Exploring patient ideas, concerns, and expectations in surgeon-patient consultations.

OBJECTIVES: This study explores patient perspectives (ideas, concerns, and expectations) in surgeon-patient consultations. METHODS: We examined 54 video-recorded consultations using applied conversation analysis. Consultations took place from 2012 to 2017 in an Australian metropolitan hospital clinic centre and involved seven surgeons across six specialties. RESULTS: Patient perspectives emerged in less than one third of consultations. We describe the initiation of and response to potential perspectives sequences, demonstrating how patients and surgeons co-construct these sequences when they do occur. CONCLUSIONS: Findings suggest a need for greater attention to supporting patient agency through explicit pursuit of patient perspectives. The implications extend to the Calgary-Cambridge Guide, suggesting that it may benefit from a focus on active pursuit and appropriate responsiveness to patient perspectives. PRACTICE IMPLICATIONS: This study highlights the need for surgeons to actively engage with the patient perspective offered in consultations, emphasising the importance of respect for the patient's knowledge and expectations to improve patient satisfaction and healthcare outcomes.

Tailoring communication practices to support effective delivery of telehealth in general practice.

BACKGROUND: The unprecedented increase in telehealth use due to COVID-19 has changed general practitioners' (GP) and patients' engagement in healthcare. There is limited specific advice for effective communication when using telehealth. Examining telehealth use in practice in conjunction with perspectives on telehealth as they relate to communication allows opportunities to produce evidence-based guidance for optimal use of telehealth, while also offering practitioners the opportunity to reflect on elements of their communicative practice common to both styles of consultation. The objective of this research was to develop evidence-based resources to support effective, person-centred communication when GPs and patients use telehealth. This included examination of interactional practices of recorded telehealth consultations, exploration of GP and patient perspectives relating to telehealth, and identifying priorities for guidance informed by these analyses as well as participant co-design. METHODS: This study involved recording telehealth consultations (n = 42), conducting patient surveys (n = 153), and interviewing patients (n = 9) and GPs (n = 15). These were examined using interaction analytic methods, quantitative analysis, and thematic analyses, to create a robust, integrated picture of telehealth practice and perspectives. The process of research translation involved a co-design approach, engaging with providers, patients, and policy makers to facilitate development of evidence-based principles that focus on supporting effective communication when using telehealth. RESULTS: Three key themes relating to communication in telehealth were identified across the different analyses. These were relationship building, conversational flow, and safety netting. The draft best practice principles drawn from these themes were modified based on co-design feedback into five Best Practice Principles for Communication between GPs and Patients using Telehealth. CONCLUSIONS: Effective communication is supported through relationship building and attention to conversational flow in telehealth consultations, which in turn allows for safety netting to occur. In telehealth, GPs and patients recognise that not being co-present changes the consultation and use both intuitive and strategic interactional adjustments to support their exchange. The mixed-method examination of experiences through both a detailed analysis of telehealth consultations in practice and comparative exploration of GP and patient perspectives enabled the identification of principles that can support effective communication when using telehealth. Co-design helped ensure these principles are ready for implementation into practice.

Agency and the telephone: Patient contributions to the clinical and interactional agendas in telehealth consultations.

OBJECTIVE: Patient-centredness is central to providing safe care and is achieved, in part, through involving patients in developing the agenda of the consultation. Medical consultations have changed significantly over the last two years as a result of COVID-19 and thus understanding how patients contribute to the clinical and interactional agendas within a telehealth consultation is important to supporting quality care. METHODS: A collection (15) of consultations (in English) between specialists (3) and patients (14) were recorded in a metropolitan gastrointestinal clinic in Australia. These recordings were closely examined using conversation analysis, which focuses on the structural and sequential organisation of interaction. RESULTS: Patients used a variety of interactional approaches to contribute to the agenda throughout the consultations. This was achieved in collaboration with the doctors, whose responses generally allowed for these contributions. However, there were few doctor-driven, explicit opportunities provided to patients to contribute to the agenda. CONCLUSION: Many patients and doctors are adept at managing the interactional challenges of telehealth consultations but there are clear opportunities to extend this advantage to those patients with less agency. PRACTICE IMPLICATIONS: Providing an explicit space for patients to ask questions within the consultation would support those patients less inclined or able to assert themselves during a telehealth consultation.

Experiences of telehealth in general practice in Australia: research protocol for a mixed-methods study.

BACKGROUND: Owing to the COVID-19 pandemic, the use of telehealth has expanded rapidly. However, little is known about the impact of delivering care through telehealth on communication between clinicians and patients. At an interactional level, the ways in which clinicians establish rapport and connection with their patients in telehealth consultations is not well understood. AIM: This study will explore interactional practices of GPs and patients in telehealth consultations to develop evidence-based resources to improve communication. DESIGN & SETTING: The study will be conducted within the Australian general practice setting. METHOD: Conversation analysis and sociolinguistic discourse analysis of recorded telehealth consultations will provide direct evidence of specific elements contributing to successful and less successful instances of telehealth communication. This analysis will be complemented by co-design techniques such as qualitative and reflective interviews, and collaborative workshops with telehealth users including both GPs and patients. CONCLUSION: Effective communication is critical for telehealth consultations and is central to achieving optimal clinical outcomes and patient satisfaction. Evidence-based guidelines encompassing effective telehealth communication strategies will be co-developed with end-users in this study.

Consent for spine surgery: an observational study.

BACKGROUND: The tension between the ideal of informed consent and the reality of the process is under-investigated in spine surgery. Guidelines around consent imply a logical, plain-speaking process with a clear endpoint, agreement and signature yet surgeons' surveys and patient interviews suggest that surgeons' explanation is anecdotally variable and patient understanding remains poor. To obtain a more authentic reflection of practice, spine surgeons obtaining 'informed consent' for non-instrumented spine surgery were studied via video recording and risk/benefit discussions were analysed. METHODS: A prospective observational study was conducted at a single neurosurgical institution. Twelve video recordings involving six surgeons obtaining an informed consent for non-instrumented spine surgery were transcribed verbatim and blindly analysed using descriptive quantification and linguistic ethnography. RESULTS: Ten (83%) consultations discussed surgical benefit but less than half (41%) quantified the likelihood of benefit from surgery. The most discussed risks were nerve damage or paralysis (92%), bleeding (92%), infection (92%), cerebrospinal fluid leak (83%) and bowel and bladder dysfunction (75%). Surgeons commonly used a quantitative statement of risk (58%) but only half of the risks were explained in words patients were likely to understand. CONCLUSIONS: This study highlights inconsistencies in the way spine surgeons explain risks and obtain informed consent for 'simple' spine procedures in a real-world setting. There are wide disparities in the provision of informed consent, which may be encountered in other surgical fields. Direct observation and qualitative analysis can provide insights into the limitations of current informed consent practice and help guide future practice.

Virtual reality simulators: current status in acquisition and assessment of surgical skills.

Medical technology is currently evolving so rapidly that its impact cannot be analysed. Robotics and telesurgery loom on the horizon, and the technology used to drive these advances has serendipitous side-effects for the education and training arena. The graphical and haptic interfaces used to provide remote feedback to the operator--by passing control to a computer--may be used to generate simulations of the operative environment that are useful for training candidates in surgical procedures. One additional advantage is that the metrics calculated inherently in the controlling software in order to run the simulation may be used to provide performance feedback to individual trainees and mentors. New interfaces will be required to undergo evaluation of the simulation fidelity before being deemed acceptable. The potential benefits fall into one of two general categories: those benefits related to skill acquisition, and those related to skill assessment. The educational value of the simulation will require assessment, and comparison to currently available methods of training in any given procedure. It is also necessary to determine--by repeated trials--whether a given simulation actually measures the performance parameters it purports to measure. This trains the spotlight on what constitutes good surgical skill, and how it is to be objectively measured. Early results suggest that virtual reality simulators have an important role to play in this aspect of surgical training.

A compliant tip reduces the peak pressure of laparoscopic graspers.

BACKGROUND: Previous studies have demonstrated that high pressures are generated at the tips of laparoscopic graspers, which can cause tissue injury. This study examines the effect of a compliant edge on tip pressure. METHODS: One of a pair of identical laparoscopic graspers was modified by refashioning the tip out of silicone. A thin film pressure transducer (I-scan 6900 sensor) was deployed between the jaws of the grasper and a simulated tissue (leather strap). Load and handle pressures were kept constant. Peak tip pressure readings were taken as the load orientation was increased from the perpendicular to 135 degrees (n = 10). The data was analysed using anova and a post-hoc Duncan's multiple range test. RESULTS: Peak tip pressures generated by the compliant tipped grasper were significantly less than those developed by the unmodified grasper, particularly at high-load orientations. CONCLUSION: High pressures generated at the tip of laparoscopic graspers can be reduced by altering the mechanical properties (compliance) of the tip.

Working with registrars: a qualitative study of interns' perceptions and experiences.

OBJECTIVE: To identify and explore behavioural characteristics of registrars that interns find helpful in their working relationships and workplace learning. DESIGN, SETTING AND PARTICIPANTS: Semistructured interviews with 18 interns at Nepean Hospital, Penrith, NSW, at the end of their first working year as doctors. The survey was conducted between December 2003 and February 2004. MAIN OUTCOME MEASURE: Desirable and undesirable behavioural characteristics in registrars, as reported by interns. RESULTS: Overall, interns' opinions of registrars were positive. Desirable characteristics in registrars included approachability, availability, good communication skills, and a willingness to teach. Undesirable characteristics included an unwillingness to listen, unreasonably high expectations, a condescending attitude, apathy and rudeness. CONCLUSION: The behavioural characteristics of registrars that interns find helpful are identifiable, and there is significant room for improvement in the quality of clinical mentoring by registrars. The next step is to facilitate regular feedback from interns on registrars' performance, and to develop ways to encourage desirable behaviours in registrars while actively discouraging undesirable behaviours.