Video Consultations Between Patients and Clinicians in Diabetes, Cancer, and Heart Failure Services: Linguistic Ethnographic Study of Video-Mediated Interaction.

BACKGROUND: Video-mediated clinical consultations offer potential benefits over conventional face-to-face in terms of access, convenience, and sometimes cost. The improved technical quality and dependability of video-mediated consultations has opened up the possibility for more widespread use. However, questions remain regarding clinical quality and safety. Video-mediated consultations are sometimes criticized for being not as good as face-to-face, but there has been little previous in-depth research on their interactional dynamics, and no agreement on what a good video consultation looks like. OBJECTIVE: Using conversation analysis, this study aimed to identify and analyze the communication strategies through which video-mediated consultations are accomplished and to produce recommendations for patients and clinicians to improve the communicative quality of such consultations. METHODS: We conducted an 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 4 clinical settings across 2 trusts (1 community and 1 acute care) in the UK National Health Service. 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 conducted 37 interviews with staff and 26 interviews with patients. Using linguistic ethnography (combining analysis of communication with an appreciation of the context in which it takes place), we examined in detail how video interaction was mediated by 2 software platforms (Skype and FaceTime). RESULTS: Patients had been selected by their clinician as appropriate for video-mediated consultation. Most consultations in our sample were technically and clinically unproblematic. However, we identified 3 interactional challenges: (1) opening the video consultation, (2) dealing with disruption to conversational flow (eg, technical issues with audio and/or video), and (3) conducting an examination. Operational and technological issues were the exception rather than the norm. In all but 1 case, both clinicians and patients (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 (eg, camera) to make it possible for the clinician to see and hear adequately. 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, clinicians and patients can 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 a video link. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/10913.

Physical Examinations via Video for Patients With Heart Failure: Qualitative Study Using Conversation Analysis.

BACKGROUND: Video consultations are increasingly seen as a possible replacement for face-to-face consultations. Direct physical examination of the patient is impossible; however, a limited examination may be undertaken via video (eg, using visual signals or asking a patient to press their lower legs and assess fluid retention). Little is currently known about what such video examinations involve. OBJECTIVE: This study aimed to explore the opportunities and challenges of remote physical examination of patients with heart failure using video-mediated communication technology. METHODS: We conducted a microanalysis of video examinations using conversation analysis (CA), an established approach for studying the details of communication and interaction. In all, seven video consultations (using FaceTime) between patients with heart failure and their community-based specialist nurses were video recorded with consent. We used CA to identify the challenges of remote physical examination over video and the verbal and nonverbal communication strategies used to address them. RESULTS: Apart from a general visual overview, remote physical examination in patients with heart failure was restricted to assessing fluid retention (by the patient or relative feeling for leg edema), blood pressure with pulse rate and rhythm (using a self-inflating blood pressure monitor incorporating an irregular heartbeat indicator and put on by the patient or relative), and oxygen saturation (using a finger clip device). In all seven cases, one or more of these examinations were accomplished via video, generating accurate biometric data for assessment by the clinician. However, video examinations proved challenging for all involved. Participants (patients, clinicians, and, sometimes, relatives) needed to collaboratively negotiate three recurrent challenges: (1) adequate design of instructions to guide video examinations (with nurses required to explain tasks using lay language and to check instructions were followed), (2) accommodation of the patient's desire for autonomy (on the part of nurses and relatives) in light of opportunities for involvement in their own physical assessment, and (3) doing the physical examination while simultaneously making it visible to the nurse (with patients and relatives needing adequate technological knowledge to operate a device and make the examination visible to the nurse as well as basic biomedical knowledge to follow nurses' instructions). Nurses remained responsible for making a clinical judgment of the adequacy of the examination and the trustworthiness of the data. In sum, despite significant challenges, selected participants in heart failure consultations managed to successfully complete video examinations. CONCLUSIONS: Video examinations are possible in the context of heart failure services. However, they are limited, time consuming, and challenging for all involved. Guidance and training are needed to support rollout of this new service model, along with research to understand if the challenges identified are relevant to different patients and conditions and how they can be successfully negotiated.

Technology-Enhanced Consultations in Diabetes, Cancer, and Heart Failure: Protocol for the Qualitative Analysis of Remote Consultations (QuARC) Project.

BACKGROUND: Remote videoconsulting is promoted by policy makers as a way of delivering health care efficiently to an aging population with rising rates of chronic illness. As a radically new service model, it brings operational and interactional challenges in using digital technologies. In-depth research on this dynamic is needed before remote consultations are introduced more widely. OBJECTIVE: The objective of this study will be to identify and analyze the communication strategies through which remote consultations are accomplished and to guide patients and clinicians to improve the communicative quality of remote consultations. METHODS: In previous research, we collected and analyzed two separate datasets of remote consultations in a National Institute for Health Research-funded study of clinics in East London using Skype and a Wellcome Trust-funded study of specialist community heart failure teams in Oxford using Skype or FaceTime. The Qualitative Analysis of Remote Consultations (QuARC) study will combine datasets and undertake detailed interactional microanalysis of up to 40 remote consultations undertaken by senior and junior doctors and nurse specialists, including consultations with adults with diabetes, women who have diabetes during pregnancy, people consulting for postoperative cancer surgery and community-based patients having routine heart failure reviews along with up to 25 comparable face-to-face consultations. Drawing on established techniques (eg, conversation analysis), analysis will examine the contextual features in remote consultations (eg, restricted visual field) combined with close analysis of different modes of communication (eg, speech, gesture, and gaze). RESULTS: Our findings will address the current gap in knowledge about how technology shapes the fine detail of communication in remote consultations. Alongside academic outputs, findings will inform the coproduction of information and guidance about communication strategies to support successful remote consultations. CONCLUSIONS: Identifying the communication strategies through which remote consultations are accomplished and producing guidance for patients and clinicians about how to use this kind of technology successfully in consultations is an important and timely goal because roll out of remote consultations is planned across the National Health Service. REGISTERED REPORT IDENTIFIER: RR1-10.2196/10913.

Women's awareness of the importance of long-chain omega-3 polyunsaturated fatty acid consumption during pregnancy: knowledge of risks, benefits and information accessibility.

OBJECTIVE: To evaluate pregnant women's knowledge regarding the importance of long-chain omega-3 polyunsaturated fatty acids (LC n-3 PUFA) consumption during pregnancy and assess their views on current information availability. DESIGN: A 27-item demographic and food safety/behaviour questionnaire was administered to pregnant women during their antenatal clinic visits. chi2 tests were performed using SPSS. SETTING: Antenatal clinics at two regional hospitals in New South Wales, Australia. SUBJECTS: One hundred and ninety (n 190) pregnant women. RESULTS: Three quarters of the women had not received information regarding LC n-3 PUFA. Approximately half of the women were aware of issues relating to LC n-3 PUFA; however, their knowledge was limited, with most obtaining their knowledge from books and magazines. Women generally had low (30 %, 29 %) to moderate (28 %, 24 %) levels of concern about LC n-3 PUFA and mercury, respectively. CONCLUSIONS: Pregnant women lack knowledge of LC n-3 PUFA and health-care services do not provide pregnant women with adequate information on the importance of eating foods high in LC n-3 PUFA during pregnancy.

The use of dehydroepiandrosterone therapy in clinical practice.

Dehydroepiandrosterone (DHEA) therapy is controversial due to sensationalized reports of epidemiologic studies and the over-the-counter availability of DHEA. Human clinical trials have investigated the potential efficacy of DHEA therapy in multiple conditions with resultant inconsistencies in findings. DHEA is unique compared with other adrenal steroids because of the fluctuation in serum levels found from birth into advancing age. The lower endogenous levels of DHEA and DHEA sulfate found in advancing age have been correlated with a myriad of health conditions. Also, some studies suggest gender-specific actions of endogenous and exogenous DHEA. We reviewed only pharmacokinetic studies and human clinical trials investigating the efficacy of DHEA therapy that were placebo-controlled as these provided the most reliable scientific basis for the evaluation of DHEA therapy. Pharmacodynamic studies suggest that doses of 30-50mg of oral DHEA may produce physiologic androgen levels, especially in women. These studies report a dose-dependent effect and lack of accumulation of serum androgen levels. Pharmacologic studies also reveal a gender-specific response to DHEA therapy such that testosterone levels are increased in women but not in men. Clinical trials suggest that 50mg of oral DHEA, but not <30mg, can increase serum androgen levels to within the physiologic range for young adults with primary and secondary adrenal insufficiency, possibly improve sexual function, improve mood and self-esteem, and decrease fatigue/exhaustion. Whereas DHEA replacement therapy may be effective in treating patients with adrenal insufficiency, human clinical trials investigating its efficacy in conditions such as systemic lupus erythematosus, HIV, Alzheimer disease, advancing age, male sexual dysfunction, perimenopausal symptoms, depression, and cardiovascular disease have not provided consistent findings.

Androgen replacement therapy in women.

OBJECTIVE: Review of literature with regard to androgen replacement therapy in women. DESIGN: Review of the MEDLINE database and references from articles. CONCLUSIONS: Androgens affect sexual function, bone health, muscle mass, body composition, mood, energy, and the sense of well-being. Androgen insufficiency clearly has been demonstrated in patients with hypopituitarism, adrenalectomy, oophorectomy, and in some women placed on oral estrogen therapy which increases sex hormone-binding globulin (SHBG) levels and lowers the free and bioavailable forms of T. Symptoms of androgen insufficiency in women may include a diminished sense of well-being, low mood, fatigue, and hypoactive sexual desire disorder with decreased libido, or decreased sexual receptivity and pleasure that causes a great deal of personal distress. The preponderance of evidence from clinical trials supports the correlation of decreased endogenous androgen levels with these symptoms and alleviation of many of the symptoms with the administration of T or, in some cases, DHEA. There are no Food and Drug Administration-approved androgen preparations on the market for treating androgen insufficiency in women. The safety profile of androgens in doses used for the treatment of hypoactive sexual desire disorder has been excellent with only mild acne and hirsutism being noted in a minority of patients.