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
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.