost especially in high cost areas such as cancer care. And these might be the unsolicited calls that we will want to accept.