Maggie Mort

Remote Doctors and Absent Patients: Acting at a Distance in Telemedicine?

According to policy makers, telemedicine offers “huge opportunities to improve the quality and accessibility of health services.” It is defined as diagnosis, treatment, and monitoring, with doctors and patients separated by space (and usually time) but mediated through information and communication technologies. This mediation is explored through an ethnography of a U.K. teledermatology clinic. Diagnostic image transfer enables medicine at a distance, as patients are removed from knowledge generation by concentrating their identities into images. Yet that form of identity allows images and the expert gaze to be brought into potentially lifesaving proximity. Following Latour’s thread, images must be captured and then mobilized to the knowledge base, where they must be stabilized into standard diagnoses, then combined with different images, waiting lists, skin lesions, dermatologists, paper records, and beds, so that ultimately, outcomes are produced. This huge task requires new knowledges and a widening of agency that, if unacknowledged, may see telemedicine projects continue to founder.

Ethics and Ethnography: An Experiential Account

In this article, the authors discuss an ethical dilemma faced by the first author during the fieldwork of an ethnographic study of expertise in anesthesia. The example, written from the perspective of the first author, addresses a number of ethical issues commonly faced, namely, the researcher-researched relationship, anonymity and confidentiality, privacy, and exploitation. She deliberates on the influences that guided her decision and in doing so highlights some of the elements that combine to shape the data. The authors argue that this process of shaping the data is a symbiotic one in which the researcher and the community being studied construct the data together.

Integrating service development with evaluation in telehealthcare: an ethnographic study

Abstract Objectives To identify issues that facilitate the successful integration of evaluation and development of telehealthcare services. Design Ethnographic study using various qualitative research techniques to obtain data from several sources, including in-depth semistructured interviews, project steering group meetings, and public telehealthcare meetings. Setting Seven telehealthcare evaluation projects (four randomised controlled trials and three pragmatic service evaluations) in the United Kingdom, studied over two years. Projects spanned a range of specialties—dermatology, psychiatry, respiratory medicine, cardiology, and oncology. Participants Clinicians, managers, technical experts, and researchers involved in the projects. Results and discussion Key problems in successfully integrating evaluation and service development in telehealthcare are, firstly, defining existing clinical practices (and anticipating changes) in ways that permit measurement; secondly, managing additional workload and conflicting responsibilities brought about by combining clinical and research responsibilities (including managing risk); and, thirdly, understanding various perspectives on effectiveness and the limitations of evaluation results beyond the context of the research study. Conclusions Combined implementation and evaluation of telehealthcare systems is complex, and is often underestimated. The distinction between quantitative outcomes and the workability of the system is important for producing evaluative knowledge that is of practical value. More pragmatic approaches to evaluation, that permit both quantitative and qualitative methods, are required to improve the quality of such research and its relevance for service provision in the NHS.

Making monitoring ‘work’: human–machine interaction and patient safety in anaesthesia

This study aimed to explore the use of electronic monitoring within the context of anaesthetic practice. We conducted workplace observation of, and interviews with, anaesthetists and other anaesthetic staff in two UK hospitals. Transcripts were analysed inductively for recurrent themes. Whilst formal sources of knowledge in anaesthesia deal with the issue of monitoring in terms of theoretical principles and performance specifications of devices, anaesthetists in practice often ‘disbelieve’ monitoring information. They call on and integrate other sources of knowledge about the patient, especially from their clinical assessment. The ability to distinguish ‘normal’ and ‘abnormal’ findings is vital. Confidence in electronic information varies with experience, as does the degree to which electronic information may be considered ‘redundant’. We conclude that electronic monitoring brings new dimensions of understanding but also the potential for new ways of misunderstanding. The tacit knowledge underlying the safe use of monitoring deserves greater acknowledgement in training and practice.

Passing on tacit knowledge in anaesthesia: a qualitative study

Objective  To explore the acquisition of knowledge in anaesthetic practice using qualitative methods.

Communication between anesthesiologists, patients and the anesthesia team: a descriptive study of induction and emergence.

PurposeAlthough the importance of communication skills in anesthetic practice is increasingly recognized, formal communication skills training has hitherto dealt only with limited aspects of this professional activity. We aimed to document and analyze the informally-learned communication that takes place between anesthesia personnel and patients at induction of and emergence from general anesthesia.MethodsWe adopted an ethnographic approach based principally on observation of anesthesia personnel at work in the operating theatres with subsequent analysis of observation transcripts.ResultsWe noted three main styles of communication on induction, commonly combined in a single induction. In order of frequency, these were: (1) descriptive, where the anesthesiologists explained to the patient what he/she might expect to feel; (2) functional, which seemed designed to help anesthesiologists maintain physiological stability or assess the changing depth of anesthesia and (3) evocative, which referred to images or metaphors. Although the talk we have described is nominally directed at the patient, it also signifies to other members of the anesthetic team how induction is progressing. The team may also contribute to the communication behaviour depending on the context. Communication on emergence usually focused on establishing that the patient was awake.ConclusionCommunication at induction and emergence tends to fall into specific patterns with different emphases but similar functions. This communication work is shared across the anesthetic team. Further work could usefully explore the relationship between communication styles and team performance or indicators of patient safety or well-being.RésuméObjectifĽimportance de la communication est de plus en plus reconnue en anesthésie, mais la formation structurée sur le sujet n’a porté jusqu’ici que sur des aspects limités. Nous voulions documenter et analyser la communication apprise de façon informelle et qui a cours entre le personnel ďanesthésie et les patients au moment de ľinduction et du retour à la conscience lors ďune anesthésie générale.MéthodeNotre approche, ethnographique, était fondée sur ľobservation du personnel au travail dans les blocs opératoires et sur ľanalyse subséquente des observations transcrites.RésultatsLors de ľinduction, nous avons noté trois principaux styles ďinformations ordinairement combinés. En ordre de fréquences, la communication était : (1) descriptive, oò les anesthésiologistes expliquaient au patient ce qu’il pouvait s’attendre à ressentir ; (2) fonctionnelle, elle semblait organisée pour aider les anesthésiologistes à maintenir la stabilité physiologique ou à éva luer la différence de profondeur de ľanesthésie et (3) évocatrice, elle faisait appel à des images et à des métaphores. La conversation décrite était en principe dirigée vers le patient, mais elle indiquait aussi aux autres membres de ľéquipe comment ľinduction se déroulait. Dans certains contextes, ľéquipe pouvait aussi participer à la communication. Au réveil, la communication visait habituellement à démontrer que le patient était éveillé.ConclusionLa communication lors de ľinduction et du retour à la conscience tend vers des modèles spécifiques comportant des aspects dominants qui ont toutefois des fonctions similaires. Ce travail de communication est partagé par les membres de ľéquipe ďanesthésie. Il reste à explorer la relation entre les styles de communication et la performance de ľéquipe ou les indicateurs de la sécurité ou du bien-être du patient.Objectif Ľimportance de la communication est de plus en plus reconnue en anesthesie, mais la formation structuree sur le sujet n’a porte jusqu’ici que sur des aspects limites. Nous voulions documenter et analyser la communication apprise de facon informelle et qui a cours entre le personnel ďanesthesie et les patients au moment de ľinduction et du retour a la conscience lors ďune anesthesie generale.

Ethical implications of home telecare for older people: a framework derived from a multisited participative study

Telecare and telehealth developments have recently attracted much attention in research and service development contexts, where their evaluation has predominantly concerned effectiveness and efficiency. Their social and ethical implications, in contrast, have received little scrutiny.

Factors affecting the adoption of telehealthcare in the United Kingdom: the policy context and the problem of evidence

The adoption of telehealthcare in the United Kingdom has been slow and fragmented. This paper presents a structural explanation for this by contrasting contending themes in recent UK health policy. It is argued that the conflict between trends towards modernization and demands for evidence-based practice have made it difficult for a major policy agency to emerge that can sponsor service development , and so proponents of telehealthcare have been forced to situate their work within the domain of R&D. This has led to a fragmented field of practice characterized by short-term and small-scale projects.

Communication entre anesthésiologistes, patients et équipe ďanesthésie : une étude descriptive de ľinduction et du retour à la conscience

PurposeAlthough the importance of communication skills in anesthetic practice is increasingly recognized, formal communication skills training has hitherto dealt only with limited aspects of this professional activity. We aimed to document and analyze the informally-learned communication that takes place between anesthesia personnel and patients at induction of and emergence from general anesthesia.MethodsWe adopted an ethnographic approach based principally on observation of anesthesia personnel at work in the operating theatres with subsequent analysis of observation transcripts.ResultsWe noted three main styles of communication on induction, commonly combined in a single induction. In order of frequency, these were: (1) descriptive, where the anesthesiologists explained to the patient what he/she might expect to feel; (2) functional, which seemed designed to help anesthesiologists maintain physiological stability or assess the changing depth of anesthesia and (3) evocative, which referred to images or metaphors. Although the talk we have described is nominally directed at the patient, it also signifies to other members of the anesthetic team how induction is progressing. The team may also contribute to the communication behaviour depending on the context. Communication on emergence usually focused on establishing that the patient was awake.ConclusionCommunication at induction and emergence tends to fall into specific patterns with different emphases but similar functions. This communication work is shared across the anesthetic team. Further work could usefully explore the relationship between communication styles and team performance or indicators of patient safety or well-being.RésuméObjectifĽimportance de la communication est de plus en plus reconnue en anesthésie, mais la formation structurée sur le sujet n’a porté jusqu’ici que sur des aspects limités. Nous voulions documenter et analyser la communication apprise de façon informelle et qui a cours entre le personnel ďanesthésie et les patients au moment de ľinduction et du retour à la conscience lors ďune anesthésie générale.MéthodeNotre approche, ethnographique, était fondée sur ľobservation du personnel au travail dans les blocs opératoires et sur ľanalyse subséquente des observations transcrites.RésultatsLors de ľinduction, nous avons noté trois principaux styles ďinformations ordinairement combinés. En ordre de fréquences, la communication était : (1) descriptive, oò les anesthésiologistes expliquaient au patient ce qu’il pouvait s’attendre à ressentir ; (2) fonctionnelle, elle semblait organisée pour aider les anesthésiologistes à maintenir la stabilité physiologique ou à éva luer la différence de profondeur de ľanesthésie et (3) évocatrice, elle faisait appel à des images et à des métaphores. La conversation décrite était en principe dirigée vers le patient, mais elle indiquait aussi aux autres membres de ľéquipe comment ľinduction se déroulait. Dans certains contextes, ľéquipe pouvait aussi participer à la communication. Au réveil, la communication visait habituellement à démontrer que le patient était éveillé.ConclusionLa communication lors de ľinduction et du retour à la conscience tend vers des modèles spécifiques comportant des aspects dominants qui ont toutefois des fonctions similaires. Ce travail de communication est partagé par les membres de ľéquipe ďanesthésie. Il reste à explorer la relation entre les styles de communication et la performance de ľéquipe ou les indicateurs de la sécurité ou du bien-être du patient.Objectif Ľimportance de la communication est de plus en plus reconnue en anesthesie, mais la formation structuree sur le sujet n’a porte jusqu’ici que sur des aspects limites. Nous voulions documenter et analyser la communication apprise de facon informelle et qui a cours entre le personnel ďanesthesie et les patients au moment de ľinduction et du retour a la conscience lors ďune anesthesie generale.

Praise and Damnation: Mental Health User Groups and the Construction of Organisational Legitimacy:

‘User involvement’ is a contemporary policy initiative in the UK National Health Service which requires the managers of the service to pay greater attention to the wishes of individual patients/clients and their carers, but also to the representatives of users and the general public. This paper focuses on the responses of health and social care managers to user groups: on the the employment of groups outside the policy/managerial hierarchy as contributors to and legitimators of decisions. Such an approach to legitimation poses the risk that such outside groups will express views or engage in activities which are unacceptable to the hierarchy. This paper provides illustrative evidence about how such tensions may be dealt with in order to maintain tactical policy/managerial independence and to buttress representative democracy against the spread of participatory democracy.