Circumstances change, good practice stays the same

Associate Professor Charlotte Hespe

From telehealth consultations to outdoor clinics, many of us are having to rapidly adapt the way we’ve been practising for years – and often decades – but while the settings and the tools may have changed, the basics of sound, holistic preventive healthcare have not.
 
We’ve all got the skills, we’re now just applying them in a different context.
 
Take telehealth, for example; an initiative expected to take years to find a foothold in everyday Australian general practice has been rushed through in a matter of weeks.
 
While a necessary and welcome initiative to protect GPs and the wider public from exposure to COVID-19, it also comes with its own challenges.
 
Normally as a clinician we’re able to physically invite patients into the consulting room, and in doing so are afforded the opportunity observe them as they get up from their chair in the waiting room, walk in and sit down. We then use our valuable communication skills, observing their non-verbal, as well as their verbal, responses.
 
There is a whole lot of information we can potentially gather from that general clinical review of their movements, responses, etc, but the broad introduction of telephone and video consultations means we can’t access all those elements of clinical data-gathering.
 
Video consultations still allow us to get a pretty good idea about whether or not somebody looks well – not as rich as when they’re face-to-face, but it is still incredibly valuable.
 
On the telephone, unfortunately we lose all these visual cues. However, there is still lot of value in the information we gather, and most of us are familiar with using the phone as a tool in our daily care of patients.
 
It is important to then realise that we do use other cues from the audio consultation and what we hear – not just content, but the way in which it’s delivered, how long it takes. This can help prompt the sort of additional questions we might need to ask to get further information.
 
What is slightly challenging is having to comprehensively check whether it is the person we’re expecting to be consulting on the other end of the line, and that they are actually in a private setting in which they feel comfortable to talk about health-related issues.
 
Although it is easy to make that assumption when the patient presents in-person, the limitations of a telephone consultation mean you may not be aware if someone else is in the room with them, or the space in which they’re actually talking to you, without specifically asking.
 
I liken it to how a newly blind person adapts to life without vision – you must heighten your use of other senses.
 
Likewise, when I’m taking a history without that physical presence in the room, I need to augment my information-gathering by other means.
 
For example, most of us would never dream of doing a consultation without having the full medical file to look at either before the patient comes in, or as they’re sitting there during the consultation. Telehealth it is no different and, in fact, that information can sometimes be even more important.
 
Consulting over the phone should be done in conjunction with reviewing the file, making sure you’re comfortable with knowing who the patient is, their context, and whether there are special questions that need to be asked.
 
Of course, sound clinical practice is not limited to diagnosis and treatment, and not all consultations can be done remotely.
 
Thousands of GPs are each seeing dozens of patients across the country every day, all of whom present the risk of potential infection and the associated fear of infecting loved ones or vulnerable people.
 
Limiting the risk by observing sensible distancing with patients and colleagues, avoiding high-risk scenarios where possible, and observing the highest safety standards when unavoidable, are all part of the quality care that GPs need to provide.
 
We all know access to personal protective equipment (PPE) is limited, but GPs are innovative, resilient, and intelligent enough to recognise an unreasonable risk when we see one.
 
Reassuringly, there is still limited evidence of large coronavirus transmission rates among the general practice community.
 
Recent figures to emerge from New South Wales, which has conducted a large amount of very wide testing of a casual and close contacts for all the first cases, indicated the infection rate was only 0.5% for casual contacts.
 
Within the medical community, the highest risk is to those who are in intensive care units, while the risk for us, as GPs, is much lower.
 
This is a not an excuse for complacency, but rather a sign that if we continue to follow the high standards of clinical care we as a general practice community have set for ourselves during these most trying of times, we will overcome and life will eventually return to some sense of normalcy.
 
As the known and regular GP for our patient populations, we offer a safe place in a time of disruption and anxiety which cannot be overstated. We must recognise how important it is to keep in touch with these patients – even if it’s via a new and slightly uncomfortable medium.
 
At the end of the day, the more things change, the more they stay the same.

The following article was initially published on RACGP’s NewsGP website and is republished with the kind permission of RACGP NSW&ACT and Dr Charlotte Hespe.

I liken it to how a newly blind person adapts to life without vision – you must heighten your use of other senses.