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An expert’s experience

James Hammell
My name’s James Hammel, and I am a senior GP-based pharmacist. And I’ve been working in general practise, now, for the past five years. And I’ve been working as an independent prescriber for around the last two and a half years now. And my original scope of practise was around type 2 diabetes, but as the role has progressed, my scope of practise has expanded into other chronic disease management as well. So I lead a team of five pharmacists across four sites in the organisation, and we’re based in southwest London. And the main roles include chronic disease management, so asthma, COPD, diabetes, hypertension, cardiovascular disease, and also drug monitoring as well.
So managing therapeutic monitoring and also ensuring patients are managed appropriately on high-risk strict monitoring. And we also do this with minor ailments as well, with pharmacy team support the nurse practitioners in that. In terms of my experience relating to remote consultations, I think, until very recently, I had limited experience. The majority of the remote consultations were done via telephone. So we did have a pharmacist telephone led clinic which we used to work on every day. That was quite straightforward simple medication, reviews, medication queries, contacting patients just to discuss their recent blood test results or referring patients to appropriate services.
But due to– and actually what’s happened recently and in terms of general practise, the whole surgery has adopted a total triage model. So that has resulted in massive expansion of remote consultations involving the pharmacists as well. So currently and for the past few months, we’ve been performing remote consultation only. So that’s been a mixture of telephone calls and video calls, and also patients sending in pictures and videos for us to have a look at and then telephoning them back. So my experience over the past few months has grown significantly because of this COVID period. So we’re currently doing– currently, ourself offer about 25 remote consultations a day in the practise.
So I’ve gained a lot of experience over the past– last few months in remote consultations.
It is difficult when the patient isn’t that face-to-face and you can’t eyeball the patient, particularly if you’re not familiar with the patient and the patient isn’t familiar with yourself. And what I found is, particularly during telephone consultations, is that it can be quite hard to actually elicit some information from the patient. They can be quite reserved in what they’re telling you, maybe because they’re a little bit unsure of your environment that you’re in and because they can’t actually see you and your environment. So one of the techniques that I’ve used, which I found has been helpful, has been to show a lot of empathy towards patients.
And by showing that empathy and rapport, trying to build that relationship, what I found is that the patients are more willing to discuss their conditions in more detail, they’re more willing to give me more information which helps me make a clinical decision as to as to what to do. It is difficult because using remote consultations with telephone calls, you can’t pick up on any non-verbal cues, and also you can’t use nonverbal forms of communication via the telephone. So when I’ve done some video consultations, I have tried, still, to get some of those non-verbal communication features into my consultations. So making sure I’m still trying to make some eye contact, even though it is over video with the patient.
Trying to use some hand actions, trying to really make the consultation as similar as I would do it as in a face-to-face appointment. I think of the communication as– a aspect which I try to involve in my consultations is speaking really clearly. I find that’s important, particularly on video calls, and also giving the patient time to ask questions and because it’s normally a new thing for the patient as well as it is for us. We’re both still getting used to this setup. So giving the patient the opportunity to ask the questions.
By giving them that, I find it helpful because you can refer the patient to online resources, which may be useful after the consultations, like or NHS Choices, and asking good questions as well. So asking questions that you’re going to use the answer to aid your decision-making rather than just asking random questions or questions which don’t give you much information. I find that’s a really good skill to try and develop when you’re operating on remote consultations.
I must admit I use a mixture of consultation models. What I’ve found is when performing telephone or video consultations is– using the Calgary-Cambridge model isn’t really that practical because there’s like 71 different points in the Calgary-Cambridge model. And to do that over the phone or by video can be quite difficult. So depending on lots of different factors, the patient themself, say any– if the patient is elderly or has any communication impairments, I try to use a different selection of ls.
So I do use aspects of Pendleton’s model and I find that’s quite useful because that helps me to draw out, quite early on in the consultation, what the initial problems are and what the main issue is for the patient during the consultation. And also, it incorporates the ideas, concerns, and expectation theory, which is an important part of the consultation. And you mentioned about the Neighbour model as well. I do use aspects of that model, so I think it’s really good.
A feature which I use is to summarise a lot during the consultation, so I find by summarising you just– you’re gathering your thoughts and you’re just giving yourself a minute to think about where the consultations going and to help you start to form a diagnosis or management plan. Sometimes, as well, I find it quite good to summarise if you just– if the consultation is stalling slightly. So if you’re not quite sure where to go next or what to ask next, you can summarise and give you a time– give yourself some time to think and you can be right safe. It’s a video call, you can be writing notes as well while you’re summarising, which is quite useful.
And as well, when summarising, I think it helps and it’s a good opportunity for you to include empathy in the consultation. With the Neighbour model as well, it incorporates safety netting into the model, which safety net is always important. But particularly with telephone consultations and video conversations it’s even more important because you haven’t got the patient sat in front of you. You need a much– I find, a much lower threshold in terms of safety netting and advising the patient what to do if things don’t to improve.
So I would say, in summary, I try to use a mixture of Pendleton’s, Neighbour model, and a little bit Calgary-Cambridge, but I find it to– I think it would be too long to use a Cambridge-Calgary model solely.
Don’t forget to introduce yourself at the start. And always check that you’re actually speaking to the patient, who you’re expecting to speak to, for example, over the phone. Make sure that you’ve got a good environment, so if you’re offering video consultations ensure that people, whether it be in a GP surgery, know that you’re doing that and they’re not entering the room and disturbing you. And also, ask the patient to do that as well so they’re focused in on the consultation and you’re focused on them as well. The key thing that I’ve found is safety netting, really. It’s always important, but it’s hard, sometimes, over the phone or over video to judge how sick or how ill that particular patient is.
So that’s why safety netting is even more important then when they’re with you face-to-face. Booking follow-ups to make sure that there’s an improvement and there’s no further deterioration. And also, I would say trying to almost relax in the consultation as well because it is normally new for the patient, and it’s new– fairly new for the clinicians. And I know it’s not something we do an awful lot of, but trying to just relax and get used to using like the camera and also speaking to the patient by video link as well.

In this step we hear from an expert pharmacist practitioner talking about his experience conducting remote consultations. James Hammell is an experienced GP Practice Pharmacist. During the interview James talks about some of the challenges communicating with patients during a remote consultation and what he does to reduce those challenges. He goes on to discuss different consultation models and how he decides which model to use. James talks about risks with remote consultations throughout the video. As you watch, make notes on the risks that James identifies. Add these to your list of risks from the previous step.

You may also have thought of some other risks from your experience in practice that have not been identified by our experts. Add these risks to your list now.

You should now have a list of risks identified from the interviews with experts, and that you identified yourself. Consider what you could do to mitigate these risks.

Share your thoughts in the comments section below. When you have done that, try to respond to at least one other person’s comments.

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Conducting Remote Consultations and Triage

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