JMIR Publications

ABSTRACT

Background:

Video-mediated clinical consultations offer potential benefits over conventional face-to-face ones in terms of access, convenience and (sometimes) cost. Improved technical quality and dependability of video-mediated consultations has opened up the possibility for more widespread use. But questions remain about clinical quality and safety. Video-mediated consultations are sometimes criticised as “not as good as” face-to-face ones, but there has been little previous in-depth research on their interactional dynamics, and there is not yet agreement on what good looks like.

Objective:

Using the in-depth qualitative technique of conversation analysis, to identify and analyse the communication strategies through which video-mediated consultations are accomplished, and produce recommendations for patients and clinicians for improving the communicative quality of such consultations.

Methods:

In-depth analysis of the clinician-patient interaction in a sample of video-mediated consultations and a comparison sample of face-to-face consultations drawn from four clinical settings across two trusts (one community and one acute) in the English National Health Service (NHS). The video dataset consisted of 37 recordings of video-mediated consultations (with diabetes, antenatal diabetes, cancer and heart failure patients), 28 matched audio-recordings of face-to-face consultations and fieldnotes from before and after each consultation. We also drew on 37 interviews with staff and 26 interviews with patients. Using linguistic ethnography (combining fine-grained analysis of communication with an appreciation of the context in which it takes place), we examined in detail how video interaction was mediated by two different software platforms (Skype and FaceTime).

Results:

Patients had been selected as ‘appropriate’ for video-mediated consultation, and most such consultations in our sample were, broadly speaking, technically and clinically unproblematic. However, we identified three interactional challenges: (i) opening the video consultation, ii) dealing with disruption to conversational flow (e.g. technical issues with audio and/or video), and (iii) conducting a examination. Operational and technological issues were the exception rather than then norm. In all but one case, both clinician and patient (deliberately or intuitively) used established communication strategies to successfully negotiate these challenges. Remote physical examinations required the patient (and, in some cases a relative) to simultaneously follow instructions and manipulate technology (e.g. camera) to make it possible for the clinician to adequately see and hear.

Conclusions:

A remote video link alters how patients and clinicians interact and may adversely affect the flow of conversation. However, our data suggest that when such problems occur, clinician and patient work collaboratively to find ways to overcome them. There is potential for a limited physical examination to be undertaken remotely with some patients and in some conditions, but this appears to need complex interactional work by the patient and/or their relatives. We offer preliminary guidance for patients and clinicians on what is and is not feasible when consulting via video link.