Patient-initiated additional concerns in general surgery visits

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.

Using conversation analysis to appraise how novel educational videos impact patient medical education

OBJECTIVE

To determine in what ways, if any, do patients, caregivers, and nurses make videos relevant during in-person education.

METHODS

We applied conversation analysis to analyze interaction in 12 nurse-led education visits (1011 min of audio) in which speakers referred to a supplemental education video.

RESULTS

Patients initiated talk about the video in about half of the clinic visits analyzed, while nurses initiated talk about the video across all clinic visits analyzed. Interactions showed that patients demonstrated knowledge of video content and clarified information concerning their treatment plans by asking questions of nurses. Nurses referenced the video prior to repeating information that they recognized patients had viewed. In all instances analyzed, nurses made references to the videos in ways that re-oriented conversations back toward the content of the informal scripts that they used to deliver patient education.

CONCLUSION

Patients referenced the video in ways that demonstrated that they had viewed it and had gained knowledge concerning treatment plans, and to ask specific questions about these. Nurses referred to the videos by acknowledging patients' prior knowledge of upcoming information.

PRACTICE IMPLICATIONS

Understanding how pre-delivered supplemental videos impact patient involvement in in-person education contributes understanding to how video-based instruction supports patient-centered care.

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.

Making Conversation Analysis Accessible: A Conceptual Guide for Health Services Researchers

The quality of healthcare communication can impact both experiences and outcomes. We highlight aspects of communication that can be systematically examined using Conversation Analysis (CA) and provide guidance about how researchers can incorporate CA into healthcare studies. CA is a qualitative method for studying naturally occurring communication by analyzing recurrent, systematic practices of verbal and nonverbal behavior. CA involves examining audio- or video-recorded conversations and their transcriptions to identify practices speakers use to communicate and interpret behavior. We explain what distinguishes CA from other methods that study communication and highlight three accessible CA approaches that researchers can use in their research design, analysis, or implementation of communication interventions. Specifically, these approaches focus on how talk is produced (specific words, framing, and syntax), by whom, and when it occurs in the conversation. These approaches can be leveraged to generate hypotheses and to identify patterns of behavior that inform empirically driven communication interventions.

Expanding the Scope of the Visit: Which Patient-Initiated Additional Concerns Receive Help?

This study examines patient-initiated additional concern presentations in general surgery visits to assess which factors contribute to them getting "helped." Concern presentations were analyzed for a variety of design features (e.g., social action (inquiry vs. informing), when patients initiate during a visit, how patients fit topic to previous talk or activity) and contextual factors (e.g., concern falls inside or outside surgeon's domain of expertise, chronic vs. acute concern-types, the history of the patient-physician relationship). This study uses a mixed-methods approach, combining case-level conversation analysis and aggregate-level statistical analysis. Data are video recordings of office visits from 2013-2015, with a longitudinal focus of following the same patients across time. In total, 62 patients spanning 175 visits were analyzed. 377 patient-initiated additional concerns were found, and 188 received help. Several factors were found to increase the likelihood of patients' concerns getting helped such as designing the concern as an inquiry, raising the concern early in the visit, and mentioning the concern more than once. These findings can help guide patients on how to better design additional concerns presentations to receive help and can benefit physicians by identifying more subtle practices patients are already using to broach concerns to help reduce unnoticed or unhelped concerns.

Talking About Things: A Patient Cue for Sensitive Healthcare Problems and Effective Physician Responses

In routine healthcare consultations, patients often use prefaces containing the word "thing", including "the thing is", "there's this thing" or "one more thing". Although "thing" is an all-encompassing term that is used in myriad ways, in this article we show that thing-prefaces perform a specific job. This study uses Conversation Analysis to analyze 90 video-recorded primary care consultations with 14 primary care physicians in the United States. Patients' thing-prefaces mark the upcoming talk as a disclosure of sensitive information that may reflect negatively on the patient, physician or service (e.g., medication nonadherence, refill was not sent to pharmacy). Patients pursue explicit resolution of these problems (e.g., personalized recommendation, lab work, referral) despite these problems being downplayed and treated as delicate. Because patients may "talk around" these sensitive issues, thing-prefaces can be an important cue for physicians that patients are seeking resolution for a sensitive healthcare problem.

Visit Linearity in Primary Care Visits for Patients with Chronic Pain on Long-term Opioid Therapy

BACKGROUND

Physicians and patients report frustration after primary care visits for chronic pain. The need to shift between multiple clinical topics to address competing demands during visits may contribute to this frustration.

OBJECTIVE

This study creates a novel measure, "visit linearity," to assess visit organization and examines whether visits that require less shifting back and forth between topics are associated with better patient and physician visit experiences. It also explores whether visit linearity differs depending on the following: (1) whether or not pain is a major topic of the visit and (2) whether or not pain is the first topic raised.

DESIGN

This study analyzed 41 video-recorded visits using inductive, qualitative analysis informed by conversation analysis. We used linear regression to evaluate associations between visit organization and post-visit measures of participant experience.

PARTICIPANTS

Patients were established adult patients planning to discuss pain management during routine primary care. Physicians were internal or family medicine residents.

MAIN MEASURES

Visit linearity, total topics, return topics, topic shifts, time per topic, visit duration, pain main topic, pain first topic, patient experience, and physician difficulty.

KEY RESULTS

Visits had a mean of 8.1 total topics (standard deviation (SD)=3.46), 14.5 topic shifts (SD=6.28), and 1.9 topic shifts per topic (SD=0.62). Less linear visits (higher topic shifts to topic ratio) were associated with greater physician visit difficulty (β=7.28, p<0.001) and worse patient experience (β= -0.62, p=0.03). Visit linearity was not significantly impacted by pain as a major or first topic raised.

CONCLUSIONS

In primary care visits for patients with chronic pain taking opioids, more linear visits were associated with better physician and patient experience. Frequent topic shifts may be disruptive. If confirmed in future research, this finding implies that reducing shifts between topics could help decrease mutual frustration related to discussions about pain.

How hospitalized older adults share concerns during daily rounds

OBJECTIVE

To explore how hospitalized older adults' concerns are solicited and shared during daily rounds.

METHODS

We audio recorded 40 physician-patient conversations during daily rounds in a Veterans Affairs Hospital. We developed codes from the conversation analysis (a qualitative method) for the event sequence analysis (a quantitative method) to calculate the conditional probabilities of physicians soliciting for general concerns leading to patients sharing concerns. We used a mixed-effects Poisson regression to calculate the relationship between number of concerns shared and patient education.

RESULTS

Most of the 141 concerns were shared during the assessment questions and discussion of the plan of care, such as concerns about the patient's caregiving responsibilities. The conditional probability was higher when physicians solicited for concerns after the assessment questions (0.56) than during the opening (0.25) or the closing (0.19) of the conversation. The design of the solicitation influenced the probability of patients sharing concerns. The number of concerns shared did not differ by level of education.

CONCLUSION

Physicians can provide opportunities for patients to share concerns.

PRACTICE IMPLICATIONS

Soliciting for concerns after the assessment questions, asking "what" concerns a patient may have, and asking about caregiving responsibilities may be useful for patients to share their concerns.

Agenda setting and visit openings in primary care visits involving patients taking opioids for chronic pain

Background

Agenda setting is associated with more efficient care and better patient experience. This study develops a taxonomy of visit opening styles to assess use of agenda and non-agenda setting visit openings and their effects on participant experience.

Methods

This observational study analyzed 83 video recorded US primary care visits at a single academic medical center in California involving family medicine and internal medicine resident physicians (n = 49) and patients (n = 83) with chronic pain on opioids. Using conversation analysis, we developed a coding scheme that assessed the presence of agenda setting, distinct visit opening styles, and the number of total topics, major topics, surprise patient topics, and returns to prior topics discussed. Exploratory quantitative analyses were conducted to assess the relationship of agenda setting and visit opening styles with post-visit measures of both patient experience and physician perception of visit difficulty.

Results

We identified 2 visit opening styles representing agenda setting (agenda eliciting, agenda reframing) and 3 non-agenda setting opening styles (open-ended question, patient launch, physician launch). Agenda setting was only performed in 11% of visits and was associated with fewer surprise patient topics than visits without agenda setting (mean (SD) 2.67 (1.66) versus 4.28 (3.23), p = 0.03).

Conclusions

In this study of patients with chronic pain, resident physicians rarely performed agenda setting, whether defined in terms of “agenda eliciting” or “agenda re-framing.” Agenda setting was associated with fewer surprise topics. Understanding the communication context and outcomes of agenda setting may inform better use of this communication tool in primary care  practice.

When and how do surgeons initiate noticings of additional concerns?

OBJECTIVE

Physicians are trained on how to best solicit additional concerns from patients. What has not yet been studied is when and how physicians initiate additional concerns. This analysis focuses on when and how general surgeons share their noticings of medical problems unrelated to the upcoming (or recent) procedures that patients are being seen for.

METHODS

281 video-recorded medical encounters with 95 patients from a rural Texas (USA) general surgery private practice were reviewed for surgeon noticings of additional concerns. In addition to analyzing the videos using Conversation Analysis, the author conducted 9 months of ethnographic research to gain understanding of the local setting.

RESULTS

22 cases of surgeon noticings were found in 17 visits and were typically detected during the physical examination. Surgeons shared noticings adjacent to their discovery and predominantly framed noticings as bad news tellings. This framing helped mitigate 4 dilemmas surgeons encountered: unknown patient awareness of concern, surgeons' rights to assess areas unrelated to upcoming (or recent) procedures, not meeting the desired health optimization outcome & putting additional burden on patients, and other contextual factors specific to the visit that make sharing a noticing difficult. In addition to alerting patients and potentially activating earlier treatment, sharing noticings can also function to help build physician-patient relationships across time and curtail future patient worry.

IMPLICATIONS

Each surgeon noticing is potentially a concern that may have otherwise remained undetected and untreated, and speaks to the importance of physicians taking time to conduct thorough physical examinations.