The telephone is a form of technology that affects every area of life in
the United States, including health care. Indeed, the telephone has become
so embedded in our daily lives that we hardly think of it as technology any
more; it has taken its place in the natural order of contemporary reality.
Introduced in 1876, the telephone revolutionized medical practice by
providing a communication link between doctor and patient that was not
restricted to the physical boundaries of the hospital(1). In recent years,
beeper paging systems and telephone answering devices have augmented the
Opportunities for doctor-patient communication by eliminating many of the
limits imposed by time as well as space.
Communications technology has proved to be enormously valuable for
treatment and consultation, especially in emergency situations. In making
it possible to practice medicine at a distance, however, the telephone and
its more recent companions pose certain dangers, since they alter not only
the physical location of the physician in relation to the patient but also
that which the physician actually sees and hears of the patient. Willett
(2) points out that the use of the telephone in medical practice brings
with it a special potential for malpractice liability:
Those instances where physicians have treated a disembodied voice they couldn't identify as a patient more often seem to wind up in courts. The fact that there was no opportunity to establish the physician-patient rapport that discourages suits may contribute, but it seems more likely that physicians simply are not successful in coming to the right decisions in a telephone transaction if the patient is a relative stranger.
The use of technology in medical communications has radically altered the
physician-patient dialogue and, consequently, the process of medical
decision making. With "long-distance" medicine, even the issue of when and
where treatment begins becomes confused. Since the duty of care is the
cornerstone of liability, it is important to determine exactly when such a
duty is established. At what point does the physician talking on the
telephone assume clinical responsibility for the patient on the other end
of the wire?
When a physician offers professional services to another individual, he or
she has instigated a relationship with that person as a patient and a
resultant duty of care (3, 4). This relationship has commonly been
understood to evolve from face-to-face communication; however, malpractice
case law has established a broader arena in which the interaction may be
initiated. In O'Neill v Montefiore Hospital, a malpractice action was
brought against an emergency room doctor who offered advice to a patient
over the telephone (5). The doctor, who had never met or examined the
patient, was held potentially liable as a result of that telephone
conversation. The court held that a duty of care had been established by
the single call. This case suggests that physicians risk establishing a
duty of care when they offer professional advice over the telephone to
unseen patients.
The case of Ms. Adams, presented in Chapter 1, illustrates some of the
complex issues underlying the use of the telephone in psychiatric practice.
The story begins with Ms. Adams' call to her therapist, Dr. Olsen, and the
events that unfold are framed by a series of telephone conversations. As
the case clearly demonstrates, the concepts of "relationship" and
"dialogue" become much more complex when the face-to-face therapeutic
encounter gives way to other modes of communication.
The initial questions that arise in the Adams case center on the ambiguity
of the patient's call to Dr. Olsen. What did she expect from that call? How
did she react to his referral? Some authors maintain that the telephone is
indispensable for the follow-up of patients recently released from the
hospital and for patients, like Ms. Adams, who are in crisis (6, 7).
Ambivalent patients, communicating with the therapist by telephone rather
than in person, can experience a sense of simultaneous closeness and
distance. Yet, as a result of the immediate availability and intrusiveness
of telephone contact (versus contact during a scheduled therapy hour), the
telephone may be abused, especially by impulsive, demanding, anxious, and
overly dependent patients. The therapist may struggle with an increasing
sense of responsibility because of the patient's expectation that care will
be provided immediately at any time and at any distance. Thus, the
therapist faces a loss of control over the therapy (8).
The answering machine offers a partial solution to this problem, since it
can be used as a screening device to control the access afforded by the
telephone. The answering machine is a "socially correct" way for the
physician to limit his or her accessibility while remaining potentially
available for communication. The caller can communicate by leaving a
message on the machine, and the therapist can decide when (or whether) to
respond to the message, that is, when to be available for more direct,
reciprocal communication.
Dr. Olsen recognizes his patient's acute distress, even over the telephone,
and refers her to a local psychiatric emergency service for evaluation. The
factors underlying his decision to refer her are not clear. Aside from his
impending departure for vacation, perhaps the telephone communication with
his patient affords Dr. Olsen a measure of emotional distance that would be
difficult to sustain during an office visit. This double remove-physical
and emotional-may allow him to refer her elsewhere. Of course, Dr. Olsen
may also feel that his patient needs an immediate evaluation, which he, at
that time, simply cannot provide. Still, by talking with Ms. Adams on the
telephone and referring her to the clinic rather than seeing her, can Dr.
Olsen be considered potentially negligent in his care of the patient?
Dr. Olsen elects not to call the emergency service in advance to notify
them of the referral. Fortunately, the patient arrives, unannounced but
safe. Dr. Newell calls Dr. Olsen to clarify the referral and obtain further
information. In examining the role of this telephone communication in the
evaluation of Ms. Adams, several questions arise: what information about
his patient does Dr. Olsen convey to the resident, what information does he
omit, and what information does Dr. Newell actually take in? "Oral
communications without the advantage of eye-to-eye contact are subject to
misunderstandings at both ends of the conversation. Feedback assures that
the message is being received and understood, but it is more difficult to
obtain over the telephone" (9).
Initially, Dr. Newell has several thoughts in response to the referral from
Dr. Olsen. He speculates that Dr. Olsen, feeling that he is abandoning his
patient, may have overreacted to her distress. Of course, such speculation
may simply be the reaction of an overworked resident, irritated that his
rest is being interrupted by an "emergency." It is also possible that Dr.
Olsen, who has not seen Ms. Adams, is relieved to hand over responsibility
for this troublesome patient by means of a single, simple telephone
conversation. Finally, perhaps Dr. Olsen believes that an independent
evaluation, available in an emergency setting, is more appropriate for his
patient, since she seems to be in crisis. Nevertheless, Dr. Olsen describes
his patient as a moderate suicide risk, adding that she is manipulative and
has used threats of suicide to control the behavior of others. This
telephone referral, without benefit of face-to-face communication, leaves
the ambiguity and uncertainty of the current crisis in the hands of the
resident.
In the third phone call mentioned in the case, the first call to Dr.
Gottlieb, the resident expresses his concern that Ms. Adams may be
suicidal. Dr. Newell presents the facts of the case, his evaluation, and
the decision points; Dr. Gottlieb listens and inquires about the resident's
confidence in the information he has gathered and in his assessment.
Notably absent from the telephone call is a discussion of the abundant
subjective data available. The patient is described in the case as "pale
and drawn... in some disarray... manifestly depressed, tearful."
Consideration of appearance and behavior, both initially and in subsequent
assessments, is essential in evaluating a patient's ability to recompensate
in the course of a crisis intervention. Visual cues also form a vital part
of any dialogue between therapist and patient. Yet such subjective,
impressionistic information is not included in the telephone consultation
between Drs. Newell and Gottlieb. Of course, similar sensory data are
missing from Dr. Gottlieb's experience of Dr. Newell. In the course of
face-to-face supervisory meetings, supervisees commonly transmit a wealth
of data, of direct clinical relevance to the patient, by their manner in
the room."
Can subjective information be conveyed as clearly over the telephone as it
is experienced in the room with the patient (or with the supervisee)?
Perhaps it can, but only if the two parties to the discussion adjust their
habits of reporting, listening, and responding. Both must "learn to
compensate for the loss of these stimuli by increasing their sensitivity to
minor auditory cues, much as the blind man does when he learns to 'see with
his ears' "(7). They must be alert to silences, pauses, rhythms, and
intonations-the verbal and nonverbal representations of visual cues. In
the psychiatric setting, critical information is conveyed not only by what
is said and not said but also by the nuances-the feel-of the spoken or
unspoken message. One must find new ways to communicate such impressions,
visual and otherwise, when using the telephone for consultation.
The heuristics of decision making change as the selective perceptions of
observer and consultant are further filtered by the telephone, making them
more vulnerable to the biases of recency, availability, and locus of
control (see the discussion in Chapter 3). By consulting at a technological
distance, Dr. Gottlieb assumes the risks inherent in evaluating not only an
unseen patient but an unwitnessed transaction between the patient and the
therapist. The patient seen by Dr. Newell is not exactly the same as the
patient imagined by Dr. Gottlieb, no matter how conscientious the resident
is in presenting the case over the telephone. Moreover, since the
consultation involves two calls, two "versions" of the patient are described
and imagined, respectively. In the interval between those two calls the
image of the patient may become blurred in the supervisor's mind, so that
the second call conjures up a second image, which may replace rather than
augment the first. Of course, these problems are inherent in face-to-face
consultations as well, but the telephone adds another complex dimension.
In the fourth telephone call described in the case, Dr. Newell attempts to
draw Mr. Adams into the orbit of his wife's crisis; however, this
communication has the opposite effect: inviting the husband's rejection of
his wife. Like Drs. Olsen and Gottlieb, Mr. Adams is physically removed
from the scene of his wife's distress, and the telephone helps him maintain
an emotional distance as well. His detachment from the experience may even
play a role in the guilt and projective blaming that ultimately result in a
lawsuit.
Some authors have found the telephone to be very helpful in the emergency
setting, especially when the patient is able, by making a telephone call,
to contact someone important to the immediate crisis (6, 10). Even they,
however, caution that the telephone reinforces dyadic forms of
communication. In the Adams case, for example, interventions and
interpretations occur in the context of a series of two-person telephone
calls: Ms. Adams-Dr. Olsen, Dr. Olsen-Dr. Newell, Dr. Newell-Dr. Gottlieb,
Dr. Newell-Mr. Adams, and so forth. Such paired interactions make it
difficult for the therapist to assess the roles and relative significance
of various individuals within a complex interactional system.
As a result of the call to Mr. Adams, the patient appears "crestfallen ...
more tearful... and perceptibly angry." This description provides
information that is vital to the ongoing evaluation. The patient's
response, conveyed in visual and behavioral changes, could, of course, be
consistent with a failed manipulation. Yet whatever those changes might
signify, they are lost to Dr. Gottlieb and Mr. Adams, since neither is on
the scene.
Technological mediation tends to minimize the perceived risks in any
evaluation and decision-making process (1). The telephone, much like a
mechanical translator, may have filtered out important subjective and
affective information about Ms. Adams, even while conveying objective data
relatively intact (11). In fact, the muted affect that is common in
depression has been shown to be the most difficult to evaluate effectively
over the telephone, and anxiety the easiest (6). In addition, "a
spontaneous neutralization of affect is an effect of reporting, from the
patient to the therapist to the supervisor. Thus, a supervisor's evaluation
of the patient's affect is likely to be a diluted version of what was
actually expressed in the interview" (12). Hence, the consultant must be
particularly alert to the possibility that a sense of clinical urgency has
been lost over the telephone line.
Dr. Gottlieb concludes that the case presented by the resident is "clear
and free of ambiguity." Has she reminded herself that even a "good observer
and a candid reporter" (her expressed view of the resident) is subject to
his own conscious and unconscious mediation, which is further complicated
by the filtering effect of the telephone? The selectivity of the resident's
presentation is not necessarily negative and, in fact, is an important
element in the process of supervision (13). "The model of supervision which
uses reports given by the interviewer assumes that while therapists exhibit
varied reactions to the material of the interview, observation by the
supervisor of both the interviewer's reporting style and manner and the
patient's material will yield the essence of the patient's difficulties"
(12). However, the subjective cues by which the supervisor indirectly
"observes" the patient within and through the supervisee are difficult to
elicit over the telephone. The loss of the "ordinary counterplay of
messages in which a person reinforces what he is saying verbally through
his body language, or perhaps contradicts his verbal statement, thus giving
a mixed message," increases the risk that faulty heuristics will guide the
decision-making process (6). Subjective data simply do not stand up well to
technological translation.
Direct, face-to-face communication between supervisor and trainee is also
vital to the process of learning in psychiatry and medicine in general.
Such an opportunity for growth is regularly afforded the resident and the
supervisor in traditional supervisory settings and in early-morning rounds
following a night on call:
. . .the therapist, in presenting the material, unconsciously shift[s] his role from reporting the data of his experience with the patient to "experiencing" the experience of the patient. That is to say, during the supervisory session, one [can] see evidence of a transient identification of the student with his patient. . . . In therapy the patient oscillates between experiencing and reporting while the therapist oscillates between identifying with the patient and observing him. During supervision the therapist recapitulates this oscillation of role. (13)
Such a vivid representation of the patient within the therapist fades over
the telephone. Since consultation at a distance affords no direct
interaction between the consultant and either the patient or the therapist,
the telephone transforms an otherwise dynamic system of continuous
monitoring of affects, effects, modifications, adjustments, realignments,
feedback, and spontaneous corrections involved in the patient-therapist
dialogue (6). The patient, the therapist, and the consultant are poorer for
this transformation.
A further complication of telephone consultation is the therapist's own
potential for minimizing dangerousness, as a result of a
countertransference reaction to an emergency or to a particular patient
(15, 16). A novice clinician-harried, frightened, tired, or even determined
to achieve a rescue-may approach a patient in crisis with an agenda that
has little to do with the patient. Such preconceptions may or may not be
conscious and accessible for examination during the decision-making process.
Dr. Newell's initial assessment of Ms. Adams reveals his uncertainty about
the risk of suicide and the need for hospitalization; the subsequent
telephone consultation with Dr. Gottlieb seems to dispel that uncertainty.
One can speculate that the resident's wish to avoid "not knowing" may
magnify the certainty and omniscience that he attributes to the senior
staff member (17). The desire to escape uncertainty-and associated feelings
of inadequacy-can result in a premature closure of the consultation process
(13, 17). Consultation by telephone aids this escape. Since the supervisor
is not present, the resident has little opportunity to exchange his
idealization of her for identification. Over the telephone, the supervisor
remains the expert who is certain how to proceed rather than a therapist
who can tolerate uncertainty and with whom the resident can identify (17,
18). In fact, the "phantom" nature of the consultation increases the
illusion of omniscience and omnipotence by casting the supervisor as
someone who can know and make decisions about a patient without having to
be present.
During the suicide "autopsy," technological mediation is notably absent.
The resident and supervisor now meet face to face to engage in dialogue.
Dr. Gottlieb, while retaining the authority of her position, persistently
transfers back to the resident all introspective responsibility for the
suicide. She does not discuss her part in the decision making, nor does she
acknowledge her own uncertainty or her feelings about the outcome of their
decisions. Just as technology may have allowed the consultant to distance
herself emotionally from both the patient and the supervisee, it may have
shielded her from recognizing her own vulnerability to uncertainty.
Perhaps in an effort to be supportive, Dr. Gottlieb dissects the suicide
note, placing a disproportionate emphasis on modality and hidden meanings.
She tries to second-guess the nature of the suicide and argues that "the
woman who overdosed may not have been the same woman you saw." However, in
her attempt to reassure the resident, she unwittingly states precisely the
difficulty with telephone consultation. Just as the patient who eventually
killed herself may not have been the same patient Dr. Newell released from
the emergency room, the patient Dr. Gottlieb imagined that night may not
have been the same patient Dr. Newell saw or thought he presented to Dr.
Gottlieb.
The resident uses the "autopsy" to question whether there was anything that
he might have done differently. Among other issues, he must decide whether
he conveyed to Dr. Gottlieb the important subjective nuances of the
interview with Ms. Adams, as well as the important objective data. A woman
with whom he believed he had made a mutually formed treatment decision has
died, perhaps as a result of that decision-at least, so the plaintiffs
attorney would argue. The resident agonizes over what went wrong.
No one was clearly in error in this case, perhaps not even the patient.
Both Dr. Newell and Dr. Gottlieb appeared to act purposefully in making
careful decisions, all the while weighing the risks and benefits of various
choices. Yet the error, if there is any, may lie in their failure to
acknowledge the importance of direct dialogue between patient and
physician, and the value of subjective data thus obtained. Mutuality,
dialogue and a full consideration of subjective data are compromised by the
use of the telephone. Dr. Newell expresses vividly the dilemma of
technological medicine and the process of consultation at a distance. Asked
how it felt to be in the room with the patient, he answers, "I guess I
liked the way she seemed so real in the office, you know, really present,
right on the scene." That is, of course, precisely the problem:
Dr. Gottlieb did not and could not know the patient in this way.
The growing dependence on all types of technology in medicine has created a
buffer between patient and physician. Each patient has a personal
experience of his or her illness, which can best be elucidated by a direct
personal interaction. A therapeutic alliance and treatment collaboration
can be achieved only in the context of shared experience. While the beeper,
the telephone, the computer and all the other technological tools in the
medical armamentarium often enhance our ability to diagnose and even treat
patients more efficiently, they also may deprive us of the personal
experience of simply talking, face to face, with patients and allowing them
to talk to us. Technology, while radically changing our understanding of
the therapeutic relationship, has also dramatically increased the potential
for misplacing the person within a maze of data, wires, and microchips.
Unfortunately, if we lose touch with the patient in the therapeutic
relationship, we exponentially increase the risk of discovering that
patient in the courtroom.
REFERENCES