comfortable doing so.
Questions 2 & 3 covered understanding and addressing the patients’ and parents’ concerns. All 12 responses agreed that they could understand the concerns; 11 agreed that they were able to address those concerns and the remaining response was neutral. Responding to Question 4, all 12 agreed that they were able to explain future treatment plans and expected outcomes during the telehealth phase.
At Question 5 all 12 agreed that they were able to direct the assistant. At Question 6, 11 responses agreed that they were able to understand what the assistant was seeing, touching and doing and the remaining response was neutral.
For each patient the surgeons completed a two-item questionnaire. To the assertion that the telehealth appointment alone was satisfactory the responses were 39 “Agree”, 3 “Neither” and 2 “Disagree” covering all 44 patients. Asked whether they would have been satisfied to let the patient leave after the telehealth appointment the responses were 41 “Yes” and 3 “No”, again covering all 44 patients.
Of the two patients for whom the surgeons did not think the telehealth phase alone was satisfactory one family did not speak English and needed an interpreter and the other presented with a new problem in addition to the problem being tackled.
One of the three patients which the surgeons would not have wanted to leave after only the telehealth phase had the interpreter. For the second case the surgeon wanted to offer face-to-face reassurance about the conservative treatment plan he was proposing. The third was a new case (technically out of scope for this trial) for which the telehealth phase adequately created a plan for diagnostic investigations but was not adequate in terms of establishing the basis for a long-term doctor-patient relationship.
Interview data
During their interviews after the clinics the surgeons talked extensively about their experience and impressions of using the telehealth system. Two surgeons who each conducted four clinics worked together on the very first clinic and the exit interview was essentially a discussion between them about the situation.
In this first clinic we saw them being uncertain about how well they addressed the patients’ concerns and reflecting on not actually being with the patient:
Surgeon2: I’d be interested to see what they fill in on the questionnaire for that. I’m not sure you can [address their concerns] as being remote as much as if you were there. Maybe we like to think that as doctors that the presence or the touch has some value. I’d put neither agree nor disagree myself.
Surgeon1: I would absolutely concur ‘cause that’s the one thing that we feel – it’s an alien nature to be detached. It’s, it’s absolutely intrinsic to be involved, you know to be hands on and we almost feel jealous of <assistant> being in there and doing it.
They conclude, even at this early stage in the pilot, that it is possible to conduct these outpatient clinics using this system:
Surgeon2: You become more the expert witness rather than the actual operator, which is sad for us because we like being the operator. Um, but it works, it certainly works.
We also saw them reflecting on the learning process ahead of them.
Surgeon1: I don’t think anything went badly, I mean I think we’ll improve as the month goes by … I know that I will try and work out a comfortable way for me to address those concerns about not being physically involved and not being able to get hands-on information which is what I depend on all the time.
[This surgeon mentioned an early field trip of ours when one of the researchers had charted his movements all around the clinic room and then compared that to sitting in the surgeon’s chair in the telehealth suite]
We saw them discussing the limits of such a telehealth approach. They discussed the difficulty of seeing new patients and discharging old patients with this system.
Surgeon2: I think the ones that are most difficult are the ones that you probably want to get rid of, you want to discharge. Like the boy, the fractures. He for me was the most difficult because you almost want that hands on to reassure you that you can just say right okay we’ve done all we can, goodbye.
Surgeon1: We’ve not yet explored what it would be like to see a new patient. I don’t think I’m brave enough to do that yet because there would be so much uncertainties things, the tension’s already quite high when they come and see us
Later in the trial, however, we saw these surgeons comfortably discharging patients in the telehealth phase, and even successfully dealing with a new patient with multiple complex conditions.
They discussed the issue of the patients’ paper-based medical records which had been placed in with the assistant for that clinic. They resolved to place the medical records with the surgeon so that he could brief the assistant prior to the patient entering the
room. They also discussed planning the consultation with the assistant, using shared access to the X-rays, and placing a clock in the surgeon’s room so that they might aim for a standard 15 minutes for the telehealth phase.
The following day Surgeon2 conducted the next clinic:
Surgeon2: It’s amazing what a difference a day makes. … the learning curve is very fast … you sort of adapt your technique.
He commented on the procedural change of reading the notes/briefing the assistant before the patient enters:
Surgeon2: It worked better if you sit down and read the notes a little bit so there’s not a large pause and I think in a clinic the pauses don’t seem so awkward but on this they seem a little bit more awkward.
Surgeon1 made a similar comment after his second clinic at the start of week 2:
Surgeon1: I’m getting quite confident with this now, and I’m able to direct things in a way that will allow me to get through it far more efficiently
He also commented on their new way of using the patients’ medical records:
Surgeon1: I think it worked very well for me, ‘cause it crystallised my thoughts, got me much better prepared to kind of get things running in the conversation with the parents and the kids themselves and allowed <assistant> to clarify in his mind how he would like the consultation and examination to go …that’s why we were able to keep well to time, which is critical to making this work.
In discussing the criterion for success for this type of telehealth consultation he said:
Surgeon1: … routine reviews where success is not having to change the plan, the examination remains consistent and repeatable. Where it gets to things that are slightly off or where there are concerns that require specific intervention or investigations it may work as a preamble but better face to face
This surgeon concluded the exit interview with:
Surgeon1: … overall I think by the end of the month I’ll be quite happy to do this, this kind of consultation … so if this were to be a long term plan I’d be quite comfortable doing it
After the third clinic of that first week Surgeon3 commented on the quality of the video subsystems:
Surgeon3: You feel like you could make eye contact with the patient, so it was good, yeah. Later, commenting again on the support for personal communication
Surgeon3: It was pretty much, pretty similar to a face to face really. Had a sort of close to and face to face feel about it.
The fourth surgeon only conducted one clinic. He commented on the way the system worked and on the skill level of the assistant:
Surgeon4: Ah, no, I don’t think there were any issues at all. I think in fact it works, the system seems to work the way it’s set up it works very well
Surgeon4: I was, yeah but I think you’ll need an experienced person at the other end ‘cause I could then just ask them to do things, I didn’t have to direct him on how to do what I wanted to see.
After his second clinic Surgeon3 commented:
Surgeon3: I thought well they were all pretty much like normal appointments to me, I don’t see any shortfalls so far ah except for the macro issue for close ups [he had tried to use the arm-mounted camera pair to look for millimetre-height texture on the patient’s face and this went beyond the capability of the camera lens]
For his third clinic Surgeon1 doubled the number of patients to see if the system could cope with approximately normal patient scheduling. The surgeon was confident in his use of the telehealth system:
The surgeon noted two changes in the role the assistant is playing [he has worked with this same assistant for all three clinics]. The assistant is able to anticipate how the patient examination should proceed and is presenting the surgeon with the results:
Surgeon1: He makes sure that I can see what he wants me to note … we vocalise everything, verbalise everything so that it gets said, it registers.
The surgeon noted that he was communicating less about the physical findings with the patient because the assistant was doing this. Communication between the assistant and patient occurred in lay language; communication between the assistant and the surgeon occurred in clinical language. He also commented that he is able to take advantage of not having to manage the patient and the details of the examination to write up his clinical notes:
Surgeon1: It makes sure that all the important things are written down without the chance of forgetting to write the sort of document down, ‘cause note-keeping is so critical as being a record of what happened. For me that’s an indirect benefit of this which I never expected at all.
At Surgeon2’s third clinic he observed that this system really worked for long-term cases – patients that they see repeatedly:
Surgeon2: Where you just want a little bit of what’s happening now. Rather than making big decisions, rather than planning out operations and corrections – where, “Are we actually on track like I think we should be?”
He also reflected on changes:
Surgeon2: I think we adapted some of our stuff that we do, but not in a huge way. I think we just got more comfortable with it. … I suppose I’m getting used to the fact that I can’t go and touch them.
Surgeon5 also conducted only one clinic. He commented on using the telehealth system:
Surgeon5: Yeah, it works fine, yeah you could establish a rapport with family and get where you need to get, yeah.
He also commented on learning to use the system:
Surgeon5: Actually I started to warm up and be able to work out which camera I wanted and how to direct it so … I was learning on the job.
Surgeon5: [commenting on using the cameras to examine the patient] … you only need to do it once and you realise where it will work and where it won’t
In this last week of the trial Surgeon1 summarised the overall outcome of the trial for him, after having an unexpectedly difficult case in his last clinic:
Surgeon1: I think ah we overall challenge ourselves in different ways and I’m glad we did because it would’ve been a false sense of achievement if we had got very simple cases and then say oh yeah this we can do and oh yeah this is no problem at all to be faced with real difficulties when you try to reproduce that in the real world. This one [i.e. this pilot trial] has allowed us to say can we do interpreters, can we do kids with complex disabilities, can we do kids who have more than one problem.
In his final exit interview Surgeon2 explored the boundaries of where this telehealth concept would work for his speciality (orthopaedics):
Surgeon2: The whole thing’s concept works extremely well, the whole thing can run really smoothly, but I think it works best for the patients that you know well
He then cited the example of that last clinic to show how touch is important:
Surgeon2: When I went into the room to see her … you appreciate why she’s got knee pain ‘cause <list of clinical first-hand observations> and when you see her in the flesh you can appreciate that. … How do you assess knee pain if you can’t touch the patient?
11.3.4
Assistants
Question 1 dealt with their level of comfort in managing the greeting stage of the