The video window: How video consultation technology reveals and redefines the art of medicine in Danish specialist practice.

In the contemporary landscape of technologically mediated healthcare, video consultations introduce a dynamic interplay of challenges and opportunities. Taking the notion of 'the art of medicine' as an analytical frame, and drawing on interviews with medical specialists as well as participant observation of video consultations with patients (carried out between February 2022 and January 2023), this article investigates how video consultation technology changes the practices of medical specialists in the Danish healthcare system. Informed by post-phenomenology, we approach video consultations metaphorically as 'windows' between medical specialists and patients, unveiling three pivotal dimensions characterizing these changes. First, the shift from a physical to a virtual consultation room requires a reevaluation of the authoritative nature of the clinic, emphasizing the need for negotiating and staging the clinical space online. Second, while video consultations limit doctors' ability to rely on traditional non-verbal cues such as body language, they offer glimpses into patients' home environments, exposing the influence of social preconceptions on medical evaluations. Third, the adoption of video consultations introduces new conditions for doctors' use of senses, accentuating the importance of reflecting on the roles of different sensory impressions in the art of medicine. Our study illuminates how video consultation technology simultaneously expands and constrains the engagement between medical specialists and patients. Despite their inherent limitations, video consultations bring medical specialists closer to some of the intricacies of patients' lives. This proximity offers new insights and renders visible the roles of caregivers and relatives in the patient's care. The metaphor of 'the video window' encapsulates this tension between distance and closeness in video consultations, portraying the patient as both fragmented and socially situated. Our study extends beyond traditional patient and provider satisfaction evaluations, providing nuanced insights into how video consultations reconfigure the art of medicine.

Conceptualizing negotiation in the clinical encounter - A scoping review using principles from critical interpretive synthesis.

OBJECTIVE: Negotiation as an analytical concept in research about clinical encounters is vague. We aim to provide a conceptual synthesis of key characteristics of the process of negotiation in clinical encounters based on a scoping review. METHODS: We conducted a scoping review of relevant literature in Embase, Psych Info, Global Health and SCOPUS. We included 25 studies from 1737 citations reviewed. RESULTS: We found that the process of negotiation is socially situated depending on the individual patient and professional, a dynamic element of the interaction that may occur both tacitly and explicitly at all stages of the encounter and is not necessarily tied to a specific health problem. Hence, negotiation is complex and influenced by both social, biomedical, and temporal contexts. CONCLUSIONS: We found that negotiation between patient and health professional occurs at all stages of the clinical encounter. Negotiation is influenced by social, temporal, and biomedical contexts that encompass the social meeting between patient and health professional. We suggest that health professionals strive to be attentive to patients' tacit negotiation practices. This will strengthen the recognition of the patients' actual wishes for their course of treatment which can thus guide the health professionals' recommendations and treatment.

A Symphony of Challenges: Multi-Drug Resistant Tuberculosis, Pleurocutaneous Fistula, and Empyema Necessitans in Concert.

This case report details the clinical course of a 37-year-old male with multi-drug-resistant tuberculosis (MDR-TB) who initially presented with respiratory symptoms. Following a month of anti-TB therapy, the patient developed a painful chest swelling, diagnosed as empyema necessitans, with a subsequent spontaneous rupture leading to a pleurocutaneous fistula. Despite recommendations for surgery, the patient opted for active surveillance. The follow-up revealed symptom improvement. This case underscores the unique challenges of managing rare complications of MDR-TB, particularly when patients decline surgical interventions. The observed symptom improvement, despite the absence of surgery, illuminates the intricate decision-making process and alternative management strategies involved in addressing such complications, highlighting the complexities inherent in MDR-TB care.

Short animated video increases knowledge and perceived comfort in clinical counseling on inequitable health impacts of air pollution among interprofessional health learners and clinicians.

BACKGROUND: Air pollution is a major health risk contributing to global morbidity and mortality, yet clinicians do not routinely engage in counseling patients on this topic. Clinicians cite their lack of education as a common barrier. We developed a two-minute animated video on mitigating air pollution health risks and evaluated the efficacy of this video as an educational tool. METHODS: In March-June 2021, a convenience sample of Minnesota interprofessional health learners and clinicians viewed the video and completed an electronic survey that assessed pre-/post-video intervention changes in (a) didactic and clinically applied knowledge on health impacts of air pollution, (b) perceived comfort in identifying at-risk patients and counseling them on relevant preventive health behaviors, (c) intentions/barriers to counseling patients, (d) beliefs and attitudes related to the health harms of air pollution, and (e) perceptions of the overall acceptability of the intervention. RESULTS: The 218 participants included learners and clinicians in medicine, nursing, and advanced practice provision. Respondents' knowledge scores and self-reported level of comfort in identifying high-risk patients and counseling them on preventative health behaviors increased significantly pre-/post-intervention. The video also effectively altered participants' misperceptions about the health impacts of air pollution. While less than half of participants (43.6%) reported they intended to engage in counseling patients as a result of watching the video, 52.3% indicated they might do so. Lack of time during clinical encounters and lack of training were reported as persistent barriers to engaging in this counseling. Overall, participants found the video to be an effective educational tool, indicating that they wanted their colleagues and patients to watch the video and would like to see further short, animated videos on other environmental health topics. CONCLUSIONS: A two-minute animated educational video significantly improved knowledge of inequitable health impacts of air pollution and improved perceived comfort in identifying and counseling at-risk patients among health professional learners and clinicians regardless of profession, level of training, or pre-intervention knowledge level. Academic health professional training programs and health systems should consider adopting this modality as a tool for educating learners, clinicians, and patients on environmental health risks.

Communication Interactions, Needs, and Preferences During Clinical Encounters of African American Parent-Child Dyads.

Human papillomavirus (HPV) vaccination rates remain suboptimal among African American adolescents. Although provider recommendations during clinical encounters are believed to be highly effective in increasing uptake and series completion, little has been reported about parent-child perspectives on the counseling received during these encounters. Among African American parent-child dyads, we sought to explore and compare interactions, needs, and preferences during clinical encounters by child's HPV vaccination status. We applied a qualitative, phenomenological study design to conduct semi-structured interviews with African American parent-child dyads representing children who were unvaccinated (n = 10), had initiated but not completed (n = 11), or had completed the HPV vaccine series (n = 9). Using iterative, inductive-deductive thematic analysis, five themes were generated: (1) parents' attitudes varied about the HPV vaccine but were mostly positive for vaccines in general; (2) patient-parent-provider clinical encounters from the parent perspective; (3) patient-parent-provider clinical encounters from the child perspective; (4) methods of distribution of supplemental HPV information; and (5) communication desired on HPV vaccination by parents and children. Parents stating they received a provider's recommendation increased by vaccination status (unvaccinated: 6 out of 10; initiated: 7 out of 11; completed: 9 out of 9). Most parents and children were not satisfied with provider communication on the HPV vaccine and used supplemental materials to inform decision-making. Ongoing communication on the HPV vaccine was requested even post-vaccination of the child. During clinical encounters, children and parental messaging needs are similar yet dissimilar. We offer communication strategies and messaging that can be used for African American parent-child dyads by child HPV vaccination status during a clinical encounter.

Interventions to Promote End-of-Life Conversations: A Systematic Review and Meta-Analysis.

CONTEXT: Although several interventions aimed to promote end-of-life conversations are available, it is unclear whether and how these affect delivery of end-of-life conversations. Measuring the processes associated with high-quality end-of-life care may trigger improvement. OBJECTIVES: To estimate the effect of interventions aimed to promote end-of-life conversations in clinical encounters with patients with advanced chronic or terminal illness or their family, on process indicators of end-of-life conversations. METHODS: Systematic review with meta-analysis (PROSPERO no. CRD42021289471). Four databases (PubMed, CINAHL, PsycINFO, and Scopus) were searched up to September 30, 2021. The primary outcomes were any process indicators of end-of-life conversations. Results of pairwise meta-analyses were presented as Risk Ratio (RR) for occurrence, standardized mean difference (SMD) for quality and ratio of means (ROM) for duration. Meta-analysis was not performed when fewer than four studies were available. RESULTS: A total of 4,663 articles were scanned. Eighteen studies were included in the systematic review and 16 entered at least one meta-analysis: documented occurrence (n = 8), patient-reported occurrence (n = 4), patient-reported-quality (n = 4), duration (n = 4). There was significant variability in settings, patients' clinical conditions, and professionals. No significant effect of interventions on documented occurrence (RR 1.54, 95% CI 0.84-2.84; I2 91%), patient-reported occurrence (RR 1.52, 95% CI 0.80-2.91; I2 95%), patient-reported quality (SMD 0.83, 95% CI -1.06 to 2.71; I2 99%), or duration (ROM 1.20, 95% CI 0.95-1.51; I2 65%) of end-of-life conversations was found. Data on frequency were conflicting. Interventions targeting multiple stakeholders promoted earlier and more comprehensive conversations. CONCLUSION: Heterogeneity was considerable, but findings suggest no significant effect of interventions on occurrence, patient-reported quality and duration of end-of-life conversations. Nevertheless, we found indications for interventions targeting multiple stakeholders to promote earlier and more comprehensive conversations.

Six attitudes to promote personal, patient-centred care in an era of addictive technology.

In contrast with the rapid advances in medical knowledge and technology, the clinical encounter may often appear as perfunctory, impersonal, and unworthy to both patient and practitioner who is often immersed in the computer screen rather than the patient, stressed by improbable time constraints, and often finds deceptive relief in inappropriate test-ordering, prescriptions, and referrals. We suggest routinely adopting six attitudes to achieve a more balanced, personal, and patient-centred encounter: conducting a curiosity-driven encounter; emphasizing humanistic values; performing a complete physical examination; increasing patients' face time; addressing the patient's health as a whole; and rational test-ordering and judicious prescribing.

Demand for and Occurrence of Medication Cost Conversations: A Narrative Review.

High medication prices can create a financial burden for patients and reduce medication initiation. To improve decision making, public policy is supporting development of tools to provide real-time prescription drug prices. We reviewed the literature on medication cost conversations to characterize the context in which these tools may be used. Our review included 42 articles: a median of 84% of patients across four clinical specialties reported a desire for cost conversations (n = 7 articles) but only 23% reported having held a cost conversation across six specialties (n = 16 articles). Non-White and older patients were less likely to report having held a cost conversation than White and younger patients in 9 of 13 and 5 of 9 articles, respectively, examining these associations. Our review indicates that tools providing price information may not result in improved decision making without complementary interventions that increase the frequency of cost conversations with a focus on protected groups.

Legitimacy in clinical practice: How patients with chronic muscle pain position themselves in the physiotherapy encounter.

RATIONALE, AIMS & OBJECTIVE: Patients who seek healthcare for long-lasting pain and symptoms without a detectable disease must put in extra work to be taken seriously and gain recognition as a patient. However, little is known about how patients' help-seeking is performed in clinical practice. The aim of the current study was to gain knowledge about the ways in which patients with chronic muscle pain position themselves as help-seekers during their first physiotherapy encounter. METHOD: The material consisted of observation of 10 therapist-patient clinical interviews in primary care clinics and was analyzed using perspectives from discourse theory and the concept of positioning. RESULTS: The study highlights how the patients positioned themselves in continually shift between two discourses: that of disease (considering the patient as an object under study) and that of illness (positioning the patient as an active and participating but also troubled individual). This shifting of position was negotiated in interaction with the therapist: patients' opportunities to position themselves within the discourse of illness were limited by therapists' focus on facts and causal relationships within the discourse of disease. CONCLUSION: Patients with chronic muscle pain seek to establish their legitimacy through the positivistic discourse of medicine and also through their compliance with the moral discourse of the patient as someone active, willing to take responsibility for their own health-and therefore worthy of treatment.

Video-based observation research: A systematic review of studies in outpatient health care settings.

OBJECTIVE: To examine the use of video-based observation research in outpatient health care encounter research. METHODS: We conducted a systematic search of MEDLINE, Scopus, Cochrane and other databases from database inception to October 2020 for reports of studies that used video recording to investigate ambulatory patient-clinician interactions. Two authors independently reviewed all studies for eligibility and extracted information related to study setting and purpose, participant recruitment and consent processes, data collection procedures, method of analysis, and participant sample characteristics. RESULTS: 175 articles were included. Most studies (65%) took place in a primary care or family practice setting. Study objectives were overwhelmingly focused on patient-clinician communication (81%). Reporting of key study elements was inconsistent across included studies. CONCLUSION: Video recording has been used as a research method in outpatient health care in a limited number and scope of clinical contexts and research domains. In addition, reporting of study design, methodological characteristics, and ethical considerations needs improvement. PRACTICE IMPLICATIONS: Video recording as a method has been relatively underutilized within many clinical and research contexts. This review will serve as a practical resource for health care researchers as they plan and execute future video-based studies.

Face-to-Face with the Doctor Online: Phenomenological Analysis of Patient Experience of Teleconsultation.

The global crisis of the COVID-19 pandemic has considerably accelerated the adoption of teleconsultation-a form of consultation between patient and health care professional that occurs via videoconferencing platforms. For this reason, it is important to investigate the way in which this form of interaction modifies the nature of the clinical encounter and the extent to which this modification impacts the healing process. For this purpose, I will refer to insights into the clinical encounter as a face-to-face encounter drawn from the phenomenology of medicine (R. Zaner, K. Toombs, E. Pellegrino). I will also take into account a criticism that has been expressed by various contemporary phenomenologists (H. Dreyfus, T. Fuchs, L. Dolezal, H. Carel), namely, that due to the lack of physical proximity to the other in all types of online encounters, such encounters lack significant features that are present in face-to-face encounters, with the most important of these being the possibility of attaining an empathetic perception of the other and a sense of embodied risk. As these elements are essential features of the clinical encounter, the aim of this paper is to determine whether teleconsultation exhibits these features. To do that, I will integrate phenomenological philosophy with qualitative research drawing materials from both the philosophical tradition, particularly with respect to the concepts of the face-to-face encounter and embodied risk (A. Schutz and H. Dreyfus), and qualitative research study regarding patient experiences of teleconsultation. I will argue that teleconsultation does involve both the possibility of perceiving the other empathetically and the possibility of experiencing a sense of embodied risk.

How to Help Your Complex Patient If You Don't Know What Is Wrong.

Perspectives from a complex patient point-of-view on how clinicians can improve therapeutic empathy skills and how to help a complex patient who is undiagnosed and you do not know what is wrong.

Can Humanism Be Infused Into Clinical Encounters in a Time-Constrained, Technology-Driven Era?

A humanistic, personal, empathic, and patient-centered attitude towards the patient and family during the clinical encounter is often neglected in many settings. However, patients give it an utmost priority; moreover, the Institute of Medicine stressed it as a fundamental approach to improve the quality of care in the US, and the potential benefits accrued by its implementation are substantial. These benefits encompass patients (including increased satisfaction, trust, adherence, and 'hard' health outcomes), physicians (including rediscovering meaning and escaping burnout), and health care systems. Highlighting the quintessential value of humanism and patient-centeredness in the encounter, we discuss the cornerstones of adopting a 'personal' attitude that requires sincere friendly 'connecting' to the patient which can be accomplished with little loss of time, and their myriad advantages, to motivate clinicians to be more mindful of the patient and his or her circumstances.

Experiences of individuals receiving a sex chromosome multisomy diagnosis.

Sex chromosome multisomies (SCMs) are genomic conditions with variable phenotypes that range from undetectable to requiring extensive clinical intervention. Currently, many individuals with SCMs are diagnosed in adolescence or adulthood based on physical symptoms related to pubertal development and infertility. Given the expansion of genetic testing in routine clinical practice, the diagnosing clinician is increasingly a primary care or family medicine provider. This study aims to help providers better understand the patient experience of receiving a diagnosis. We conducted a survey of individuals (n = 55) with SCMs using closed and open-ended questions. Open-response questions were qualitatively analyzed and are reported here with the descriptive results of the closed-ended questions. Most participants were diagnosed with 47,XXY (n = 51; 85.0%), identified as White race/ethnicity (n = 46; 88.5%), and were college graduates or higher (n = 29; 54.7%). Many participants reported dissatisfaction with the delivery of the diagnosis, expressing that it was rushed and their provider lacked detailed information about the condition. Participants were frustrated by the general lack of availability of high-quality informational resources from both medical and other sources at the time of diagnosis. Some participants also described the social and psychological impact of the diagnosis and how it was delivered. To the best of our knowledge, this is the largest survey of individuals diagnosed with SCMs, which is notable considering their prevalence and low diagnostic rate. Our findings provide patient-informed insight on how to improve the delivery of SCM diagnoses, especially delivery in a primary care setting, including the provision of up-to-date information and proactive referral to specialty care and counseling services.

Health Communication and Sexual Orientation, Gender Identity, and Expression.

The purpose of this article is to provide guidance on completing a thorough, competent, and culturally appropriate health history with details specific to the care of lesbian, gay, bisexual, transgender, queer, intersex, and asexual (LGBTQIA) persons and communities.

Adaptive leadership in clinical encounters with women living with HIV.

BACKGROUND: Women living with HIV (WLWH) report low engagement in health care, missed office visits, and less engagement in the clinical encounter. Strengthening the clinical encounter for WLWH may improve health outcomes and quality of life. The Adaptive Leadership Framework for Chronic Illness offers specific adaptive leadership strategies for providers to improve patient-provider interactions. The purpose of this study was to examine adaptive leadership behaviors that contribute to the development of effective patient-provider communication from the perspectives of WLWH. METHODS: The descriptive, cross-sectional and qualitative study conducted interviews with 22 WLWH to assess perceptions of the clinical encounter related to HIV-related stigma, engagement in care, medical distrust, and experiences with discrimination and quality of life. Members of the study team using a set of a priori codes analyzed data using NVivo 12.0. RESULTS: Participants described two primary themes and subthemes of each for adaptive leadership behaviors. The primary theme for adaptive leadership of providers was "my provider cares about me"; subthemes were communication, trust building takes time, and supportive providers are trusted. The primary theme for adaptive leadership of WLWH themselves was "I care about me; subthemes were self-advocacy and self-empowerment. CONCLUSIONS: Providers can use adaptive leadership behaviors during clinical encounters to support WLWH, improve patient-provider communication, enhance trust, and improve patient outcomes.

Pain management communication between parents and nurses after pediatric outpatient surgery.

PURPOSE: The purpose of this study was to explore parent-nurse pain management communication during a child's discharge process following pediatric outpatient surgery. DESIGN AND METHODS: Thirty-two clinical encounters at discharge between parents (N = 40) and nurses (N = 25) at BC Children's Hospital were audio recorded and transcribed verbatim. Content analysis was applied on the audio recordings and corresponding transcripts using MAXQDA qualitative research software and Microsoft Excel. RESULTS: Overall, nurses delivered pain management instructions at an average sixth grade readability level and frequently used communication elements of reassurance, optimism, and question-asking. Less consistent communication elements included open-ended questions, interruptions, and promotion of parental decision-making. Parents most frequently asked one to five questions, with pain medication being the most inquired topic. CONCLUSIONS: Several strengths of the nurse communication approach were identified, and parent questions highlighted a need for greater understanding around pain medication. PRACTICE IMPLICATIONS: These findings will help guide effective pain management communication and care for young patients and their families.

"I'm not the doctor; I'm just the patient": Patient agency and shared decision-making in naturally occurring primary care consultations.

OBJECTIVES: To explore interactional processes in which clinical decisions are made in situ during medical consultations, particularly the ways in which patients show agency in decision-making processes by proposing and opposing actions, and which normative dimensions and role-expectations their engagement entail. METHODS: Narrative analysis of verbatim transcripts of 22 naturally occurring consultations, sourced from a corpus of 212 consultations between general practitioners and patients in England. After thematically coding the whole dataset, we selected 22 consultations with particularly engaged patients for in-depth analysis. RESULTS: Patients oppose further actions more often than they propose actions, and they oppose more directly than they propose. When they explain why they propose and oppose something, they reveal their values. Patients' role-performance changes throughout the consultations. CONCLUSION: Assertive patients claim - and probably also achieve - most influence when they oppose actions directly and elaborate why. Patients display ambiguous role-expectations. In final concluding stages of decision-making processes, patients usually defer to GPs' authority. PRACTICE IMPLICATIONS: Clinicians should be attentive to the ways in which patients want to engage in decision-making throughout the whole consultation, with awareness of normative dimensions of both process and content, and the ways in which patient's actions are constrained by their institutional position.

Becoming data. Patient perspectives on using an eTool in physiotherapy sessions.

The purpose of this investigation was to gain insights into how patients experience using an electronic tool as part of their physiotherapy assessment, goal setting, and treatment planning.The research data were generated through close observation of eight clinical encounters in primary health care, where the electronic tool was used. Observations were followed by interviews with physiotherapists and patients involved. This manuscript elaborates on the patient informants' perspectives. The analyses, inspired by postphenomenological theory and research, sheds light on patients' concerns whether reliance on what they perceive as fragmented and incomplete data generated from PROM tools will obscure health matters rather than provide health benefits.By various means, including translations, adaptions, and editing together with their physiotherapist, patients were often able to manage their data into, for them, an acceptable, recognizable form.The investigation highlights that for patients to have confidence in this technology, and particularly the methodology of PROMs, they need to trust the way data is handled and interpreted.

Telehealth-Based Family Conferences with Implementation of Shared Decision Making Concepts and Humanistic Communication Approach: A Mixed-Methods Prospective Cohort Study.

Smartphone-enabled, telehealth-based family conferences represent an attractive and safe alternative to deliver communication during the COVID-19 pandemic. However, some may fear that the therapeutic relationship might be filtered due to a lack of direct human contact. The study aims to explore whether shared decision-making model combining VALUE (Value family statements, Acknowledge emotions, Listen, Understand the patient as a person, Elicit questions) and PLACE (Prepare with intention, Listen intently and completely, Agree on what matters most, Connect with the patient's story, Explore emotional cues) framework can help physicians respond empathetically to emotional cues and foster human connectedness in a virtual context. Twenty-five virtual family conferences were conducted in a national medical center in Taiwan. The expression of verbal emotional distress was noted in 20% of patients and 20% of family members, while nonverbal distress was observed in 24% and 28%, respectively. On 10-point Likert scale, the satisfaction score was 8.7 ± 1.5 toward overall communication and 9.0 ± 1.1 on meeting the family's needs. Adopting SDM concepts with VALUE and PLACE approaches helps physicians foster connectedness in telehealth family conferences. The model has high participant satisfaction scores and may improve healthcare quality among the pandemic.