Physical examinations via video? Qualitative study of video examinations in heart failure, using conversation analysis (Preprint)
Authors: Seuren Lucas Martinus , Wherton Joseph , Greenhalgh Trisha , Cameron Deborah , A'Court Christine , Shaw Sara E. 
Published: October 2019

BACKGROUND

Video consultations are increasingly seen as a possible replacement for face-to-face consultations. Direct physical examination of the patient is impossible, but a limited examination may be undertaken via video (e.g. 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

To explore the opportunities and challenges of remote physical examination with patients with heart failure using video-mediated communication technology.

METHODS

Seven video consultations (using FaceTime) between patients with heart failure and their community-based specialist nurses were video-recorded with consent. We used conversation analysis to identify the challenges of remote physical examination over video and the verbal and non-verbal communication strategies used to address them.

RESULTS

Apart from a general visual overview, remote physical examination in heart failure patients was restricted to assessing fluid retention (by the patient or relative feeling for leg oedema), blood pressure and pulse rate and rhythm (using a self-inflating blood pressure monitor incorporating an irregular heart beat 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: (i) adequate design of instructions to guide video examinations (with nurses required to explain tasks using lay language, and checking instructions were followed); (ii) 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 (iii) doing the physical examination while simultaneously making it visible to the nurse (with patients and relatives needing adequate technological knowledge in order 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 roll out 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.