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Research on the use of video-mediated technology for medical consultations is increasing rapidly. Most research in this area is based on questionnaires and focuses on long-term conditions. The few studies that have focused on physical examinations in video consultations indicated that it poses challenges for the participants. The specific activity of wound assessment through video in postsurgery consultations has not yet been studied. Furthermore, a comparative analysis of face-to-face and video settings on the moment-to-moment organization of such an activity is original.
The aim of this study was to examine the impact of video technology on the procedure of postsurgery wound assessment and its limits.
We recorded 22 postoperative video consultations and 17 postoperative face-to-face consultations. The primary purpose of the consultation was to inform the patient about the final pathology results of the resected specimen, and the secondary purpose was to check on the patient’s recovery, including an assessment of the closed wound. The recordings were transcribed in detail and analyzed using methods of conversation analysis.
The way that an assessment of the wound is established in video consultations differs from the procedure in face-to-face consultations. In the consultation room, wound assessments overwhelmingly (n=15/17) involve wound showings in the context of surgeons reporting their observations formatted with evidentials (“looks neat”) and subsequently assessing what these observations imply or what could be concluded from them. In contrast, wound assessments in video consultations do not tend to involve showing the wound (n=3/22) and, given the technological restrictions, do not involve palpation. Rather, the surgeon invites the patient to assess the wound, which opens up a sequence of patient and physician assessments where diagnostic criteria such as redness or swollenness are made explicit. In contrast to observations in regular consultations, these assessments are characterized by epistemic markers of uncertainty (“I think,” “sounds...good”) and evidentials are absent. Even in cases of a potential wound problem, the surgeon may rely on questioning the patient rather than requesting a showing.
The impact of video technology on postoperative consultations is that a conclusive wound assessment is arrived at in a different way when compared to face-to-face consultations. In video consultations, physicians enquire and patients provide their own observations, which serve as the basis for the assessment. This means that, in video consultations, patients have a fundamentally different role. These talking-based assessments are effective unless, in cases of a potential problem, patient answers seem insufficient and a showing might be beneficial.
Video consultations are generally found promising for use in the medical domain, especially due to advantages such as remoteness, convenience for patients and informal caregivers, and reduced anxiety [
Conversation analytical studies of medical video consultations are beginning to uncover microlevel dimensions and challenges of video-mediated consultations [
A key domain of interest to medical video consultations is the physical examination, which requires the physician’s visual access to the patient’s body. Visual access is an affordance [
When physicians examine patients, they may communicate the findings of their observations to the patient [
There are two primary formats for communication along with physical examination, namely, reports of observations and assessments of what is observed [
Assessments are evaluations of objects and events in talk-in-interaction [
A specific occasion for the occurrence of assessments are “informative showings” [
The question this paper addresses is how assessments of a surgical closed wound are collaboratively produced in video consultations where the physician lacks direct perceptual access to the assessable, which is available in the face-to-face setting. This question provides insights to the ways that video technology as a mode of communication affects clinical practice.
The data consist of 39 video recordings of follow-up consultations after abdominal cancer surgery, including 17 copresent consultations (average length 13 minutes and 40 seconds) and 22 video consultations (average length 12 minutes and 20 seconds). The data were collected in the context of a study comparing the conversational organization of video-mediated consultations with regular consultations at the outpatient clinic during the first postoperative consultation after discharge [
A waiver for medical ethical approval was obtained from Radboud Medical Center Ethical Committee in June 2017. The data were collected in June-July 2017 and March-June 2018. Each consultation was recorded using two cameras, one directed mainly at the surgeon and one at the patient and those that accompanied them, either in the consultation room or on the surgeon’s desktop computer. The recordings, thus, reflect the real-life circumstances of the surgeon, who does not have access to whatever the patient sees or hears such as delays, perturbations, or sequential mismatches (cf [
To juxtapose assessments in copresent and video-mediated consultations, we first identified all wound assessment activities in the data and whether it involved a showing or not. The next step was to examine each case microanalytically using multimodal conversation analysis [
We found that in the copresent setting, wounds were generally assessed on the basis of a showing of the wound. On the contrary, in the video-mediated setting, showings were rare.
Frequency of showing-based and talk-based wound assessment in copresent and video-mediated consultations.
Group | Showing-based wound assessment, n (%) | Talk-based wound assessment, n (%) | No wound assessment, n (%) |
Copresent (n=17) | 15 (88) | 1 (6) | 1 (6) |
Video-mediated (n=22) | 3 (17) | 12 (51) | 7 (32) |
Total (N=39) | 18 (46) | 13 (33) | 8 (21) |
In the following section, we first analyzed the face-to-face default method and then the default video-mediated communication (VMC) method. We found no communicative differences between laparoscopic wounds and other wounds. The two assessment procedures were mostly initiated by the physician who enquires about how the wound is healing. We also discuss one video consultation where the wound assessment is initiated by a patient who reports a potential problem. This allows for an in-depth understanding of the intricacies of wound assessment through video.
Showing-based wound assessments are characterized by a relatively stable structure. It is initiated by the physician asking whether the wound(s) are healing well. The patient’s answer is a tentatively positive evaluation of the wound, upon which the physician expands the sequence with a request to show the wound or an invitation to undress behind the curtain for a physical examination. During the showing or examination, the physician produces observation reports using evidentials and evaluations (“looks neat,” “looks uneventful”). The evaluations tend to be rather brief with general descriptors like “neat,” “good,” and “uneventful.” The excerpt in
Excerpt 1. Regular consultation number 25 (video time: 5:50).
The showing-based wound assessment activity begins with the physician’s yes/no-question (line 1), asking whether the small wounds healed well. The patient confirms with an epistemic downgrade (“according to me” line 2), thus, making an independent assessment by the surgeon a relevant next action. The request to show the wound “can you- briefly pull up the shirt” (line 3) displays a relatively high entitlement [
Screenshot for excerpt 1 (video time: 5:59).
Giving visual access in the showing-based assessment activity does not need to be requested explicitly, as it was in
Excerpt 2. Regular consultation number 36 (video time: 7:37).
When asking how the wound is healing (line 2), the physician points at the patient’s belly, indirectly orienting to the show-ability of the wound. After a single-item positive assessment by the patient’s partner (line 3) and one from the patient (line 4), the patient rises to initiate a showing (
Screenshot 1 for excerpt 2 (video time: 7:38).
Screenshot 2 for excerpt 2 (video time: 7:41).
The VMC default method is a talk-based assessment, which is characterized by a different structure and different epistemic marking compared to showing-based assessments. These sequences also typically begin with the physician asking whether the wound is healing well.
Excerpt 3. Video consultation number 16 (video time: 3:53).
The assessment activity opening question received a positive assessment from the patient, in this case with the epistemic upgrade “a hundred percent” (line 2), which formulates the confirmation as an extreme case and, thus, legitimizes it [
Even when patients produce slightly less overtly rhetoric wound assessments than “hundred percent,” showings are not oriented to relevant next actions. This can be seen in
Excerpt 4. Video consultation number 12 (video time: 3:10).
In response to the activity-opening question (line 1), the patient first confirms, produces a general description of what can be seen on the body (“bruises are gone (.) almost”), and then gives an explicit verbal confirmation that the wounds are healing well. This is elaborated with a formulation of the visual observation of the wounds as the epistemic basis of this claim (“you almost don’t see them anymore some you can’t see anymore” line 6). Note that the patient uses the impersonal “you,” designing this claim as objective rather than as epistemically marked as her own observation.
The patient then expands the positive assessment with a minor problem (“only near my navel” line 9, “that one is still a bit” line 12) although this is contrasted with an overall positive assessment (“but the rest is gone” line 12), which proposes a closing of the assessment. The physician responds with the qualified assessment “well that is all NICE to Hear,” not orienting to the minor problem report but treating the patient’s wound assessment as relatively unspecific (“all”) and as news that he had no direct independent access to. The presented conclusion that follows (“so uh yeah then it did all go WELL”) is built on this general, positive news receipt and covers the whole surgery process, thus, moving out of the activity of wound assessment.
In summary, talk-based wound assessment sequences include the specification of diagnostic criteria (“redness,” “swollenness”), perceptual basis (“some you don’t see anymore”), or reference to a location on the body (“near my navel”). These may be elicited by the physician or volunteered by the patient. Generally, in such VMC talk-based assessments, physicians arrive at qualified wound assessments, marking them as epistemically grounded in the patient’s evaluation rather than in their own observation or examination.
In the examples so far, the assessment sequences were initiated by the physician enquiring about the wound. However, wound assessments may also be initiated by patients rather than physicians with a report or question addressing some sort of trouble with regard to the wound. Although wound (or location) showings do occur (n=3/22 of video consultations), even patient-initiated sequences, which make a wound assessment relevant, may unfold as
To begin with, the patient refers to the viewable wound in her presentation of the problem (lines 4-5), which creates an opportunity for the physician to request a showing (a so-called “touched-off” showing [
Excerpt 5. Video consultation 1 (video time: 1:54).
The physician, asking whether the patient also sees something at the wound, orients to the viewability and, thus, potential show-ability of the wound. The patient denies something can be seen, and the physician expands by making explicit what could be seen, namely, redness (line 15). This further question also receives a “no,” but is then elaborated on with an account that implicitly proposes a scale of redness indicating the wound is not “extra red” (line 19). “Not extra red or so” implies the wound is (a bit) red, which may be a flag for trouble to the physician. Saliently, the patient produces this assessment without direct visual access (ie, she is not simultaneously inspecting the wound). Moreover, it is marked with an epistemic downgrade (“I find” line 19), thus, designing this observation as not only rooted in her earlier observation but also as subjective (or “subject-side” [
From this point onward, the patient reports tactile observations including that it is “not swollen there” (line 32), followed by a further potentially troublesome description “it’s a bit (.) hard” (line 36), which introduces yet another category. Nevertheless, the sequence is collaboratively closed with an orientation to the problem as minimal (“that’s all actually” line 43) and, thus, not in need of further discussion. The physician then starts a new but related sequence on the patient’s activities during the past weeks (data not shown), which eventually leads to his wound and pain assessment as “innocent” (line 45) with multiple disfluencies and hedges (“uh’s,” “at first really”), and an epistemic downgrade (“I consider that”). Hence, a talk-based assessment in cases of potential trouble may reside in talk to avoid a showing request. It includes the explication of multiple diagnostic criteria and may involve reference to various sensorial observations by the patient, and it eventually leads to a qualified wound assessment.
Our primary finding is that video consultations differ from copresent consultations with regard to wound assessment. Talk-based wound assessment is the dominant trajectory in video consultations, while showing-based wound assessment is the dominant method in copresent consultations. Both trajectories are generally initiated with an informing question by the physician, but the subsequent steps differ. The activity continues with either a showing or examination of the wound, or with one or more questions enquiring the absence of specific diagnostic criteria (eg, redness, swollenness). Showing-based assessments work toward evidentially grounded general assessments (“neat,” “good,” “uneventful”), while talk-based assessments arrive at qualified assessments, which display a lack of direct access to the assessable (“sounds,” “I consider that”). Hence, wound assessments in video consultations are grounded in patient assessments, which implies a shift in clinical practice from primacy of the doctor’s gaze to the patient’s evaluation of how the wound(s) are healing. Even in cases of potential wound trouble in video consultations, physicians may rely on talk and avoid requesting a showing of the wound despite its apparent relevance. Such talk-based assessment sequences can be stretched substantially, with physicians bringing up multiple questions to enquire about symptoms and observations from the patient, both visual and tactile. Hence, despite the possibility of visual access and the interactional relevance, the participants displayed an orientation to avoid a showing in video consultations.
We may speculate about the reasons for the avoidance of showing closed surgical wounds in video consultations. A general reason could be that asking a patient to undress or show part of the nude belly or torso while being in the private sphere (usually the living room) with others potentially present and showing part of the nude body on camera are delicate things to do. In contrast, the hospital’s consultation room is marked with a clinical setup and assets (eg, physician wearing white coat, curtain, examination table, medical instruments), creating a context where showing the body and physical examinations may become relevant or may be expected by patients or physicians. Possibly, as participants’ experience with video interactions evolve, showing practices may occur more naturally. The avoidance of showings and, thus, direct visual access by the physician in video consultations implies that the “ecological advantage” [
This means that physicians have less authority in diagnosing the wound and that patients are instead more agentive and epistemically amplified compared to face-to-face consultations. Similarly, Seuren et al [
A limitation of our study is that we cannot exclude that the patients who chose a hospital consultation were more insecure about their recovery, including the wound(s), than those who opted for a video consultation. In that case, our findings could not only be explained by the medium of communication. However, in examining the data, we found multiple cases of patients in the hospital setting who did not present any insecurity with regard to their recovery, and we also found cases of potential insecurity (ie, patient reporting pain) in the video data. Another limitation is that the observed phenomenon may be related to the specific goal of the consultation. In our data, the reason for the consultation was the news delivery of the pathology results, and an examination of the wound was not explicitly announced. However, in the face-to-face consultations, showings and the physicians’ invitations to “have a look” were utterly unproblematic. Nevertheless, it is possible that in video consultations where the goal of the interaction is more closely linked to examination, medically relevant showings are more common and are also volunteered by patients (cf [
Overall, it has become clear that video-mediated and copresent medical interactions differ with regard to assessments of medical assessables such as wounds. It was particularly the comparative perspective that yielded new insights, providing evidence of normative orientations with regard to showing that intersect the medical dimension of the talk and the medium of communication. This underscores the relevance of the communication channel for the organization of institutional talk-in-interaction [
A practical implication of our study is that physicians may have to do “extra work” in video consultations to facilitate showing-based assessments. Furthermore, they should consider under which circumstances (eg, closed wound inspection) a hospital visit is more suitable than a video consultation. Another practical implication is that talk-based assessment seems to reduce the physician’s medical authority, as it ascribes more authority to the patient. This reliance on patient observation and judgement is in line with increased self-management as a form of patient empowerment in video consultations [
Transcription conventions.
video-mediated communication
We would like to thank Christian Licoppe for a data session at Télécom Paristech and the participants of data sessions at Copenhagen University and at King’s College London for their valuable input to the analysis of our data. We are also grateful to Willem van de Heuvel and the computer and information sciences MA students for their initial transcriptions of the videos, Anita Pomerantz for her feedback on an earlier version of the manuscript, and to two anonymous reviewers for their valuable comments.
None declared.