Budokan 2018

On average, the image was used during 12.9% (range: 4.5% - 30.6%) of the consultation. Doctors were verbally dominant during the discussions of the images (as shown in Table 9). All patients participated in the discussion about the image, although in several consultations their input was minimal. The mean number of doctor utterances relating to the image was 68, (range 11 -181) compared to a mean of 7 (range 1 – 15) patient utterances relating to the image.

142

Table 9: Verbal dominance during the discussion of the medical images Consultation Number Doctor (Clinician and Consultant) Patient (Patient and Family Member) Ratio (Patient : Doctor) Percentage of consultation discussing image 1 181 10 1 : 18.1 24.7 6 66 4 1 : 16.5 11.9 7 50 1 1 : 50 8.6 8 11 1 1 : 11 4.5 9 16 3 1 : 5.3 10.3 10 101 7 1 : 14.4 30.6 11 42 11 1 : 3.8 9.8 12 49 9 1 : 5.4 4.9 13 66 15 1 : 4.4 10.3 14 100 9 1 : 11.1 11 Mean 68 7 1: 9.7 12.9

In all consultations, the majority of utterances relating to the image were coded as “explains image”. In half of the consultations, the image was also used to explain treatment and in six consultations, the image was used to answer patients’ questions. Table 10 shows the number of utterances coded into each image code for each consultation. Patients were also involved in the discussions of the image, even when their input was minimal. Patient 7, for example, only made one utterance related to the image. He asked a question about the image, suggesting engagement with the image.

143

Table 10: Frequency of each image code within each consultation and percentage of consultation discussing images

Image Code P1 P6 P7 P8 P9 P10 P11 P12 P13 P14 Total

Explains Image 118 55 47 7 17 82 34 50 75 105 590

Patient Responds to Image 2 0 0 0 2 1 7 1 1 2 16

Patient Asks Question about the Image 5 0 1 0 0 4 2 0 2 1 15

Treatment Explained Using the Image 60 15 0 5 0 13 5 0 0 0 98

Clinician Answers a Question using the Image 6 0 3 0 0 8 5 0 3 1 26

Total 191 70 51 12 19 108 53 51 81 109 745

Boxes one and two present excerpts from the data to provide examples of discussion relating to the image codes. Box one shows a consultant explaining the image and the patient responding to the image. The consultant explains what can be seen in the image before explaining the problem with the patient’s hip. Box two shows a patient asking questions about the image and his clinician answering a question using the image. In this excerpt from the recording, we can see that the clinician returns to a different image to answer the patient’s question.

144

Con2 So this is the back of your hip joint here (shows on 3D image) and this is part of the socket (shows on 3D image) and that is the top end of the thigh bone (shows on 3D

image)

P13 yes

Con2 and this is the shaft of the thigh bone (shows on 3D image) and there is the ball sitting inside the socket (shows on 3D image) – you will see the ball there as we come round (as image is rotated by consultant). Now at the back in this area as I move it you will sense there is a bit of a recess here and that is not surprising because if you put the ball in the socket like this (demonstrating with hands) P13 mhmm

Con2 – you, and you are building this as part of your engineering you would make a recess there

P13 yes

Con2 so that you have a good range of movement P13 yes

Con2 so we can see that recess there, now can you see that at the front here? (shows on

3D image) there is a little area here where the recess is not so good

P13 yes Con2 yes

P13 so that should continue round?

Con2 it should – this little bit of bone here (shows on 3D image) is a little bit prominent P13 mhmm

Con2 it is not big, P13 mhmm

Con 2 it’s not very very large and that is why you have been able to do all the things you can do without running into trouble

P13 mhmm

Con2 but what you have also see is that just here (shows on 3D image) there is a prominent bit of rim

P13 yes

Con2 of the socket and again if I move it you can see there is the edge of the socket there that looks nice and smooth and then suddenly this bit sticks out just here

P13 yes, so that should then come round smooth right the way round here (points to

image)

Con2 yes so it be coming in like that (shows on 3D image), yes.

145

P7 So going back to the other one (3D image) the left hip. Where you said you might reshape the bone

C2 yes

P7 my understanding of arthritis is it is the re-growing of the bone would that re-grow here then?

C2 Ah ok, yes, so this shape here (shows on 3D image) P7 yes

C2 has probably been here since you were a teenager P7 yes

C2 when I talked about re-growing of the bone, you are right, there are lots of different things that go on in arthritis, the main thing is you lose your cartilage P7 Yes

C2 so the cartilage goes so you have got bone…… P7 & C2 bone rubbing on bone

C2 the bones response to that is to try and grow some extra bone P7 yes

C2 to spread the load a little bit more. That’s why I pointed out here (shows on 2D

image)

P7 yes

C2 see here there is this nice notch P7 yes

C2 and that is normal P7 yes

C2 a little bit further down here (shows on 2D image) there is an extra bit of bone P7 oh has that grown over the notch sort of thing?

C2 yes

Box 2: Discussion of medical images, where clinician answers patients question using the images

146

The additional image codes were coded alongside the RIAS codes. This allowed exploration of which RIAS codes were used when the image was being discussed. As expected, medical images were used to give patients medical and therapeutic information. Images were also used for what is described as “emotional” talk. Specifically, the image was used during statements of reassurance and concern. Utterances related to the image were also coded as “positive talk”. As shown in Table 11, this means that during the discussion of the image, patients and physicians expressed agreement and laughed. None of the utterances related to the image were coded as “negative” talk.

Table 11: Number of image related utterances and the RIAS codes they relate to

Category Number of Image related Utterances

Biomedical 551

 Gives Medical Information 450

 Gives Therapeutic Information 93

 Closed Medical Question 8

Positive Talk 34  Agreement 31  Laughter 3 Emotional Talk 28  Concern 14  Reassures 14

Examples of the use of the image to reassure patients were identified within the video- recordings. Reassurance utterances informed patients that an aspect of the image was normal or nothing to worry about. These are listed below.

“But I wouldn’t worry too much about that at all because you are not getting any pain there” (C3 to P11)

147 “So that looks fine” (C3 to P11)

“And that’s nothing sinister or anything to worry about all that is is little fluid filled pockets within the bone” (Con 1 to P10)