Title: Improving preoperative breast reconstruction consultations: a qualitative study on the
impact of personalised audio-recordings.
Version: 3 Date: 31 Aug 2021
Reviewer's report:
Thank you for inviting me to review this interesting paper.  Recording of consultations
about breast reconstruction, using the patient’s own mobile phone as a recording device, is a
seemingly simple, inexpensive intervention that aims to increase understanding and recall of
the information given. I like the idea of this study. I see this is a resubmission, I did not review
the original paper.  I like the idea of the study, but I do have further points that I think must
be addressed:
• The authors are right to refer to a body of previous research into audio recordings of
consultations, mostly in oncology. It would be useful if they were to clearly justify why another
study is needed.  What is different about consultations and decision making about breast
reconstruction that means the results of previous research cannot just be transferred to that
scenario? This is an important point to make, and would justify the novel aspect of this study,
but it needs to be justified clearly.
• I would not expect any discussion of ‘power’ in a qualitative paper, nor a pre-set sample
size. Please rephrase this, considering the current literature around data saturation in qualitative
research (e.g. Braun, V. & Clarke, V. (2021). To saturate or not to saturate? Questioning data
saturation as a useful concept for thematic analysis and sample-size rationales, Qualitative
Research in Sport, Exercise and Health, 13:2, 201-216, DOI: 10.1080/2159676X.2019.1704846)
• There are potential negative consequences of recording consultations – the benefit of the
recording is only as good as the consultation and communication skills of the clinician.  The
authors are right to note a limitation of the current study is that it only involved consultations
that were conducted by one surgeon. It is not unreasonable to suggest that a surgeon who was
willing to be recorded for a study would be skilled and confident in their communication skills.
This might not be the case for all health professionals, and a recording of poor communication
that does not address a patient’s information needs could be problematic. This issue has been
considered in the broader literature around recording consultations, and I would encourage the
authors to consider these issues and include them in the discussion of this paper.  (e.g. see Scott
et al (2001). Giving tape recordings or written summaries of consultations to people with cancer:
a systematic review.  Health Expect. 4(3): 162–169.
• I am somewhat confused that, having seen the original reviewers’ comments, the paper has
now been re-written so as not to be an RCT, but it still refers to random allocation.  This needs
clarifying.  Was this a qualitative study nested within an RCT? If so, this needs to be clearly
stated.  Rather than random allocation at all, an exploratory study like this would be better
if women were offered the choice of recording or not, and their motivations for choice and
subsequent experiences would be of great interest – and could inform a subsequent trial.  The use
of any kind of random allocation is confusing in the context of an exploratory study. OR is this
a pilot of an RCT and did it include the acceptability of randomisation?  It all needs clarifying.
• Its referred to as a cohort study.  Were ALL women who were considering breast reconstruction
offered the option of taking part? How many declined?
• Who conducted the interviews? Did the same person conduct them all? What is their experience
of breast reconstruction and of qualitative research? Were the interviews conducted by the same
people who did the analysis? Ie. a reflective element is needed.
• Was there any further detail about the type of reconstruction being considered? Ie were these
patients having immediate or delayed procedures? The logistics of conducting this study with
women undergoing immediate reconstruction need to be explained.
• It would be useful to add more information about the participants to table 1, e.g. ethnicity,
type/timing of reconstruction.
• I cannot see the use of asking those in the control group how many times they would have
listened to the recording. This is a totally hypothetical situation.  The reality could be very
different, so I do not think this information serves any purpose and the data in table 2 cannot be
relied upon. Table 2 is not needed.  Similarly, I am not convinced of the purpose of the control
group.  The study is written as if from a quantitative perspective, but the experiences of women
who were in the intervention group is sufficient for an exploratory qualitative study like this.
If women had been offered the choice of whether or not they recorded their consultation, then
it would be useful to interview those who did not choose to do so, in order to understand the
barriers to implementing this within routine care. But, since women did not have the choice,
I’m sorry but I cannot see what the interviews with those who weren’t given the option adds
to the study.
• The discussion of small sizes and uneven samples in each group is further example of a
qualitative paper being written from a quantitative perspective.   The sample size is very
appropriate for an exploratory qualitative study, it does not need justifying.
• The discussion states a limitation being that interviews were preoperative, “which limited our
assessment of any potential changes in participants’ attitudes or ideas post-surgery” – but the
aim of the study was not to use the recordings to change patients’ views about surgery. I think
this point is superfluous.
• It is worth mentioning the need for participants to speak English to be a limitation of the study.
The potential use of recordings to help those patients who are not fluent in English and/or rely
on an interpreter in a consultation would be an interesting avenue for future research.
Overall, I like the idea of this study and I think it could be of interest and use to health
professionals working with women contemplating breast reconstruction, but the paper needs
significant changes before in my opinion, it is published.