Moving towards Europe: international clinical ... - Europe PMC

Journal of the Royal Society of Medicine Volume 86 September 1993

Moving towards Europe: international clinical conferencing on the telephone

Paul McLaren MA MRCPsych' C J Ball MRCPsych' E Brostoff MSc1 J P Watson MD FRCP FRCPsych1 M Lipsedge MPhil FRCP FRCPsych1 W Gaebel2* B Gallhofer3 A Abraham4 J Gilkman4 'Division of Psychiatry, United Medical and Dental School Guy's Hospita4 London SE1 9RT, UK, 2Psychiatrische Klinik and Poliklinik (WE12), Standort Charlottenburg, Universitatsklinikum Rudolf Virchow, Freie Universitat Berlin, 3Head of the Independent Psychopathologie Unit, Centre for Psychiatry, Justus-Liebig University School of Medicine, Giessen, Germany, and 4Psychiatres des Hopitaux, Centre Hospitalier de Ville Evrard, 2 Avenue Jean Jaures, 93330 Neuilly sur Marne, France Keywords: clinical case conferencing; international teleconferencing; telephone; psychiatry; Europe

Introduction The attention of the profession has been drawn to the need for greater commitment towards Europe by Brearley and Gentleman'. Despite the fact that a single market for doctors has existed since 1973 contact between clinicians 'on the ground' remains limited. International conferences and multicentre trials have improved cooperation, but the time and expense involved in travel restrict the opportunity for wider involvement. Clinicians throughout the European Community have much to gain from increased communication in terms of understanding approaches to clinical management, education, and administration of health care systems. The opening of the single European market may increase the demand for direct international communication on patient management between clinicians. Communications technology offers the opportunity for regular and effective contact. Using the telephone, doctors can engage in a clinical conference with colleagues in similar hospitals anywhere in the Community without travelling outside their own hospital or department. After a modest investment in basic equipment, the cost is that of the telephone call. Teleconferencing has a long but patchy history of use in business and education2-4 since the 1930s and has still to realize its full potential. Some universities offer entire degree courses by telephone but the exploitation of the telephone for education has been very variable. Evaluation in education has focused on direct observation and eliciting the subjective responses of users5'6. A study of clinical case conferencing over the telephone, referred to as clinical teleconferencing, is reported here. There is a wide range of professional teleconferencing equipment available designed for use in dedicated studios. The aim was to evaluate teleconferencing using the most basic equipment available and develop guidelines for the conduct of teleconferences. The clinical case conference was selected as it is an important means of information exchange and postgraduate medical education in many countries. Clinical teleconferencing in psychiatry is described but the principles could apply equally to other clinical specialities. Correspondence to: Dr McLaren This study was funded by the Telemed project RACE-1086 *Professor Gabel is currently Director of the Psychiatrische Klinik der Heinrich Heiner, Universtat Bergische, Landstrasse 2W4000 Dusseldorf, Germany

Method The transfer of the clinical case conference to the teleconference format required identification of the minimum requirements for the clinical conference. The following were identified as desirable elements: mutual comprehension of language; a detailed history and report of a clinical examination; participants observing a clinical interview with the patient; participants having the opportunity to question the patient directly; participants having the opportunity to question the responsible clinician(s); and a discussion of the diagnosis and management plan. The combined use of videotaped visual information and interactive teleconferencing has been reported in education7. In psychiatry, a videotape of a clinical interview with a patient may be shown at a case conference rather than asking the patient to attend in person. While this sacrifices the possibility of direct interaction between patient and participants it spares the patient what may be a distressing experience. Such a videotape could be viewed by teleconference participants by posting it between sites. A pilot study was set up to investigate how readily the clinical conference could be replicated using a videotape of a clinical interview and the telephone. The results suggested that the role of the chairman would be of central importance to the effective running of the teleconference and that strict timetabling and explicit rules for speaking would be necessary to prevent rambling and to strengthen the hand of the chairmen at either end. The rules evolved are reported in Appendix 1. The following protocol was then devised for the international conferences.

Teleconferencing protocol A summary of the history and current mental state of the subject for the conference should be received by all participants at least 24 h before the conference. A videotape of a clinical interview with the subject for the conference should also be sent to the remote site. Participants at each site should meet an hour before the teleconference to review the clinical material. The teleconference was timed to last 1 h. A detailed timetable for the conference should be devised and sent to all participants in advance, and it should contain the following information: (a) Who would initiate the contact. (b) Telephone numbers of both sites.

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(c) Contact time (to check that the connection and equipment are operational at least 20 min before the scheduled starting time). (d) Starting time. (e) Time for questioning of the responsible clinicians on the history. (f) Time for questioning the responsible clinician on the videotaped interview. (g) Time for discussion of the diagnosis. (h) Time for discussion of the management plan.

Results

A total of 29 different clinicians from three countries (UK, France and Germany) participated in the study. They included psychiatrists, nurses, psychologists and social workers. All the teleconferences were conducted in English. The teleconferences were technically successful and there were no breakdowns in communication. All participants completed the self-report questionnaire and a total of 36 were obtained for analysis. Overall responses were very favourable. The mean values for each site are presented in Table 1.

In addition, participants were given written reminders of the need for confidentiality. Patient videotapes were posted separately from the written material. Identification codes were used and all videotaped material had to be returned to the site of

London-Giessen Professional teleconferencing equipment was used at both sites. All written material was in English and there were no problems with translation during the teleconference. There were seven participants at each end, including nurses, psychologists, psychiatrists and a Gerinan social worker. There were several comments on the poor quality of the sound on the videotape which had been recorded in a busy ward. The demands of translation rendered this a greater problem for the German participants. The highest mean ratings for the sound reproduction were recorded in this teleconference (4.0 and 3.9) which was expected as professional teleconferencing equipment was used. The ratings for willingness to participate again were 4.6 for London and 4.9 for Giessen.

origin.

In the international study different types of conferencing equipment were compared. The handsfree telephone used was the British Telecom React 320 or equivalent. This was compared with professional telephone conferencing equipment. At the London site the British Telecom Teleconferencing 2000 system was used. This consists of a small control module and a loudspeaker about the size of a standard HiFi loudspeaker. The system plugs into the telephone socket and dialling takes place through a standard handset. Different combinations of the equipment were tested in each of the teleconferences in this study. The combinations used were: handsfree telephone with handsfree telephone; teleconferencing equipment with teleconferencing equipment; and handsfree telephone at one end with teleconferencing equipment at the other. To compare the effectiveness of the teleconference using the different combinations of equipment and to measure participants' responses, a questionnaire was developed for participants to complete immediately after the teleconference. It contained the following questions and participants were asked to rate their responses on an ordinal scale of 1-5 (1 representing 'not at all' and 5 'very'). 1. 2. 3. 4. 5.

London-Paris There were six participants at each end. A handsfree telephone was used in Paris and teleconferencing equipment in London. Psychologists, psychiatrists and a psychiatric nurse took part. Language was anticipated as a potential barrier as only one of the French participants spoke fluent English and only two of the British participants spoke fluent French. A French transcript of the videotaped interview and French translations of the clinical summary were sent to the French participants. The teleconference was conducted in English but all interchange had to occur through the French chairman who spoke fluent English. It was noted that the strict and explicit rules for speaking helped to ensure that all communication was channelled through the chairmen. Despite the potential for language to interfere, high mean scores for satisfaction were obtained at both sites (4.5 Pairs, 3.8 London). Three French participants commented that they would have liked to have viewed the videotape several days before the teleconference. Two reported that they found some of the English terminology confusing in translation and wished to improve their English. Again several participants commented that they would have preferred if the videotape had better sound quality. This telecon-

Overall satisfaction with the conference. Satisfaction with sound quality. Helpfulness of the videotape interview. Helpfulness of the rules for speaking. Willingness to participate again.

At the end of the questionnaire participants were asked to give their general comments on the conference. Three two-way international teleconferences are reported between Guy's Hospital and the Freie University of Berlin, Germany; Guy's Hospital and the School of Medicine, Justus-Liebig University, Giessen, Germany; and between Guy's Hospital and the Centre Ville Evrard, Paris.

ference had the lowest mean scores for sound reproduction (1.7 at London and 2.3 at Paris) despite

Table 1. Mean participant scores on self-report questionnaires for each site

Satisfaction Sound reproduction Videotape Rules for speaking Willingness to participate again

LondonIGeissen

London/Paris

LondonIBerlin

4.2 4.0 4.3 4.3 4.6

3.8 1.7 3.5 4.0 4.7

4.0 2.3 4.8 4.0 4.8

3.9 3.9 4.0 4.4 4.9

4.5 2.5 4.2 4.2 4.8

4.7 3.3 4.8 4.0 4.7

Journal of the Royal Society of Medicine Volume 86 September 1993 Table 2. Mean scores from all three teleconferences

Satisfaction Sound quality Use of videotape Rules for speaking Participate again

use

of

teleconferencing

No.

Mean

Standard deviation

36 36 36 36 36

4.2 3.1 4.3 4.2 4.7

0.7 1.2 0.8 0.7 0.5

equipment at the London

end.

London-Berlin Handsfree telephones were used at each end. There were six participants in Berlin and four in London. The teleconference was conducted in English and there were no problems with translation. The mean scores for sound reproduction were 3.3 in Berlin and 2.3 in London. Two of the London participants commented that they would have liked better sound reproduction. Despite this the scores for satisfaction were high (4.7 in Berlin, 4.0 in London). The pooled scores from all three teleconferences are presented in Table 2. This shows that the mean values for responses other than the sound quality were greater than 4.0, suggesting a high degree of satisfaction with the method. Discussion The results show that clinical teleconferencing is technically feasible even with basic equipment. The main area for improvement and further study is that of sound reproduction. The above results support the advantages of teleconferencing equipment for this application but an unexpected effect was observed when handsfree and teleconferencing equipment were used in combination. The sound reproduction scores showed that mismatching, using a handsfree telephone at one end and teleconferencing at the other may produce a less satisfactory result than using two handsfree sets. The lowest mean score (1.7) was found at the site of the teleconferencing equipment with a handsfree telephone at the other end. This may be an equipment effect, teleconferencing equipment distorting the handsfree signal, or a subjective effect, hearing poor sound being more unsatisfactory than having to talk in a manner to compensate for poor sound reproduction from your site. This point needs further clarification as it may be clinicians would wish to try initially handsfree telephones to assess the potential of the application. Important lessons were learned concerning the organization of clinical teleconferences. The pilot study within a single site offered valuable information and a dry run should be made with any equipment before an international teleconference is attempted. With French clinicians, language may be a barrier and the language skills of participants should be clarified well in advance. To avoid confusion, written material and a transcript of the videotaped interview should be translated into French (or English). Language is less likely to be a problem with German clinicians many of whom speak English. Any material should be sent to participants at least 48 h and preferably 1 week before the teleconference to allow adequate time for review.

The videotaped interview is a vital part of the teleconference and close attention must be paid to the quality of the recording. Recording on a ward with a portable videorecorder is difficult and will rarely produce a good result. The recording should be made in a quiet room which is well lit and two people are required. Clinical teleconferencing requires time for preparation over and above that which would be required by the presentation of a clinical conference at a postgraduate meeting. Two hours should be allowed for the preparation of a 45 min videotape, 5 h for translation and preparation of written material, 1 h (at each side) for the setting up of the teleconferencing room, making a total of 8 h. In addition, all participants should allow 2 h for the conference and at least 1 h each before the meeting to view the clinical material. Providing a formal framework for the teleconference is essential. Effective chairmen, timetabling and rules for speaking are all important for the smooth flow of the meeting. Two people having an aside during the teleconferencing can be very distracting to the participants at the remote end. Participants identifying themselves before speaking was regarded as helpful. The interchange of information during the teleconference could be improved in a variety of ways and there may be different requirements for different specialities. Written material, such as an updated participant list or summary of the main discussion points could be faxed between sites. Patients could be interviewed live on the telephone by clinicians at the remote site. Videotapes could be made of the participant groups asking questions about the clinical material well in advance of the planned teleconference. This would allow participants to see what they looked like. It would also require even more time and planning. Whether any ofthese elements will improve the quality of the teleconference will be the subject of further study.

Conclusion Clinical teleconferencing offers the opportunity for European clinicians to communicate directly about patient management. As a minimum two handsfree telephones are required, but professional teleconferencing equipment gives a more satisfactory result. While this offers a new opportunity for international communication, attention needs to be paid to the planning and preparation of the meeting. A strict timetable and formal rules for speaking must be agreed. Videotapes of clinical interviews must be prepared carefully and their quality checked. The communications links, the telecommunications equipment and the need for contact between clinicians in Europe exists. Clinical teleconferencing should be the subject of further detailed research and evaluation to maximize its efficiency and usefulness. Appendix 1 Rules for speaking during a teleconference All participants 1. Speak loudly and clearly. 2. Only chairmen can interrupt a speaker. 3. If you want to speak, draw the chairman's attention nonverbally beforehand. 4. Wait for the chairman to ask you to speak. 5. Start by giving your surname. 6. State to whom your remarks are addressed.

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7. Aim to make your points in one speech. 8. Mark the end of your speech by saying 'thank you'.

Chairmen 9. Keep interruptions to a minimum. 10. Interrupt by saying 'can I interrupt?' 11. Always give way to an interruption. References 1 Brearley S, Gentleman D. Doctors and the European Community. BMJ 1991;302:1221-2 2 McConnell D, Sharples N. Distance teaching by CYCLOPS: an educational evaluation of the Open University's telewriting system. Br J Educ Techn 1983;14:109-26 3 Reid FJM, Champness BG. Wisconsin Educational Telephone Network: how to run educational teleconferencing successfully. Br JEduc Technol 1983;14:14-15

Forthcoming events Colposcopy (Basic) 21-22 September 1993, London, UK Further details from: Royal College of Obstetricians & Gynaecologists, 27 Sussex Place, Regent's Park, London NW1 4RG (Tel: 071-262 5425 ext 207) Principles of Colon and Rectal Surgery 29 September-1 October 1993, Minnesota, USA Further details from: Dr S M Goldberg, CME, University of Minnesota Medical School, Radisson Hotel Metrodome, Suite 107, 615 Washington Avenue Southeast, Minneapolis, Minnesota 55414, USA (Tel: 612 626 7600; Fax: 612 626 7766) 18th International Symposium on Blood Transfusion 6-8 October 1993, Groningen, The Netherlands Further details from: Symposium Secretariat, Red Cross Blood Bank Groningen-Drenthe, PO Box 1191, 9701 BD Groningen, The Netherlands (Tel: 50 137 777; Fax: 50 137 777) Senior Registrars' & Registrars' Conference 11-15 October 1993, London, UK Further details from: (see entry for 21-22 September 1993) MRCP Part II Course 18-22 October 1993, London Further details from: Dr D Geraint James, Royal Free Hospital, Pond Street, Hampstead, London NW3 2QG, UK Hygiene and Health Management in the Working Environment 20-22 October 1993, Ghent, Belgium Further details from: Ms R Peys, c/o TI-K VIV, Desguinlei 214, B-2018 Antwerp, Belgium (Tel: 216 09 96; Fax: 216 06 89) Man and Management: The Jerry Erskine Lecture 25 October 1993, London, UK Further details from: Dr Jeff Morgan, UK Forum for Organizational Health, Bronturnor Uchaf, Maentwrog, Gwynedd, North Wales LL41 3YU, UK (Tel: 0766 85627) Intrapartum Fetal Surveillance 4 November 1993, London, UK Further details from: (see entry for 21-22 September 1993) Respiratory Tract and Mediastinum 6-8 November 1993, Arizona, USA Further details from: Thom Lowther EdS, Medical Conference Planner, Armed Forces Institute of Pathology, Washington, DC 20306-6000, USA (Tel: 301 427 5231; Fax: 301 427 5001)

4 Parker LA, Olgren CH. Teleconferencing and interactive media. London: Artech House Inc., 1981 5 Rutter DR, Robinson B. An experimental analysis of teaching by telephone: theoretical and practical implications for social psychology. In: Stephenson GM, Davis JH (eds). Prog Appl Soc Psychol 1981;1:345-74 6 Rutter DR. Communicating by telephone, Vol. 15. Intemational series in experimental and social psychology. Bristol: John Wiley, 1987 7 Vesorani GJ, Yeatch WC. Mixing teleconference and videotape for inter-university instruction. In: Parker LA, Olgren CH. Teleconferencing and interactive media. London: Artech House Inc., 1981:234-41

(Accepted 12 October 1992)

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