Travel Medicine and Telephone Advice

Karl Neumann, MD

To give or not to give travel health advice over the telephone; that is the question that many of us ponder. Should we refuse to speak to callers and so risk the slings and arrows of their displeasure? Or is it nobler to advise them, knowing this can cause us a sea of trouble, to sleep no more or to suffer dreadful dreams if, perchance, outraged travelers claim that the advice has caused them heartaches and all the thousand natural shocks that flesh is heir to?

Shakespeare aside, handling telephone calls about travel health issues - often calls from total strangers - is a dilemma for many of us. This dilemma involves medical, ethical, legal, and financial issues. So, to get opinions on the subject, once again we turned to ISTM ListServ members, a group that is easily reachable - we jut post the question on the website. This is a group not shy about stating their opinions. We thank them for their responses to this and previous queries. (This time: 37 responses from 7 countries.)

The question posted: How do you handle telephone calls for advice? Here are representative answers.

"The pressure from patients is clear. In our clinic we have tried to alleviate the issue with clear guidelines. According to our College of Physicians (Canada) - and supported by legal decisions in the past - a consultation on the phone, in a corridor or in an office is still a consultation. Here is our policy:

1-   No specific recommendations are made over the phone to a person without a chart. Generalities such as 'yellow fever vaccine is mandatory for entry into that country' and 'updating routine immunization is always recommended' are given over the phone. We encourage callers to visit Health Canada, and other travel medicine web sites.

2-   Patients who have a chart - from previous visits to our clinic - can have a telephone consultation if booked in advance, and for a fee. All information regarding the telephone consultation is noted on the chart.

3-   For patients calling for additional information after a visit, the chart is always available for the doctor or nurse taking the call, even for simple questions regarding possible minor side effects after a vaccine, for example. Often, patients do not comprehend what was given to them and confuse names. We have had patients convinced that we had given them malaria vaccine."

 "We should give enough advice to push the traveler along the path to definitive preparation. We should not give enough detail to make the traveler think that they do not need a consultation with a travel physician. I give basic risk information then ask them if they would like to make an appointment with us or refer them to another travel clinic and/or ask them to check the CDC (USA) travel website."

"When they ask about cost of a visit, I say that protecting your health while traveling in the developing world will cost around 10-15% of the airfare, money well spent!"

"Phone calls for information are a problem. I take each phone call personally and do not give information unless they are traveling to a no-risk area. In that case I advise them that no special precautions are necessary. For all others I explain that they will be traveling to an area that presents potential health risks. Then I advise them that adequate medical preparation for such travel is a complex process that cannot be carried out over the phone, that face-to-face consultation is needed and then refer them to the appointment desk…"

"Travel medicine must get the message out that there is more to a consultation than "giving shots"… Unfortunately, at some travel clinics "giving shots" is the only thing done. Therefore, we must also work on improving the standards of our profession."

"I take all telephone calls myself rather having the caller speak only to our very polite and knowledgeable receptionist. This results in more appointments and fewer no-shows… I am well traveled and have usually been in the area the caller will visit. I can talk briefly about their specific itinerary. This establishes a bond immediately.…"

"I do not hesitate to give very simple advice over the telephone. I do tell callers who have no medical issues and are going to a "healthy" destination that they may not need to see a travel medicine physician. Sometimes I tell them to consult their own physicians for minor problems. I am very aware of legal issues but it seems a little far-fetched to be sued for giving very simple advice over the telephone."

"… It is an interesting phenomenon that many strangers feel free to call travel medicine practitioners for telephone advice. I do not think that they expect advice from orthopedists and cardiologists they have never visited…?"

"I will give advice over the phone to a colleague, especially someone I know well. For others, I'll give some advice over the phone. Generally, though, I'd say something like:  "You've raised some important questions, and the best way to go over this is in the Travel Clinic.  Let me put you on hold and our clerk will schedule an appointment."

I do give basic information over the telephone, but I tell them that there are some variables based on medical history that we will discuss at the time of the visit. I find that I establish a relationship with the patients that extend to the visit.  Occasionally, callers are just shopping price and go elsewhere… but the ones who do come to me know up front the costs and appreciate my time on the phone. Many callers report the reason they chose our office is the courtesy I extended them on the phone."

… When time allows, it is a good idea to give callers appointments several weeks ahead rather than immediately to give them time to get their medical records from their various health providers, and to finalize their itineraries."

"No advice over the phone.  The patients medical history/immunizations/travel itinerary etc. cannot be adequately discusses/evaluated and education provided over the phone."

"Telephone advice is unavoidable but must be given within a carefully developed framework.  Here are our clinic's guidelines:

1. No advice is ever offered by the secretarial/support staff, only by the professional staff (physician, nurse practitioner).  If the caller is not sure an appointment is needed we suggest they make an appointment - it is rare for a patient to be seen with no issues to discuss.

2. No advice is given to individuals who are not registered patients in the practice. (Our travel clinic is part of a large general practice,) Even a question such as, "Do I need shots for a trip to England?" which appears to be easily answered can be misleading.  Much of travel medicine is not concerned with shots.  Perhaps the caller is at risk for deep vein thrombosis due a coagulation problem or has COPD.

3. Telephone calls which are follow-ups to a recent appointment ("I forgot to take all my oral typhoid vaccine", "My itinerary has changed", "I just realized I'm allergic to sulfa drugs") may be answered by phone, but often will still require an office visit.

4. Calls relating to illness after travel almost always require an appointment and should not be dealt with by phone.

5. The tough calls are those relating to a repeat trip to the same country ("I'm going back to Haiti for the 3rd time this year and just need more malaria pills; you told me I wouldn't need any more shots.", "You saw me two years ago for my trip to Kenya, now I'm going to India...").  There is a level of expectation that since the traveler has been seen once they never have to come back again for an appointment."

"I feel comfortable giving updated information and renewing malaria and diarrhea medications over the telephone for our established patients that saw me within the past year and are going to the same destination."

"As an Emergency Physician my prospective is different. I periodically get called regarding health concerns including "I just returned from .... I think I got..." Because we don't know the patients, the official policy of our department is not to give any advice over the phone….

"As a 'company doctor' I engage in telephonic or email travel health advice almost daily, but exclusively for employees or family members whose medical care I am either involved in, aware of, or can easily access. Several times a year I receive calls or emails from complete strangers, about vaccines, malaria prophylaxis, etc, and respond with a limited answer to any specific question, and advise them to contact one of several public travel health clinics in their area and provide contacts for these."

"Working in a pharmacy, we get a lot of phone questions with the expectation that we will give out information for 'free.'  Our approach is not to provide advice on medications that we have not filled and counseled on at our pharmacy and only to provide urgent advice (i.e., patient calls from overseas) to travelers who came to us for a pre-travel consultation."

"Dealing with phone calls has been a major issue in our clinic and I suspect it is in most.  Very frequently travelers think that there is a 'list' somewhere of the needed immunizations for a destination.  Many call and DEMAND we provide them the information. Some become very angry when we tell them that the answer depends on many factors."

"Our clinic services a military population; finances and liability are lesser issues. My experience is that people who get information over the phone and then come to the clinic have a set opinion about what they should receive. They seem to be invested in the telephonic advice vs. discussing the full itinerary and risk issues in person. 

"I'll give advice over the phone to a colleague or friend, especially if they don't live nearby, and the advice is not too complicated.  Others are referred to the CDC web site and told anything more detailed requires a consultation...  A bigger problem is more distant colleagues; i.e. I've never met the person but they are a doctor at my hospital and got my name from someone, and are obviously trying to avoid a clinic visit. I try to edge them into the clinic. … there are medical, legal, and economic sides to the question.  From a medical standpoint, 'over the phone' pretty typically means without a full medical history, so mistakes may be made.  From a legal standpoint, there's no documentation. 

"… you are responsible for ANY problems the traveler encounters not just  for the question dealt with on the telephone. It is YOUR responsibility to identify and deal with ALL issues (as in a routine consults) … I had a patient nearly die from malaria because he misunderstood the advice about malaria prophylaxis given by phone."

"We are a governmental agency and do not give advice over the telephone but will answer fax and email questions. This reduces errors, saves time (people like to talk on the phone), and enables us to document the communication."

Karl is the editor of NewsShare and Webmaster for the ISTM webpage.