The Telephone Consultation (TC) in the pain unit

Non-facetoface consultations , due to current life circumstances and favored today by many different technical means, are gaining wide popularity. But in addition, the conditions imposed by the current pandemic have contributed to speeding up the use of the various means of communication at our disposal : fixed and mobile telephony, short messages, e-mail ... etc. New technologies are bringing improvements in communication between doctor and patient [1]. The consultations by telemedicine have been satisfactory for the patients and the investment of time less than with the face-to-face consultation [2]. The increasing expansion of these methods should lead to the inclusion of appropriate computer skills in the studies of medical schools in order to adequately respond to the reality of new information and communication techniques [3,4].

The use of telephone communication for non-face-to-face consultation is still valid [6] and even more so with the possibilities of mobile telephony and the addition of video calls. The telephone, invented in 1876, was introduced in the 1960s as a means of contact for patients with the doctor [7].
For the assistance of the pain clinic, the use of the telephone as a means of non-face-to-face consultation contains some peculiarities that give it special interest: 1. It is a synchronous medium. When communicating, the patient confirms that he is being listened to at that time, which is of interest to most calls from this class of patients. The patient is more likely that the anxiety that accompanies certain entity pains can be attenuated in the course of the conversation. In addition, direct conversation allows the patient to request the necessary explanations and clarifications. Therefore, this type of communication would be more advantageous than asynchronous ones, such as email. However, no means excludes others and the advantages of one and the other can be used.
2. Telephone communication is based on the story. But precisely in the case of pain consultation, the anamnesis is always what the patient feels and tells us. For other specialties the transmission, for example, of images is of great importance in the out-of-person consultation, as in the case of the specialty of Dermatology, in which the patient may sometimes show a skin lesion and this image may be the key to all the query. In any case, the video-conference may add the image to the phone and allow access to the image of the patient who speaks to us.
3. On the other hand, the telephone is a well-known and usual medium, especially among the elderly, and this circumstance favors communication.
The use of the telephone route, already common in our pain units, makes it interesting to update it, and more so in this time of increasingly widespread use of the non-face-to-face consultations.

Work plan for TC
Space and time for TC Space for TC: We need usually a) a place to exercise comfortably the calls telephone and in the that have easy access to e-Clínical history. It should be noted, however, that flexible criteria are usually followed for the non-face-to-face consultations, allowing them to be carried out in different spaces and not necessarily in the workplace. b) We must also have a call control place, admission and area to deposit reports for the patient.

Time for TC:
The time we spend on calls is the other component of our work. With experience in each specialty, the time usually necessary for TC can be calculated . We must also devote for the entire sector calls a schedule that can be at the beginning of the day, at the end (which is less desirable) and even spread throughout the day interspersed between face-to-face consultation. Obviously, this time spent on CT must be respected by everyone (both team staff and patients).

Preparation of the TC
Preparation on the diary. This diary will include two groups of citations: a) Citations for requests for consultation by the Patient. b) Appointments scheduled by members of the health team.

Preparation on the Clinical History:
a) The data of the patient: The name, surname , age and sex are mandatory data in every interview, but that in TC acquire special relevance to ensure (without being present) the identity of the patient with whom we are going to talk.
The initial attitude should be to listen, encouraging the patient to complete his story if he was the one who requested the call. In the event that the call has been by our initiative, as soon as we communicate the reason, we will we will encourage him to tell us about his process and from time to time we can make a brief summary of what he is telling us (in order to convey that we learn correctly what he tells us).
When it is our responsibility to inform, be careful to explain clearly, using terms that the patient can understand. Structured and motivated information is better retained. Asking for his agreement with what we indicate and for us to repeat the indications and even it is convenient to instruct the patient to write the most important indications.
The final conversations should include warnings about possible undesirable developments or unexpected events, making clear where to go if necessary . That is, we leave as a "safety net" [6].

After TC
The recording of the interview must be done, just as in a face-toface consultation and therefore it is up to the end of the call to write a record of the conversation, indicating the most relevant data.
In any case, it will be noted if the patient is indicated for a new TC or face-to-face consultation, admission or referral to a certain specialist.

Advantages and problems of TC Advantages
During the last years the medical literature has been collecting opinions and data that show the advantages of introducing the nonface-to-face consultation in general and the TC in particular within the healthcare process [6,8,[13][14][15][16][17][18]. We can summarize the advantages indicated for TC in the following relationship: d) It is not necessary for the professional to make the consultation from the workplace, as it can be done from another place, always having access to the patient's medical history. e) With the TC it is possible to assess the need or not for face-to-face consultation f) In the case of a video call, the behavior regarding communication between patient and doctor tends to be similar to that of the faceto-face consultation (6) ; apart from the fact that in this case it is already possible to appreciate postures, movements, various reactions and attitudes, skin coloration or request that it show us some visible alteration and that may be of interest ... etc.
b) The data on the disease and its treatment: It should be reviewed among other data the type of pain (neuropathic, mechanical ...), disease causing pain, associated pathologies , previous and current pain treatments and other treatments carried out by the patient.

Reason for the consultation
It is related to the various kinds of non-contact consultation already described by other authors [6,8]. In the specific case of TC in which we are centered, we establish two groups: with the request by the doctor and the consultation requested by the Patient.

Consultation requested by the doctor and / or health team:
a. Chronicles Consultation, which is usually focused on asking about the evolution, indication of a change in the dose of any medication, reporting any news about the patient's process or about its treatment. You can be part of these queries the guidance on web pages, social networks (Instagram, Face book, etc.), information on services and public resources, that they come from reliable sources, such as health institutions or scientifics societies or documents generated in the consultation [9][10][11][12]. We usually offer a program on Instagram that we update a group provided itself of specialists and in which we are notifying news regarding knowledge about pain and advances in its treatment.
b. The notification of complementary tests is another frequent reason for calling. Among them, those that reveal normal results in many cases may obviate face-to-face consultations.
c. Administrative indications : It should be borne in mind that the administrative personnel in our service collaborate in many aspects related to the evolution of the patients and the indications of one and the other occur in the context of this collaboration. The administrative indication normally depend on the evolution of the disease and characteristics of the patient, so we include this group in consultations requested by the team of health.
Before the consultation it will be interesting to write down questions regarding information that we want to obtain and that we want to provide to the patient and that we believe are relevant, so that we do not forget them [6].

Consultation requested by the patient:
a. uncontrolled pain: This is usually the most common reason for c onsultation. In these cases, it is initially required to specify if the pain is treated with our means in the pain unit and the reason for the consultation or is some other discomfort or new-onset symptom or possible side effects of medications or feeling of general discomfort to which the patient wants to refer.
b. Questions about pain or treatments that may have been pending or forgotten in the previous consultation or that simply respond to the patient's curiosity.
c. Information on health episodes in the time elapsed since the previous consultation, for example, a visit to the specialist or the emergency department for various reasons ... etc. That is, it deals with information that the patient wishes to supply us.

Realization of the interview
It is always necessary to make our presentation at the beginning of the telephone conversation, while making sure of the identity of our interlocutor.
g) The number of people attending the health center can be reduced by the TC and finally, there could be more time for face-to-face consultations.

TC problems:
Naturally, like any healthcare procedure the TC and their problems should consider us a lot and have been pointing out in recent publications [14,19,20]. They would be the following: Privacy Setting is fundamental issue in all clinical interview (faceto-face or non-face-to-face consultation) and also the patient must be sure of it, because as we know, the doctor-patient relationship is based on trust and confidentiality is a pillar of trust [5].
Disregarding the image of the person, their attitudes, gestures and reactions supposes a limitation in the relationship and a need for the doctor to increase empathy. The possibility of adding the image in the case of a video call would reduce this problem. On the other hand, it is also true that the patient who is called usually perceives the call as a sign of interest by professionals, who think about him, despite the physical distance and this facilitates empathy.
The doctor must be very aware of the clarity of his messages and it is even convenient to request in the course of the conversation that the patient tell him what he has understood.
It should also be borne in mind that some professionals are not comfortable with this type of communication, which could be a problem in some work centers.
During the initial time of starting non-face-to-face consultations, more time is usually invested in the new procedure. Although a decrease in the time invested in the interview is expected from the TC, occasionally the telephone consultation may consume more time than is desirable. It is precise in this sense carry out studies that assess the result in terms of time Invested.
Advantages and problems of TC among professionals: The TC among professionals could be useful to save time for diagnosis and treatment and to avoid in some cases the referral and displacement of the patient; although it would be convenient to establish criteria to determine the utility and appropriateness of the consultations, as has already been proposed for all electronic consultations [21].

Conclusión
In summary, we believe that TC with its advantages and disadvantages and problems is a useful means of communication, very important to some cases and it brings possibility improve empathy with the patient. It is essential that it is always properly used, complementing the face-to-face consultation.