Why Telephone Consultations Now Appear in OSCEs
Remote and telephone consulting has become a core clinical skill. Since 2020, the majority of GP consultations begin as telephone triage calls, and telephone assessments are routine across NHS 111, acute medical units, and out-of-hours services. OSCE setters have reflected this shift — you are increasingly likely to face a station where you must take a history, make an assessment, and safety net without being able to see the patient.
This station exposes a very different set of skills from a face-to-face history. You cannot observe the patient's appearance, breathing, skin colour, or distress. You cannot examine them. Your entire assessment relies on what the patient tells you and how skilfully you ask.
What the Examiner Is Looking For
| Domain | Specific behaviours |
|---|---|
| Opening | Clear introduction, confirm patient identity (name, DOB, address), confirm they can talk freely |
| History structure | Systematic SOCRATES-based history without visual prompts |
| Red flag assessment | Actively screen for life-threatening features |
| Shared decision-making | Explain options clearly, involve the patient in the plan |
| Safety netting | Specific, clear, written-down instructions for when to escalate |
| Documentation | Offer to send a text summary; note that a record will be made |
| Closing | Confirm the patient understands the plan; check for questions |
The Structure of a Telephone Consultation
Opening
"Hello, this is [name], I'm one of the doctors at [practice/hospital]. Am I speaking with [full name]? Could I confirm your date of birth and address please? Thank you. Is now a good time to talk — are you somewhere private where you can speak freely?"
The identity check is non-negotiable. Disclosing medical information to the wrong person is a serious IG breach. Confirming they can speak freely matters — a patient whose partner is listening may not volunteer important information.
💡 Tip
Always introduce your role and where you're calling from. "This is a doctor calling from the practice" is vague and suspicious. Say your name and role clearly — patients are more engaged and honest when they know who they are speaking to.
History Taking Without Visual Cues
You must be more explicit in asking about things you would normally observe:
Replace visual observation with direct questions:
- Instead of observing breathing: "Are you finding it difficult to breathe? Can you speak in full sentences comfortably?"
- Instead of observing skin colour: "Has anyone mentioned that you look pale or yellow? Do you feel flushed?"
- Instead of observing distress level: "On a scale of 0 to 10, how would you rate the pain right now?"
- Instead of observing mobility: "Are you able to stand and move around? Have you been bed-bound?"
💎 Clinical Pearl
The speaking-in-sentences test: Ask the patient to describe their symptoms and listen to whether they can speak in full sentences without breathlessness. Inability to complete a sentence is a red flag for respiratory distress even over the phone.
Red Flag Screening — Do This Systematically
Before reaching a management plan, run through a checklist of red flags relevant to the presenting complaint. For any presentation involving chest, abdomen, or neurological symptoms, explicitly ask:
Chest/cardiovascular:
- "Any chest pain or pressure?"
- "Any palpitations or feeling like your heart is racing or skipping?"
- "Any coughing up blood?"
Neurological:
- "Any sudden severe headache — the worst you've ever had?"
- "Any weakness, numbness, or difficulty speaking?"
- "Any loss of consciousness?"
Abdominal:
- "Any blood in your stool or vomit?"
- "Any severe abdominal pain that won't settle?"
- "Any chance you could be pregnant?"
General:
- "Have you had a fever or rigors — severe uncontrollable shaking?"
- "Are you drinking and keeping fluids down?"
⚠️ Red Flag
Never omit red flag screening in a telephone consultation — it is the main safety mechanism replacing clinical examination. The most common reason for serious harm from telephone consultations is a missed red flag that would have been obvious face-to-face. If in doubt, ask the question.
The Decision: Come In, Wait and Watch, or 999?
This is the core clinical judgement and what the OSCE is really assessing. Your options:
| Decision | When appropriate |
|---|---|
| 999 / blue light | Any life-threatening features: chest pain + diaphoresis, severe respiratory distress, suspected stroke (FAST positive), anaphylaxis, overdose, altered consciousness |
| Same-day face-to-face | Unclear diagnosis needing examination, worsening symptoms, high-risk patient (elderly, immunocompromised, comorbidities), parent with a sick child |
| Attend next available | Non-urgent, stable symptoms, no red flags, clear diagnosis probable |
| Self-manage with advice | URTI in a healthy adult, mild diarrhoea and vomiting, known condition flare with clear management plan |
| Prescribe remotely | If confident in diagnosis, no examination needed, patient has capacity, follows up if not improving |
💡 Tip
When in doubt, bring them in. A telephone consultation cannot replace an examination. It is always defensible to say "I'd like to see you to examine you properly" — it is much harder to defend a decision to manage remotely if the patient deteriorates.
Safety Netting: The Most Important Part
Safety netting is what protects the patient when your remote assessment turns out to be incomplete. It must be specific, actionable, and given both verbally and in writing (most GP systems send a text summary).
Weak safety netting (loses marks):
"If things get worse, come back."
Strong safety netting (gains marks):
"I'd like you to try the paracetamol and rest for the next 24 hours. If any of these things happen, call 999 immediately: you develop chest pain, you have trouble breathing, or you feel very unwell very quickly. If the temperature doesn't come down within 48 hours or you're not improving by Thursday, call us back and we'll arrange for you to come in. Do you understand those instructions? I'll send you a text message summarising all of that."
🧠 Mnemonic
SMART safety netting:
- Specific symptoms to watch for (not vague "if worse")
- Mode of escalation (999 vs call back vs A&E)
- Action by the patient (not passive — they know what to do)
- Review timeframe (when should they contact you if not improving)
- Text/written confirmation sent
ICE in a Telephone Consultation
Do not forget ICE just because you can't see the patient:
- Ideas: "What do you think might be causing this?"
- Concerns: "Is there anything in particular you're worried it might be?"
- Expectations: "What were you hoping we might be able to do for you today?"
These questions are just as important on the phone. A patient calling about a headache may be worried about a brain tumour. A parent calling about their child's rash may be terrified of meningitis. Unless you ask, you won't know — and failing to address their underlying concern means they won't follow your advice.
Closing the Call
"So to summarise — I think you have [assessment]. The plan is [plan]. I'd like you to [specific action]. If [specific red flags] happen, call 999. If you're not improving by [time], call us back. I'm going to send you a text message with all of this written down. Is there anything else you'd like to ask before we finish? Thank you — take care, goodbye."
Always summarise before ending. Always confirm the patient can act on the plan (they have the medication, they have transport if they need to come in, they understand the instructions).
Common Examiner Follow-Up Questions
"A mother calls about her 3-year-old who has had a fever of 39.2°C for 24 hours and is irritable. What would you ask and what would you do?"
"I would systematically assess for red flag features: a non-blanching rash (possible meningococcal disease — 999 immediately), seizures or abnormal movements, altered consciousness or unrousability, difficulty breathing, or a severe headache. I would ask about fluid intake — is the child drinking? Are they passing urine normally? I would ask about the rash, and whether the fontanelle appears bulging (in a child young enough to have an open fontanelle). I would perform a telephone-based NICE traffic light assessment — a child who is lethargic, has reduced skin turgor, has a dry mouth, and is not responding normally is amber or red and needs same-day face-to-face review. Given the duration, age of the child, and irritability, I would arrange a same-day appointment to examine the child rather than advising home management."
"How does documentation of a telephone consultation differ from a face-to-face consultation?"
"The core documentation requirements are the same — date, time, patient identifiers, presenting complaint, history, assessment and differential diagnosis, plan, and safety netting given. However, for telephone consultations I should additionally document: that the consultation was conducted by telephone, that identity was confirmed, whether I was able to assess the severity of symptoms adequately over the phone, any limitations of the assessment (inability to examine), and that safety netting information was provided both verbally and in writing. In some trusts and GP systems a template is used to ensure consistent documentation. If there was any uncertainty about the diagnosis or clinical picture, this should be explicitly recorded alongside the reason for the chosen management plan."
"A patient calls saying they have chest pain. What is your immediate response?"
"Chest pain over the phone is a potential emergency until proven otherwise. My immediate priority is to establish whether this is a life-threatening cardiac or aortic event. I would ask: onset and character of the pain — is it crushing, pressure, or tearing? Does it radiate to the arm, jaw, or back? Are they sweating, nauseous, or breathless? Have they had a similar pain before? Are they known to have heart disease? If there is any suspicion of acute MI or aortic dissection — crushing central chest pain with radiation and diaphoresis — I would direct them to call 999 immediately while I stay on the line, or call 999 on their behalf. I would not attempt to manage potential ACS remotely under any circumstances."