Communication challenges can generate common and in some cases serious errors in clinical case management by telephone. The paucity of training in telephone medicine in residency programs may be a significant contributor to telephone communication errors. Although 25% of interactions between physicians and patients occur on the telephone, only 6% of residency programs teach telephone medicine.20,21
Textbooks, books of protocols, and review articles designed for internists exist but are not widely available to residents and physicians.22–25
Physicians in practice and in training can benefit from regular review of telephone cases, both for educational purposes and for making practice policies.25
Case vignettes such as those presented here can formulate part of a curriculum either in telephone medicine or in medical errors. A brief curriculum for residents in telephone error prevention might include discussion of typical and challenging cases such as those described in this manuscript, with a focus on identifying specific individual and systems approaches that could reduce or prevent such errors.26
Audiotaped vignettes are excellent triggers for discussion. In our experience, residents are enthusiastic about case-based discussions of errors in clinical management by telephone and vignettes frequently prompt discussions about key issues. Simulations of medical events with scripted dialogue (in which participants read the script aloud and then discuss it) have also been described as an effective mode of teaching about patient safety. Simulations minimize emotional threats to trainees and serve as a comprehensible and engaging means of addressing systems issues.27
A curriculum in telephone error prevention could be evaluated using standardized patients in an objective structured clinical examination.28
For practicing physicians, continuing medical education courses on patient safety might be expanded to include telephone cases such as those presented in this paper.
Asynchronous communication using technologies such as e-mail, web-based communication, and telemedicine is becoming increasingly popular between physicians and patients.29
Some principles discussed here, such as how and when to notify patients of significant test results to ensure confidentiality and avoid excess stress, are relevant to e-mail and web-based communication, as are establishing standard practice policies for prescribing controlled medications outside the office visit.
In other situations, what works on the phone may not fit into the framework of other non face-to-face technologies. With e-mail, for example, clues to a patient's emotion that might be uncovered through careful listening are unavailable. The asynchronous nature of e-mail and web-based communication makes it difficult to follow the evolution of an acute illness over a short period of time.
In addition to preventing management errors, good doctor-patient communication has been associated with many other clinically significant benefits, including enhanced diagnostic accuracy30,31
and improved patient satisfaction,32
whereas poor communication has been associated with increased risk of malpractice lawsuits.33,34
Telephone communication will remain a major part of doctor-patient communication for the foreseeable future, despite the advances in other distance technologies. Recognizing and learning about communication challenges in telephone medicine is essential for good clinical practice.