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

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.

Communication in Telehealth: A State-of-the-Art Literature Review of Conversation-Analytic Research

We provide a state-of-the-art review of research on conversation analysis and telehealth. We conducted a systematic review of the literature, focusing on studies that investigate how technology is procedurally consequential for the interaction. We discerned three key topics: the interactional organization, the therapeutic relationship, and the clinical activities of the encounter. The literature on telehealth is highly heterogeneous, with significant differences between text-based care (e.g., via chat or e-mail) and audio(visual) care (e.g., via telephone or video). We discuss the extent to which remote care can be regarded as a demarcated field for study or whether the medium is merely part of the "context," particularly when investigating hybrid and polymedia forms of care involving multiple technological media.

Health Communication Research Informs Inflammatory Bowel Disease Practice and Research: A Narrative Review

Background

In the absence of targeted empirical evidence on effective clinical communication in inflammatory bowel disease (IBD), a broad overview of existing evidence on effective communication in healthcare and available recommendations for communication in telehealth is provided and mapped onto IBD research and practice.

Methods

A narrative literature review was conducted using Pubmed and Scopus databases and snowballing literature search.

Results

Evidence-based relationship building strategies include communicating emotions, acknowledging and addressing patients' hesitancy, and ensuring continued support. A particular recommendation regarding telehealth interaction is to avoid long stretches of talk. Effective informational strategies include facilitating and supporting information exchange and considering patients' preferences in decision-making. In teleconsultations, clinicians should ask direct questions about patients' emotional state, clarify their understanding of patients' concerns and check patients' understanding, address at least one patient-reported outcome when discussing the recommended treatment, and shorten the consultation where possible. Strategies for maximizing effective clinical communication in the spoken communicative mode include using infographics and simple language, and assessing adherence at the beginning of the consultation. For teleconsultations, clinicians are advised to allow patients to explain the reason for their call at the beginning of the teleconsultation, probe additional concerns early and before ending the teleconsultation, and be mindful of technical issues such as voice delays.

Conclusions

Use of question prompt lists, decision aids, micro-lessons, and communication training interventions for clinicians could be beneficial in IBD care. Further research into the implementation of such interventions as well as clinical communication concerns specific to IBD is warranted.

Patients' Experiences With the Fit of Virtual Atrial Fibrillation Care During the Pandemic: Qualitative Descriptive Study

BACKGROUND

In-person health care has been the standard model of care delivery for patients with atrial fibrillation (AF). Despite the growing use of remote technology, virtual health care has received limited formal study in populations with AF. Understanding the virtual care experiences of patients in specialized AF clinics is essential to inform future planning of AF clinic care.

OBJECTIVE

This qualitative descriptive study aimed to understand patients' virtual AF clinic care experiences during the COVID-19 pandemic.

METHODS

Participants were recruited from a pool of patients who were receiving care from an AF clinic and who were enrolled in a larger survey study. A total of 8 virtual focus groups (n=30) were conducted in 2 waves between March 2021 and May 2021. Facilitators used a semistructured discussion guide to ask participants questions about their experiences of virtual care and the perceived quality of virtual care and technology support. Three team members initially open coded group data to create a preliminary coding framework. As the analysis progressed, with subsequent focus groups, the code clusters were refined.

RESULTS

The participants were primarily male (21/30, 70%), aged ≥65 years (20/30, 67%), and college graduates (22/30, 73%). Patients found virtual care to be highly beneficial. Central to their experiences of virtual care was its fit or lack of fit with their health needs, which was integrally connected to communication effectiveness and their preferred virtual care future. Practical benefits included flexibility, convenience, and time and cost savings of virtual care. Virtual care fit occurred for small, quick, and mundane issues (eg, medication refills) but was suboptimal for new and more complex issues that patients thought warranted an in-person visit. Fit often reflected the effectiveness of communication between patient and provider and that of in-clinic follow-up. There was near-complete agreement among participants on the acceptability of virtual communication with their providers in addressing their needs, but this depended on adequate reciprocal communication. Without the benefit of in-person physical assessments, patients were uncertain and lacked confidence in communicating the needed, correct, and comprehensive information. Finally, participants described concerns related to ongoing virtual care with recommendations for their preferred future using a hybrid model of care and integrating patient-reported data (ie, blood pressure measurements) in virtual care delivery.

CONCLUSIONS

Virtual care from a specialty AF clinic provides practical benefits for patients, but they must be weighed against the need for virtual care's fit with patients' needs and problems. The stability and complexity of patients' health needs, their management, and their perceptions of communication effectiveness with providers and clinics must be considered in decisions about appointment modality. Patients' recommendations for future virtual care through use of hybrid models together with systems for data sharing have the potential to optimize fit.