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Journal of Genetic Counseling, Vol. 9, No. 1, 2000
Recommendations for Telephone Counseling Kelly E. Ormond,1,7,8 Jody Haun,2,7 Lola Cook,3,7 Debra Duquette,4,7 Carol Ludowese,5,7 and Anne L. Matthews6,7
Telephone counseling can provide a convenient, accessible, and valuable source of information to the general public, health care providers, and other professionals. In the genetic counseling profession, telephone counseling is often associated with teratogen information services. However, genetic counselors routinely utilize the telephone in a number of different counseling encounters. Nevertheless, the literature provides very little guidance to how that encounter might be conducted, what information should be obtained and provided, or how the encounter should be documented. We present a brief overview of the history of telephone counseling, a description of the major differences between telephone counseling and a faceto-face counseling session, and a framework to optimize a telephone counseling session. KEY WORDS: Telephone counseling; genetic counseling.
INTRODUCTION In its ideal, telephone counseling provides a clinical service to the public and professionals that is convenient, accessible, and educational, and that maximizes the availability of resources. Some genetic services can be provided over the 1 Department
of Obstetrics and Gynecology, Division of Genetics, and Illinois Teratogen Information Service, Northwestern University Medical School, Chicago, IL. 2 Clinical Genetics Center and Wisconsin Teratogen Project, University of Wisconsin, Madison, WI. 3 Indiana Teratogen Information Service, Department of Medical Genetics, Indiana University, Indianapolis, IN. 4 Butterworth Hospital Genetic Services, Grand Rapids, MI. 5 Hennepin County Medical Center, Minneapolis, MN. 6 Department of Genetics, Case Western Reserve University, Cleveland, OH. 7 Great Lakes Regional Genetics Group (GLARGG) Teratogen Subcommittee. 8 Correspondence should be directed to Kelly Ormond, 333 E Superior, Suite 1543, Chicago, IL 60611. 63 C 2000 National Society of Genetic Counselors, Inc. 1059-7700/00/0200-0063$18.00/1 °
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telephone to clients, nurses, physicians, and other professionals; these often deal with questions regarding a pregnancy, including teratogen inquiries, family history of a genetic disease, or genetic testing. While institutional policies may differ in the scope and depth with which these topics may or may not be covered on the telephone, genetic professionals traditionally have provided telephone counseling as a significant part of their clinical services. Regardless of specialization, all genetic counselors are likely to provide some genetic counseling by telephone. While the amount and exact use of the telephone for counseling may vary depending on one’s clinical focus, common features exist. The purpose of this article is to share the greater than 50 years combined experience of six counselors, much of which has focused on the provision of counseling services by telephone. Specifically, several authors have been involved in the coordination of telephone-based teratogen information services. The recommendations presented in this article are based on a combination of experience and the limited literature in other health professions on the provision of care by telephone. Historically, telephone counseling evolved from psychiatric services and medical triage experiences. In the late 1950s, crisis hotlines focusing primarily on suicide prevention began in both Europe and the United States and rapidly expanded (Hornblow, 1986). These hotlines, despite a lack of empirical evidence of their effectiveness, soon became an important part of community psychiatric services. Over the next decade, other medical providers followed suit, so that most major medical centers and private health care facilities now formally offer some form of telephone triage and counseling. Larger, more exclusively telephone-oriented services, such as poison control and teratogen information services, directly resulted from the early successes of these experiences. Robinson and colleagues (1997) suggested that up to 30% of primary medical care occurs by telephone, and anecdotal reports from genetic counselors suggest they spend a similar proportion of time providing genetic services via the telephone. Young’s (1993) survey of genetic counselors in New Jersey, Delaware, and West Virginia found that all of the counselors surveyed (N = 26) reported doing some counseling by phone. With increasing reliance on other forms of telecommunication, such as e-mail and the Internet, client contact outside office visits is likely to continue. However, despite the commonness of telephone counseling, there is little research on how best to provide it (Hornblow, 1986).
TELEPHONE VERSUS FACE-TO-FACE COUNSELING All of the skills described in the American Board of Genetic Counseling competencies (Fine et al., 1996) are relevant to telephone consultations. In fact, telephone counseling can be seen as an adaptation of the skills required in a more traditional face-to-face consultation. While there are broad differences between
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counseling in the office and counseling on the telephone, telephone counseling brings both advantages and disadvantages to the counseling encounter. A major advantage of telephone counseling is its significant convenience for the caller. The telephone allows access to a wider section of the public who would not, for geographic or socioeconomic reasons, otherwise have access to counseling services (Wheeler and Siebelt, 1997). Telephone contact with health care professionals may also decrease the number of unnecessary clinic visits and increase the number of appropriate referrals (Lester, 1995; Williams, 1995; Wheeler and Siebelt, 1997). Moreover, the immediacy of the communication, whether needed or not, is usually identified by the caller as a benefit (Coleman, 1997). A major difference between these two counseling approaches is in the specific nature of inquiries usually addressed by telephone. Traditionally, telephone inquires usually deal with issues that clients perceive as less complex or that involve lower degrees of risk. For example, a client may contact the genetic counselor to obtain more information about the discovery of a new cancer gene that was announced on the local news, or about an exposure to a drug or chemical during pregnancy. Additionally, many callers claim not to be the specific patient in question, but a friend or relative who calls with questions about concern for a family member or friend. The effect of the resultant anonymity of the caller is decreased intimacy, which may make contact less threatening (Furnham, 1982), particularly when the call is regarding a sensitive or embarrassing subject, such as substance abuse during a pregnancy or a history of a birth defect that is not readily discussed by the family. Furnham (1982) states that all communication methods use a combination of verbal, vocal, and visual cues and involve variations in the number of communicators, their physical proximity, and the immediacy of feedback. Clients may choose a specific type of encounter based on their perception of the importance of each of these factors. Because telephone counseling involves physical separation, one cannot rely on the physical and emotional cues (such as body language and facial expressions) that would normally be available in a “face-to-face” counseling session. This loss of visual cue intensifies reliance on verbal and vocal cues (Robinson et al., 1997). As a result, counselors must rely more on their listening and communications skills, including attention to specific wording and intonations. Because of the increased focus on verbal content, caution in phrasing is important, as is the use of unambiguous terms. Another major difference between the two scenarios is that clients may maintain more control throughout certain aspects of the telephone encounter. This is true in the timing of the call, the amount of noise and distractions, the pace of counseling, clients’ agenda, and the amount of information they provide, including their name (Lester, 1995). Moreover, the counselor is less likely to have written documentation to verify self-reported information. Without medical documentation,
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the counselor must rely totally on the information a caller provides and her or his responses to questions. This perceived lack of control in a telephone encounter may create a sense of frustration, particularly for less experienced counselors. Reimbursement for telephone consultations is another difference between face-to-face counseling and telephone counseling. Young (1993) reports that fewer than 25% of counselors bill clients for telephone counseling, and third-party reimbursement is poor. In an era of managed care, which emphasizes billable time, it remains debatable whether unbilled telephone consultations are a cost-effective use of the counselor’s time.
THE CALL Who and What Telephone callers may include a variety of individuals beyond a potential client, such as physicians, nurses, and other primary-care providers. Callers may also be professionals such as social workers and educators who are working with clients who have genetic conditions. Family members and friends may also utilize the telephone to obtain information and support. The types of information that callers typically seek include advice about a specific question, general information, referrals, psychological support, intervention, and crisis counseling (Edmonds, 1997). Young (1993) cites calls for prenatal procedure counseling, carrier screening, testing follow-up, and teratogen inquiries as the most common reasons for genetic counseling by telephone. When and Where When and where telephone calls are made vary. For example, a caller may seek information from a genetic counselor after learning she is pregnant and becoming concerned about a medication she took recently, or after reading the newest Ladies Home Journal article about a newly available genetic test. Anecdotally, callers use the telephone from home, work, the car, and their relative’s house—almost anywhere and in any setting. Many times, a call is made at a time when the client has limited time for a conversation; this places certain pressure on the counselor when providing counseling and information. It is obvious that some settings are less conducive to thoughtful interaction and discussion of the client’s concern. Clients can be encouraged to set aside a specific time for follow-up conversations to optimize the counseling interaction. In general, when conducting an assessment by telephone, the counselor needs to be sure to obtain enough information; this may take time, and it may be appropriate to conduct research and recontact the client in a timely manner (Wheeler
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and Siebelt, 1997). This is where genetic counseling via the telephone is different from “hotline”-based services, and this should be clarified with the client at the time. In our experience, most clients are comfortable with this approach if they understand that someone is aware of their concern and will recontact them. Regardless of its purpose, the telephone counseling call can be divided into four areas: intake, triage and assessment, relaying information, and follow-up: Each is discussed below. Intake The counselor must first get a general sense of the reason for the call (Wheeler and Siebelt, 1997). As in any clinic setting, following introductions, which may include identifying information regarding affiliation and title, the counselor can establish whether this is an appropriate time to talk. Obviously, the counselor will keep in mind that the client may not have set aside specific time for this encounter as he or she would have in a face-to-face counseling session. Because of the loss of many visual cues, it becomes more critical to use understandable language, and to ask the client to describe in detail the symptoms or concerns, moving from general to specific (Wheeler and Siebelt, 1997). Listening to understand, not interrupting, and providing opportunities for the client to elaborate, including open-ended questions, are useful techniques in obtaining relevant information. The counselor should try to identify the client’s prior knowledge (and its source), hidden agendas, and misconceptions. Avoid making premature judgments; stereotyping and second guessing can alienate clients (Wheeler and Siebelt, 1997). One challenge is to develop trust and rapport quickly with the client, as this influences the degree of information that clients provide (Dale, 1995; Wheeler and Siebelt, 1997). Counseling is best viewed if preceded by empathic discussion and questioning (Libow and Doty, 1976). The development of rapport may also influence the caller’s behavior and likelihood of follow-up (Fifield, 1996). While simply an introduction and presenting one’s credentials can develop much trust and rapport with the client, the counselor’s voice provides the first impression, just as physical appearance does in the clinic. The pace and tone of the counselor’s voice are important and can reassure the client of the counselor’s empathy and understanding. Specific demographic information should be obtained with any telephone consultation, regardless of type. This minimally includes the date and time of the call, caller name if provided, contact information (e.g., phone, address), the specific concerns and questions of the client, and the responses given by the counselor. As appropriate, one can obtain more specific information, such as pregnancy and family history, and specifics regarding the disease or exposure in question. Protocols may ensure the consistency and accuracy of the information obtained and provided (Robinson et al., 1997). Regardless of the use of protocols, questions should be similar in structure and content to those included in a clinic visit.
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Triage and Assessment After obtaining initial information from the caller, the counselor should assess the client’s agenda and the level of knowledge and concern regarding the situation. These factors, combined with the specific medical information, can then be used to determine if the caller’s concern can be addressed on the telephone or if it requires a clinic visit. While each institution has its own policy regarding telephone consultation, it may be particularly useful for the client to attend clinic when a high risk is ascertained, the information is complex or lengthy, the caller expresses significant anxiety, the level of caller understanding is unclear, or a review of medical records, a physical examination, or testing is necessary. People may be willing to be seen for a clinic visit or referral if its need is explained. If a client is unable to attend clinic, institutional policy and personal judgment can determine whether the information is appropriate to provide by telephone. However, when the counselor feels strongly that the caller should be seen in person, other referrals may be necessary, such as referring the client to the primary-care provider or another local health care provider, including genetic counselors. While there is no need to answer all questions at the time of the initial call, agreeing to answer the inquiry commits the counselor to following through. It may be appropriate to contract with the client to schedule a specific “appointment” time for a follow-up call that will be convenient and agreeable to both parties. Relaying Information When initiating a return call, confidentiality is essential. The counselor should first establish that this is an appropriate time to talk, and that the caller is in a private location, if possible. The counselor should avoid giving confidential information to a person who is not the consultand, or leaving messages on answering machines with identifying information. Again, since the counselor cannot see the caller, verbal and vocal cues are paramount. Information should be given slowly and should include pauses to assess the caller’s understanding and reactions. Use clear and simple terms, avoiding jargon. The counselor should strive to maintain a compassionate unhurried voice and avoid raising the inflection of words at the end of sentences. Avoid explicatives. Additionally, the counselor should be aware of background noises (typing, computer sounds, coworkers, nervous giggling, other extraneous noises). Filler words, such as um are much more noticeable on the telephone. As with any counseling session, summarize what is and is not known, including the quality of the supporting data. If documentation of the diagnosis is weak, phrasing should reflect this, such as “If the diagnosis is X, then the risk could be Y.” As always, continual reassessment of the client’s understanding and emotional status is important; repeat any unclear information.
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Because many callers are looking for reassurance (Fifield, 1996), and because of the difficulty in assessing emotional responses on the telephone, it is particularly important for the counselor to purposefully elicit such responses. The counselor might ask, “Is this what you were expecting to hear?” or “Are you more or less worried about this information now?” When appropriate, the counselor should make referrals to other support services. Finally, before concluding the call, the counselor should summarize the information briefly and reemphasize any followup that is necessary. The counselor should inform the client of his or her availability for further conversations as needed, and how best to reach him or her. Follow-Up Documentation of the telephone counseling encounter is analogous to the genetic counseling letter to the family. Documentation should occur immediately following the telephone encounter and should be recorded in a notebook or ledger; this should be kept in a centralized location, such as with other clinic charts. The counselor should document fully the information provided, including the spirit of how it was communicated. As with all legal documents, notations should be in ink and in legible handwriting. If necessary, use error, date, and initials to correct mistakes. Concise, concrete terminology is important, as is avoiding inappropriate or derogatory terms and abbreviations. Document questions asked, even when responses are negative (Coleman, 1997). All documentation should be signed and dated.
LEGAL ISSUES Legal liability associated with telephone counseling is a significant concern of genetic counselors (Young, 1993). First, counselors should remember that they are under no legal obligation to provide information by telephone (Henry, 1994). Once information is given, however, whether by telephone or in person, the counselor assumes a legal responsibility for the interaction with the client and the information provided (Robinson et al., 1997). At that time, any incomplete or incorrect information could be considered negligence (Henry, 1994). Robinson notes that “negligence is the most common reason for lawsuits in medical practice litigations” (Robinson et al., 1997, p. 180). However, negligence suits are based on a breach of the standard of care, and since there is a dearth of standards regarding telephone contacts, few lawsuits are on record. Regardless of the lack of standards, documentation is imperative to minimize liability (Henry, 1994). Many states require that these records be maintained for an average of 7–10 years (Robinson et al., 1997), but it is important to know one’s own institutional policies.
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ADDITIONAL APPLICATIONS With the increasing usage of electronic communication such as e-mail and the Internet, the above issues will become all the more germane. While these also provide anonymity and convenience, these new telecommunications occur without even vocal cues, forcing reliance solely on verbal communication. Kane and Sands (1998) suggest that e-mail is often used as a hybrid between letter writing and telephone contact as it provides spontaneity and permanence but also allows more detail in specific wording than a telephone contact might. There is, however, not necessarily any immediacy to this communication, or any interaction to determine the level of client understanding. Information is therefore limited to a simplistic communication and is without all the “counseling” and individualization that we associate with the genetic counseling process. While there are a few examples of the Internet as a counseling modality in health care (Pergament, 1998; Ormond et al., 1998), little information exists on its use in these settings. As telecommunication between clients and health care providers increases, it will be interesting to assess whether “counseling” can truly be performed via Internet communication. CONCLUSION Telephone counseling can provide a convenient, easily accessible, and valuable source of reliable, accurate information for the general public and health care professionals. In spite of the differences from face-to-face counseling encounters, telephone counseling relies on the same knowledge base and counseling skills that the genetic counselor brings to any clinical setting. If the genetic counselor is able to establish rapport with the telephone client and accurately assess the client’s problems and needs, he or she can offer reliable information and appropriate interventions to meet the client’s needs. The genetic counselor can also fill a valuable referral role by facilitating access to care for those requiring further intervention, such as face-to-face genetic counseling services.
REFERENCES Coleman A (1997) Where do I stand? Legal implications of telephone triage. J Clin Nursing 6:227– 231. Dale J, Crouch R, Patel A, Williams S (1997) Patients telephoning A&E for advice: A comparison of expectations and outcomes. J Accid Emerg Med 14:21–23. Dale J, Williams S (1995) Development of telephone advice in A & E: Establishing the views of the staff. Nursing Standard 9:28–31. Edmonds E (1997) Telephone triage: 5 years’ experience. Accid Emerg Nurs 5(1):8–13. Fifield M (1996) Telephone triage: Protocols for an unacknowledged practice. Aust J Adv Nursing 13:5–9.
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Fine BA, Baker DL, Fiddler MB and ABGC Consensus Development Consortium (1996) Practicebased competencies for accreditation of and training in graduate programs in genetic counseling. J Genet Couns 5:113–121. Furnham A (1982). The message, the context and the medium. Language and Communication 2:33–47. Henry PF (1994) Legal principles in providing telephone advice. Nurse Pract Forum 5:124–125. Hornblow AR (1986) The Evolution and effectiveness of telephone counseling services. Hospital and Community Psychiatry 37:731–733. Kane B, Sands DZ (1998) Guidelines for the clinical use of electronic mail with patients. JAMA 5:104–111. Lester D (1995) Counseling by telephone: Advantages and problems. Crisis Intervention 2:57–69. Libow JA, Doty DW (1976) An evaluation of empathic listening in telephone counseling. J Couns Psych 23:532–537. Ormond K, Fiddler M, Pergament E (1998) An Internet approach to teratogen counseling. Teratology 57:283. Pergament D (1998) Internet psychotherapy: Current status and future regulation. Health Matrix: J Law-Med 8:233–279 Robinson DL, Anderson MM, Erpenbeck PM (1997) Telephone advice: New solutions for old problems. Nurse Practitioner 22:179–192. Wheeler SH, Siebelt B (1997) Calling all nurses: How to perform telephone triage. Nursing 97 27:37– 41. Williams S, Crouch R, Dale J (1995) Providing health-care advice by telephone. Professional Nurse 10:750–752. Young T (1993) Issues in quality assurance explored: is telephone counseling an oxymoron? Perspectives Genet Couns 15:2–3.
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Recommendations for Telephone Counseling Kelly E. Ormond,1,7,8 Jody Haun,2,7 Lola Cook,3,7 Debra Duquette,4,7 Carol Ludowese,5,7 and Anne L. Matthews6,7
Telephone counseling can provide a convenient, accessible, and valuable source of information to the general public, health care providers, and other professionals. In the genetic counseling profession, telephone counseling is often associated with teratogen information services. However, genetic counselors routinely utilize the telephone in a number of different counseling encounters. Nevertheless, the literature provides very little guidance to how that encounter might be conducted, what information should be obtained and provided, or how the encounter should be documented. We present a brief overview of the history of telephone counseling, a description of the major differences between telephone counseling and a faceto-face counseling session, and a framework to optimize a telephone counseling session. KEY WORDS: Telephone counseling; genetic counseling.
INTRODUCTION In its ideal, telephone counseling provides a clinical service to the public and professionals that is convenient, accessible, and educational, and that maximizes the availability of resources. Some genetic services can be provided over the 1 Department
of Obstetrics and Gynecology, Division of Genetics, and Illinois Teratogen Information Service, Northwestern University Medical School, Chicago, IL. 2 Clinical Genetics Center and Wisconsin Teratogen Project, University of Wisconsin, Madison, WI. 3 Indiana Teratogen Information Service, Department of Medical Genetics, Indiana University, Indianapolis, IN. 4 Butterworth Hospital Genetic Services, Grand Rapids, MI. 5 Hennepin County Medical Center, Minneapolis, MN. 6 Department of Genetics, Case Western Reserve University, Cleveland, OH. 7 Great Lakes Regional Genetics Group (GLARGG) Teratogen Subcommittee. 8 Correspondence should be directed to Kelly Ormond, 333 E Superior, Suite 1543, Chicago, IL 60611. 63 C 2000 National Society of Genetic Counselors, Inc. 1059-7700/00/0200-0063$18.00/1 °
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telephone to clients, nurses, physicians, and other professionals; these often deal with questions regarding a pregnancy, including teratogen inquiries, family history of a genetic disease, or genetic testing. While institutional policies may differ in the scope and depth with which these topics may or may not be covered on the telephone, genetic professionals traditionally have provided telephone counseling as a significant part of their clinical services. Regardless of specialization, all genetic counselors are likely to provide some genetic counseling by telephone. While the amount and exact use of the telephone for counseling may vary depending on one’s clinical focus, common features exist. The purpose of this article is to share the greater than 50 years combined experience of six counselors, much of which has focused on the provision of counseling services by telephone. Specifically, several authors have been involved in the coordination of telephone-based teratogen information services. The recommendations presented in this article are based on a combination of experience and the limited literature in other health professions on the provision of care by telephone. Historically, telephone counseling evolved from psychiatric services and medical triage experiences. In the late 1950s, crisis hotlines focusing primarily on suicide prevention began in both Europe and the United States and rapidly expanded (Hornblow, 1986). These hotlines, despite a lack of empirical evidence of their effectiveness, soon became an important part of community psychiatric services. Over the next decade, other medical providers followed suit, so that most major medical centers and private health care facilities now formally offer some form of telephone triage and counseling. Larger, more exclusively telephone-oriented services, such as poison control and teratogen information services, directly resulted from the early successes of these experiences. Robinson and colleagues (1997) suggested that up to 30% of primary medical care occurs by telephone, and anecdotal reports from genetic counselors suggest they spend a similar proportion of time providing genetic services via the telephone. Young’s (1993) survey of genetic counselors in New Jersey, Delaware, and West Virginia found that all of the counselors surveyed (N = 26) reported doing some counseling by phone. With increasing reliance on other forms of telecommunication, such as e-mail and the Internet, client contact outside office visits is likely to continue. However, despite the commonness of telephone counseling, there is little research on how best to provide it (Hornblow, 1986).
TELEPHONE VERSUS FACE-TO-FACE COUNSELING All of the skills described in the American Board of Genetic Counseling competencies (Fine et al., 1996) are relevant to telephone consultations. In fact, telephone counseling can be seen as an adaptation of the skills required in a more traditional face-to-face consultation. While there are broad differences between
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counseling in the office and counseling on the telephone, telephone counseling brings both advantages and disadvantages to the counseling encounter. A major advantage of telephone counseling is its significant convenience for the caller. The telephone allows access to a wider section of the public who would not, for geographic or socioeconomic reasons, otherwise have access to counseling services (Wheeler and Siebelt, 1997). Telephone contact with health care professionals may also decrease the number of unnecessary clinic visits and increase the number of appropriate referrals (Lester, 1995; Williams, 1995; Wheeler and Siebelt, 1997). Moreover, the immediacy of the communication, whether needed or not, is usually identified by the caller as a benefit (Coleman, 1997). A major difference between these two counseling approaches is in the specific nature of inquiries usually addressed by telephone. Traditionally, telephone inquires usually deal with issues that clients perceive as less complex or that involve lower degrees of risk. For example, a client may contact the genetic counselor to obtain more information about the discovery of a new cancer gene that was announced on the local news, or about an exposure to a drug or chemical during pregnancy. Additionally, many callers claim not to be the specific patient in question, but a friend or relative who calls with questions about concern for a family member or friend. The effect of the resultant anonymity of the caller is decreased intimacy, which may make contact less threatening (Furnham, 1982), particularly when the call is regarding a sensitive or embarrassing subject, such as substance abuse during a pregnancy or a history of a birth defect that is not readily discussed by the family. Furnham (1982) states that all communication methods use a combination of verbal, vocal, and visual cues and involve variations in the number of communicators, their physical proximity, and the immediacy of feedback. Clients may choose a specific type of encounter based on their perception of the importance of each of these factors. Because telephone counseling involves physical separation, one cannot rely on the physical and emotional cues (such as body language and facial expressions) that would normally be available in a “face-to-face” counseling session. This loss of visual cue intensifies reliance on verbal and vocal cues (Robinson et al., 1997). As a result, counselors must rely more on their listening and communications skills, including attention to specific wording and intonations. Because of the increased focus on verbal content, caution in phrasing is important, as is the use of unambiguous terms. Another major difference between the two scenarios is that clients may maintain more control throughout certain aspects of the telephone encounter. This is true in the timing of the call, the amount of noise and distractions, the pace of counseling, clients’ agenda, and the amount of information they provide, including their name (Lester, 1995). Moreover, the counselor is less likely to have written documentation to verify self-reported information. Without medical documentation,
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the counselor must rely totally on the information a caller provides and her or his responses to questions. This perceived lack of control in a telephone encounter may create a sense of frustration, particularly for less experienced counselors. Reimbursement for telephone consultations is another difference between face-to-face counseling and telephone counseling. Young (1993) reports that fewer than 25% of counselors bill clients for telephone counseling, and third-party reimbursement is poor. In an era of managed care, which emphasizes billable time, it remains debatable whether unbilled telephone consultations are a cost-effective use of the counselor’s time.
THE CALL Who and What Telephone callers may include a variety of individuals beyond a potential client, such as physicians, nurses, and other primary-care providers. Callers may also be professionals such as social workers and educators who are working with clients who have genetic conditions. Family members and friends may also utilize the telephone to obtain information and support. The types of information that callers typically seek include advice about a specific question, general information, referrals, psychological support, intervention, and crisis counseling (Edmonds, 1997). Young (1993) cites calls for prenatal procedure counseling, carrier screening, testing follow-up, and teratogen inquiries as the most common reasons for genetic counseling by telephone. When and Where When and where telephone calls are made vary. For example, a caller may seek information from a genetic counselor after learning she is pregnant and becoming concerned about a medication she took recently, or after reading the newest Ladies Home Journal article about a newly available genetic test. Anecdotally, callers use the telephone from home, work, the car, and their relative’s house—almost anywhere and in any setting. Many times, a call is made at a time when the client has limited time for a conversation; this places certain pressure on the counselor when providing counseling and information. It is obvious that some settings are less conducive to thoughtful interaction and discussion of the client’s concern. Clients can be encouraged to set aside a specific time for follow-up conversations to optimize the counseling interaction. In general, when conducting an assessment by telephone, the counselor needs to be sure to obtain enough information; this may take time, and it may be appropriate to conduct research and recontact the client in a timely manner (Wheeler
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and Siebelt, 1997). This is where genetic counseling via the telephone is different from “hotline”-based services, and this should be clarified with the client at the time. In our experience, most clients are comfortable with this approach if they understand that someone is aware of their concern and will recontact them. Regardless of its purpose, the telephone counseling call can be divided into four areas: intake, triage and assessment, relaying information, and follow-up: Each is discussed below. Intake The counselor must first get a general sense of the reason for the call (Wheeler and Siebelt, 1997). As in any clinic setting, following introductions, which may include identifying information regarding affiliation and title, the counselor can establish whether this is an appropriate time to talk. Obviously, the counselor will keep in mind that the client may not have set aside specific time for this encounter as he or she would have in a face-to-face counseling session. Because of the loss of many visual cues, it becomes more critical to use understandable language, and to ask the client to describe in detail the symptoms or concerns, moving from general to specific (Wheeler and Siebelt, 1997). Listening to understand, not interrupting, and providing opportunities for the client to elaborate, including open-ended questions, are useful techniques in obtaining relevant information. The counselor should try to identify the client’s prior knowledge (and its source), hidden agendas, and misconceptions. Avoid making premature judgments; stereotyping and second guessing can alienate clients (Wheeler and Siebelt, 1997). One challenge is to develop trust and rapport quickly with the client, as this influences the degree of information that clients provide (Dale, 1995; Wheeler and Siebelt, 1997). Counseling is best viewed if preceded by empathic discussion and questioning (Libow and Doty, 1976). The development of rapport may also influence the caller’s behavior and likelihood of follow-up (Fifield, 1996). While simply an introduction and presenting one’s credentials can develop much trust and rapport with the client, the counselor’s voice provides the first impression, just as physical appearance does in the clinic. The pace and tone of the counselor’s voice are important and can reassure the client of the counselor’s empathy and understanding. Specific demographic information should be obtained with any telephone consultation, regardless of type. This minimally includes the date and time of the call, caller name if provided, contact information (e.g., phone, address), the specific concerns and questions of the client, and the responses given by the counselor. As appropriate, one can obtain more specific information, such as pregnancy and family history, and specifics regarding the disease or exposure in question. Protocols may ensure the consistency and accuracy of the information obtained and provided (Robinson et al., 1997). Regardless of the use of protocols, questions should be similar in structure and content to those included in a clinic visit.
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Triage and Assessment After obtaining initial information from the caller, the counselor should assess the client’s agenda and the level of knowledge and concern regarding the situation. These factors, combined with the specific medical information, can then be used to determine if the caller’s concern can be addressed on the telephone or if it requires a clinic visit. While each institution has its own policy regarding telephone consultation, it may be particularly useful for the client to attend clinic when a high risk is ascertained, the information is complex or lengthy, the caller expresses significant anxiety, the level of caller understanding is unclear, or a review of medical records, a physical examination, or testing is necessary. People may be willing to be seen for a clinic visit or referral if its need is explained. If a client is unable to attend clinic, institutional policy and personal judgment can determine whether the information is appropriate to provide by telephone. However, when the counselor feels strongly that the caller should be seen in person, other referrals may be necessary, such as referring the client to the primary-care provider or another local health care provider, including genetic counselors. While there is no need to answer all questions at the time of the initial call, agreeing to answer the inquiry commits the counselor to following through. It may be appropriate to contract with the client to schedule a specific “appointment” time for a follow-up call that will be convenient and agreeable to both parties. Relaying Information When initiating a return call, confidentiality is essential. The counselor should first establish that this is an appropriate time to talk, and that the caller is in a private location, if possible. The counselor should avoid giving confidential information to a person who is not the consultand, or leaving messages on answering machines with identifying information. Again, since the counselor cannot see the caller, verbal and vocal cues are paramount. Information should be given slowly and should include pauses to assess the caller’s understanding and reactions. Use clear and simple terms, avoiding jargon. The counselor should strive to maintain a compassionate unhurried voice and avoid raising the inflection of words at the end of sentences. Avoid explicatives. Additionally, the counselor should be aware of background noises (typing, computer sounds, coworkers, nervous giggling, other extraneous noises). Filler words, such as um are much more noticeable on the telephone. As with any counseling session, summarize what is and is not known, including the quality of the supporting data. If documentation of the diagnosis is weak, phrasing should reflect this, such as “If the diagnosis is X, then the risk could be Y.” As always, continual reassessment of the client’s understanding and emotional status is important; repeat any unclear information.
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Because many callers are looking for reassurance (Fifield, 1996), and because of the difficulty in assessing emotional responses on the telephone, it is particularly important for the counselor to purposefully elicit such responses. The counselor might ask, “Is this what you were expecting to hear?” or “Are you more or less worried about this information now?” When appropriate, the counselor should make referrals to other support services. Finally, before concluding the call, the counselor should summarize the information briefly and reemphasize any followup that is necessary. The counselor should inform the client of his or her availability for further conversations as needed, and how best to reach him or her. Follow-Up Documentation of the telephone counseling encounter is analogous to the genetic counseling letter to the family. Documentation should occur immediately following the telephone encounter and should be recorded in a notebook or ledger; this should be kept in a centralized location, such as with other clinic charts. The counselor should document fully the information provided, including the spirit of how it was communicated. As with all legal documents, notations should be in ink and in legible handwriting. If necessary, use error, date, and initials to correct mistakes. Concise, concrete terminology is important, as is avoiding inappropriate or derogatory terms and abbreviations. Document questions asked, even when responses are negative (Coleman, 1997). All documentation should be signed and dated.
LEGAL ISSUES Legal liability associated with telephone counseling is a significant concern of genetic counselors (Young, 1993). First, counselors should remember that they are under no legal obligation to provide information by telephone (Henry, 1994). Once information is given, however, whether by telephone or in person, the counselor assumes a legal responsibility for the interaction with the client and the information provided (Robinson et al., 1997). At that time, any incomplete or incorrect information could be considered negligence (Henry, 1994). Robinson notes that “negligence is the most common reason for lawsuits in medical practice litigations” (Robinson et al., 1997, p. 180). However, negligence suits are based on a breach of the standard of care, and since there is a dearth of standards regarding telephone contacts, few lawsuits are on record. Regardless of the lack of standards, documentation is imperative to minimize liability (Henry, 1994). Many states require that these records be maintained for an average of 7–10 years (Robinson et al., 1997), but it is important to know one’s own institutional policies.
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ADDITIONAL APPLICATIONS With the increasing usage of electronic communication such as e-mail and the Internet, the above issues will become all the more germane. While these also provide anonymity and convenience, these new telecommunications occur without even vocal cues, forcing reliance solely on verbal communication. Kane and Sands (1998) suggest that e-mail is often used as a hybrid between letter writing and telephone contact as it provides spontaneity and permanence but also allows more detail in specific wording than a telephone contact might. There is, however, not necessarily any immediacy to this communication, or any interaction to determine the level of client understanding. Information is therefore limited to a simplistic communication and is without all the “counseling” and individualization that we associate with the genetic counseling process. While there are a few examples of the Internet as a counseling modality in health care (Pergament, 1998; Ormond et al., 1998), little information exists on its use in these settings. As telecommunication between clients and health care providers increases, it will be interesting to assess whether “counseling” can truly be performed via Internet communication. CONCLUSION Telephone counseling can provide a convenient, easily accessible, and valuable source of reliable, accurate information for the general public and health care professionals. In spite of the differences from face-to-face counseling encounters, telephone counseling relies on the same knowledge base and counseling skills that the genetic counselor brings to any clinical setting. If the genetic counselor is able to establish rapport with the telephone client and accurately assess the client’s problems and needs, he or she can offer reliable information and appropriate interventions to meet the client’s needs. The genetic counselor can also fill a valuable referral role by facilitating access to care for those requiring further intervention, such as face-to-face genetic counseling services.
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