When virtual care falls short: GP’s telehealth caution

Telehealth consultations have transformed patient access and are now the norm for most doctors, but, as one GP member was reminded, the same professional standards must apply for virtual consultations as face-to-face appointments. This is particularly critical when seeing a new patient.

Video telehealth consultation

The GP conducted the telehealth consultation through a national mobile app service with a patient who was based interstate. Prior to the appointment, the patient was required to complete a health summary through the app, which included their personal details, medical history, current medications and presenting symptoms. The doctor was expected to review this before the consultation.

In the summary, the patient detailed she had undergone breast surgery, had asthma, allergies to latex and codeine, and was not taking any medications.

Before the consultation, the GP and patient exchanged messages via the chat function. The patient advised
the reason for her consultation was that she had gained 25kg in a year despite having a reasonably good diet
and exercising. The GP asked if she had seen a dietician. The patient said no but indicated that she ate well. After confirming her height and weight, the doctor calculated her BMI to be 30-31. 

Still via the chat function, with the information provided, the GP suggested she could try phentermine, an appetite suppressant medication. The patient looked up information on the medication and agreed to try it.

The GP then started the video telehealth consultation and discussed phentermine in more detail, explaining that
combined with a good diet, it could help reduce her BMI. He told her to take it for a few days to see how she tolerated it and provided one month’s supply with a starting dose of 30mg. He also advised the patient not to drink alcohol while taking the medication and strongly recommended she see a dietician.

Patient dissatisfied with treatment

The GP did not see the patient again but later received a complaint notification from Ahpra. The patient had
complained he did not perform a proper assessment, and she shouldn’t have been prescribed phentermine
due to her history of anxiety. She said her mental health suffered significantly after she took the medication and she experienced panic attacks, ruminating and obsessive paranoid thoughts. She also reported developing behavioural symptoms, including picking her skin and pulling her hair.

Ahpra acknowledged the patient’s dissatisfaction with the GP’s treatment and recognised the experience was
disappointing for her. The regulator proposed a caution and mentoring conditions for unsatisfactory performance in relation to providing weight loss management, prescribing principles, communication and record keeping.

GP admits consultation was subpar

Avant helped the GP submit a written response to Ahpra. In the response, the GP admitted to being under a lot of
stress at the time of the consultation and acknowledged he didn’t conduct a thorough consultation as he would
usually do.

The GP apologised for the extreme anxiety the patient experienced due to the medication. However, he said she
didn’t disclose her history of anxiety, and if she had, he would not have prescribed phentermine.

In consultation with Avant, the member agreed to reflect on his practice and proactively complete 8 hours of education on weight loss management, prescribing principles relating to weight loss, communication and record-keeping.

Ahpra’s decision

The regulator found the GP’s performance during the telehealth consultation fell below the expected standard
and was unsatisfactory because:

• He failed to take the patient’s full medical history.
• He didn’t make any arrangements or follow up in relation to the patient seeing a dietician.
• The messages between him and the patient were brief, and he didn’t perform a complete assessment before deciding a prescription for phentermine was appropriate. Instead, this was suggested as the first line of management and no other options were explored.
• There was a lack of any medical records. 

Ahpra cautioned the GP and imposed conditions on his registration for 6 months. This required him to undertake mentoring on comprehensive patient assessment and communication. 

Key lessons

The most important takeaway is when you are conducting a telehealth consultation you must adhere to the same standards as conducting a face-to-face consultation.

You are required to keep an appropriate record of the consultation. If the telehealth platform does not allow you to save your notes or messages with your patient via the chat function to the medical record, ensure you document the consultation in a separate patient record.

If you are seeing a patient for the first time, and don’t have access to their medical records, ensure you take a full medical history and probe for more information before offering treatment options. The RACGP's Guidance for appropriate use of telephone and video consultations in general practice require you to communicate with your patient to ensure the proposed treatment is not contraindicated. This is particularly important when conducting telehealth consultations where you have no prior knowledge or understanding of the patient’s condition(s) and medical history, or access to their medical records.

When considering prescribing a medication, ensure your patient has no contraindications, is aware of the side effects, and that you advise them of any alternatives.

You should recommend that the patient follow up with their usual GP with a face-to-face consultation to co-ordinate ongoing management of their condition, including further prescriptions that may be needed. If a referral to an allied healthcare professional is appropriate, the GP may also facilitate access to a local health service.

Finally, remember the Medicare Benefits Scheme item numbers define telehealth consultations as
involving an audio and/or video link, not online chat consultations.

Avant resource: Telehealth consultation checklist for doctors - Avant