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.

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.

Camera realignment imposes a cost on laparoscopic performance.

There is an unresolved question about whether realigned visual feedback is beneficial or costly to laparoscopic task performance. We provide evidence that camera realignment imposes a reliable cost on performance across both naive controls and experienced surgeons. This finding clarifies an important ongoing discussion in the literature about the effects of camera realignment, which could inform the strategies that laparoscopic surgeons use in the operating room.

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.

Natural orifice specimen extraction for colorectal surgery: Early adoption in a Western population.

AIM: Natural orifice specimen extraction (NOSE) challenges the limits of minimally invasive colorectal surgery by exploiting a natural opening for specimen delivery. Technically challenging, it is less painful, requires smaller wounds and abolishes the possibility of incisional hernia. These advantages of NOSE are seen in the obese (body mass index [BMI] >30 kg/m2 ). This audit aims to demonstrate the feasibility of NOSE colectomy in an Australian population. METHOD: Prospective data collected from 2007 to the present were retrospectively analysed. Only patients with mucosally benign colorectal conditions were included: complex diverticulosis, post-malignant polypectomy and volvulus. Left sided mucosal malignancies were excluded. Study end-points included postoperative length of stay, anastomotic leak rate and wound complications. RESULTS: In total, 159 patients underwent NOSE, mean age 59 years (19-88), mean BMI 28.2 kg/m2 (17-45). Ten (6.2%) patients developed retroperitoneal small bowel herniation; seven required further surgery. There were five (3.1%) anastomotic leaks, seven (4.4%) postoperative ileus and three (1.9%) anastomotic bleeds. One (0.6%) patient had a superficial wound infection. There were no port site hernias. Patients with BMI <30 kg/m2 (98 patients) and BMI >30 kg/m2 (59 patients) were compared; there was no difference in anastomotic leak rate (P = 0.60), complication rate (P = 0.71) and length of stay (P = 0.63). However, duration of operation increased with BMI (P = 0.000). CONCLUSION: This large series of NOSE colectomy from Australia suggests that NOSE is comparable to conventional laparoscopic colectomy in terms of postoperative outcome. Given that obesity has not featured in the NOSE literature, our study suggests that NOSE, for benign disease, is safe in obese patients, without added morbidity.

A mobile methods pilot study of surgical spaces: 'fit for purpose? Organisational productivity and workforce wellbeing in workspaces in hospital' (FLOURISH).

BACKGROUND: Good workspace design is key to the quality of work, safety, and wellbeing for workers, yet we lack vital knowledge about optimal hospital design to meet healthcare workforce needs. This study used novel mobile methods to examine the concept of Work-as-Done and the effect of workspace-use on healthcare professional practice, productivity, health and safety in an Australian university hospital. METHODS: This pilot study took place in one gastroenterological surgical unit between 2018 and 2019. Data collection involved 50 h of observations and informal conversations, followed by interpretation of five architectural plans and 45 photographs. Fieldnotes were thematically analysed and corroborated by analysis of visual data using a predefined taxonomy. RESULTS: Six themes were identified, revealing spaces that both support and hinder Work-as-Done. Fit-for-purpose spaces facilitated effective communication between staff, patients and families, conferred relative comfort and privacy, and supported effective teamwork. Unfit-for-purpose spaces were characterised by disruptions to work practices, disharmony among team members, and physical discomfort for staff. Staff employed workarounds to manage unfit-for-purpose spaces. CONCLUSION: The results identified negative impacts of negotiating unfit-for-purpose workspaces on the work and wellbeing of staff. While the use of workarounds and adaptations enable staff to maintain everyday working practices, they can also lead to unexpected consequences. Results indicated the need to identify and support fit-for-purpose spaces and minimize the detrimental qualities of unfit-for-purpose spaces. This study showed that mobile methods were suitable for examining Work-as-Done in a fast-moving, adaptive hospital setting.

Fit for purpose? OrganisationaL prOdUctivity and woRkforce wellbeIng in workSpaces in Hospital (FLOURISH): a multimethod qualitative study protocol.

INTRODUCTION: Workspaces are socially constructed environments where social relationships are produced, reproduced, challenged and transformed. Their primary function is to support high-quality service delivery to the benefit of 'patients'. They are also settings where employees can work effectively, in a safe and healthy environment, delivering a high-quality service according to a 'Work-As-Done' rather than a 'Work-As-Imagined' model. However, hospital design is currently based on a managerial understanding of work accomplishments, often falling short of understanding what is actually happening on the ground. Furthermore, the research landscape lacks rigorous assessment of these complex sociological and health research concepts, either within the Australian context where this protocol is set, or internationally.This paper describes an innovative protocol aimed at examining healthcare employees' and organisations' concerns and beliefs in workspace design. It outlines research investigating the effect of workspace use on productivity, health and safety and worker satisfaction, to clarify Work-As-Done, while creating healthy and more fulfilling environments. METHODS: This is a proof-of-concept study, taking place between June 2018 and April 2019, employing a multimethod, qualitative approach for in-depth assessment of one Australian, private, university hospital environment, using as its 'case' the Gastroenterology Surgical Unit. It involves (1) observations and informal interviews (shadowing) with employees and patients as they traverse hospital spaces and (2) visual data of spatial use. Fieldnotes will be analysed thematically, and visual data analysed using a predefined schematic framework (a visual taxonomy). Overarching themes and categories will be considered corroboratively, mixing visual and textual data to build an iterative and dynamic picture. ETHICS AND DISSEMINATION: Ethical considerations will be discussed, while approval has been granted by the University's Human Research Ethics Committee (HREC/5201800282), along with Governance approved by the Health Clinical Research Executive (CRG2018005). Study results will be disseminated through publications, research conferences and public reports.

Linguistic analysis of verbal and non-verbal communication in the operating room.

Surgery can be a triumph of co-operation, the procedure evolving as a result of joint action between multiple participants. The communication that mediates the joint action of surgery is conveyed by verbal but particularly by non-verbal signals. Competing priorities superimposed by surgical learning must also be negotiated within this context and this paper draws on techniques of systemic functional linguistics to observe and analyse the flow of information during such a phase of surgery.

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.

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.

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.