The impact of the image in different clinical contexts

Focus groups discussed the context in which the image is shown, specifically the type of illness demonstrated within the image and the time at which the image is shown. These are discussed in turn below.

5.4.6.1.Illness

Within five focus groups, participants discussed the type of illness presented in the image. They often contrasted viewing images of bone to that of cancer, stating that while they believed images of bones may be helpful to patients, patients may not want to see images of more serious conditions such as cancer. Within one group, participants proposed there may be a difference in emotional impact between seeing guts as opposed to bones and implied that seeing guts may have a more negative impact as they could cause patients to feel a sense of vulnerability. Further, in two focus groups participants were less confident that the images of cancer would aid patient understanding, with one patient explaining “I don’t think it adds any extra to what my mental image of metastases in my liver” (FG3) and one commenting “it’s not simple is it” (FG4).

Interestingly, in response to a comment that virtual colonoscopy images “could be scary” for patients, one participant argued that the “whole thing is scary” (FG3) rather than the image per se.

One 3D orthopaedic image depicting Avascular Necrosis (AN) was described as frightening and upsetting by some participants, with one participant explaining that “I think that some probably would be distressed to see that- it has a cancerous look about it”(FG3). Another participant said they would feel disheartened to see the image of AN. This image was described as “horrendous” (FG5), “terrible” (FG6) and “revolting” (FG6) while other orthopaedic 3D images such as the image of FAI were described as fantastic” (FG6) and “amazing” (FG6).

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Participants in four groups expressed concern about showing patients their images if there was no (curative) treatment available and two groups explained in this instance the images could have adverse effects. In three of the four groups, participants were hypothesising how other patients would feel but claimed that they would still want to see their own image in the absence of a treatment. However, in the fourth group a participant said that while they “wouldn’t mind having an image” of something that is treatable, they did not think they would want that of something serious. Within one group, a participant seemed more concerned by this, frequently raising the question of whether the experience of viewing the image would be different if no treatment or less straightforward treatments were available. Although he acknowledged he would not know how someone in that situation is going to feel, he was concerned that there may be a lasting impact of the image with patients saying “I keep waking up and seeing that picture” (FG3).

Within one group, participants also discussed whether images should be shown if there is one “clear cut” (FG4) treatment option. One participant explained they he was not sure there was a reason to show images to patients in this context stating, “I am not sure it adds a great deal”. He was speaking about a specific example (AN) in which the patient would need a hip replacement and said that he believed that the patient would probably have an idea of their diagnosis. It may not be the case that all patients with a “clear cut” treatment are aware of their diagnosis so the image may still be helpful in those cases.

The presence of comorbidities was also raised within one group who argued that sharing images with patients would be more complex if there were several problems rather than one simple problem, as the clinician would have to decide which aspects of the images are important and which should be disregarded.

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5.4.6.2.Time

Participants discussed the appropriate time for sharing medical images with patients, with two groups indicating that images should be shown at a later consultation rather than immediately after diagnosis, particularly after a diagnosis of cancer. One group stated that after a diagnosis of cancer viewing an image may be scary for patients, while the other group explained that patients viewing hip images had probably had at least one consultation so may be better prepared to view their images in comparison to a “first time diagnosis of cancer”(FG4). In study one, all recruited patients had previously attended a previous consultation about their hip complaint before being referred to the clinic. This may have prepared them somewhat for viewing their images.

Further, two groups discussed whether patients should be shown their images repeatedly, either pre and post treatment or to monitor their condition. Both groups agreed that seeing a post treatment image would be beneficial with one explaining that “once you have been shown one you need to be shown the rest, you know good or bad” (FG6). One of these two groups also discussed the use of images to monitor a condition, specifically one that does not require any intervention at the present time but may do in the future. They argued that it could be helpful for patients to see how their condition has changed and that sharing images intended to monitor the condition with a patient would “make it easier for both sides to see how far it has developed”. However one participant indicated that imaging patients after treatment could be problematic, explaining that it would be unnecessary radiation for the patient.

Furthermore, one participant also considered the appropriateness of showing patients endoscopic images during the procedure which he claimed was a “higher risk” (FG4) as neither the patient nor the clinician knows what they will find or how the patient will react if something can be seen within the image.

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