Reliability of coding

Two consultations (recordings 9 and 10) were double coded for reliability. A strong correlation was found between the initial coding and the double coding for reliability.

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Previous studies have assessed the reliability of RIAS coding using Pearson correlation coefficients. As Pearson correlation coefficients measure linear association not reliability per se, intra-class correlation coefficients were measured in addition to Pearson’s correlation coefficients to assess the reliability of coding. The overall coding reliability was .975 based on Pearson correlation coefficients. For consultation 9, the correlation coefficient was 0.988 and for consultation 10, the correlation coefficient was 0.947.

Overall coding reliability was measured. Reliability was also assessed for both double coded consultations separately and for the four main RIAS categories used in the analysis as demonstrated in table 13.

After consultation with a statistician, the reliability analysis was repeated with four codes removed. These four codes were deemed as outliers as they had very high frequency compared to the other codes and potentially skewed the results. The results of reliability analysis without the outliers are also presented in Table 13. For the reliability of the four main RIAS categories, two of the four codes were originally used in the biomedical content category; three were originally used in the task-focused category and one was originally used in the socio-emotional exchange category. None of the four codes were used in the lifestyle/psychosocial category. The analysis of these three categories was repeated without the outliers.

150 Table 13: Reliability of coding

Pearson’s R Intra-class correlation Coefficient

Overall .975 .979

With outliers removed .881 .838

Consultation 9 .988 .978

With outliers removed .902 .900

Consultation 10 .947 .917

With outliers removed .743 .689

Biomedical Content .952 .922

With outliers removed* .252 .313

Lifestyle/Psychosocial Content

.882 .969

No outliers

Task Focused Content .955 .965

With outliers removed .674 .682

Socio-emotional exchange .979 .970

With outliers removed .778 .661

* Removal of outliers in this category removed most of the data

4.4.

Discussion

4.4.1. Discussion of research findings

Several key findings were raised through the analysis. During consultations about hip surgery, doctors talked more than patients and the content of the consultation was primarily biomedical. On average, images were involved in approximately 13% percent of the

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discussion. They were mainly used to give medical and treatment information but also to answer patients’ questions. Most of the utterances about the image were made by the doctor, with patients making a small contribution to the discussion of the images. Finally, this analysis revealed similar results to Levinson and Chaumeton’s (1999) analysis of orthopaedic surgery consultations, with doctors verbally dominant and consultations focused on biomedical content in both data sets. In the present study, however, there was a greater discussion of psychosocial issues than previously identified.

As the consultations tended to be discussions of a diagnosis and treatment, with the codes “gives medical information” and “gives therapeutic information” most common, it seems logical that the clinician was dominant within the consultation. This is also consistent with the findings of Levinson and Chaumeton (1999) who found that doctors also spoke more than patients in consultations about surgery. Previous studies reporting a ratio of one for verbal dominance as patient centred have analysed consultations from general practice or oncology (Neal et al., 2006; Paasche-Orlow & Roter, 2003; Pawlikowska et al., 2012), where clinicians typically take patient histories using open questions allowing greater verbal dominance from patients. It could therefore be argued that for this type of consultation (i.e. a discussion about diagnosis and surgical treatments, where no patient history is taken) the ratio of doctor to patient utterances was appropriate.

Due to the nature of the consultations analysed it was expected that the majority of the dialogue would be biomedical content. A systematic review looking at communication with surgical consultations, including orthopaedics identified an emphasis on patient education and the delivery of biomedical information during consultations about surgery (Levinson et

al., 2013). Additionally, for nine of the ten recordings, the consultation was a discussion of a

diagnosis and treatments only. The patient history, which may have included more psychosocial information, such as the impact of their hip pain on their activities, was taken

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during an earlier consultation. Furthermore, the type of diagnosis and treatment discussed during the consultations are largely mechanical with the majority of patients diagnosed with FAI and recommended an arthroscopy (a type of keyhole surgery) as treatment.

It is understandable that doctor utterances were primarily biomedical as they were delivering information about diagnosis and treatments to the patients. It could be argued that half of the patients were also more focused on biomedical information than psychosocial, as there were more biomedical utterances than psychosocial utterances for five of the ten patients. Alternatively, these patients may not have had an opportunity to introduce as much as psychosocial content as they would have liked, particularly as the doctors were verbally dominant within the consultations.

The analysis of the image codes along with the RIAS codes attached to the image utterances showed that, although medical images were primarily used to deliver medical information, they were also used to answer patients’ question. This finding shows that medical images can be integrated within a discussion, as well as to present medical information.

Similarities were identified between the results of this analysis and Levinson and Chaumeton’s 1999 study. Orthopaedic surgery consultations tend to be biomedical focused, with the doctor making a greater contribution to the dialogue than patients do. Patients in Levinson and Chaumeton’s study made a greater contribution to the discussion than patients in the present study. This is could be due to the structure of the consultations examined. In the 1999 study consultations included taking the history, conducting the physical examination and education/counselling about the diagnosis and treatment. Consultations in this study differed as patients had two consultations with the clinician in one day. The consultations recorded for this study were the patients’ second consultation in the clinic, which focused on education and counselling about the diagnosis and treatment. This could

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account for the difference in patients’ contribution to the dialogue. Alternatively, patients in Levinson and Chaumeton’s study could have been afforded greater input by their clinicians.

Compared to Levinson and Chaumeton’s study, in this study there was a greater discussion of psychosocial issues, specifically discussion about patients’ work and leisure activities. This suggests that it may not be the case that patients do not wish to discuss psychosocial content with surgeons, as previously argued by McNair et al., (2016). Although patients may be focused on biomedical issues, these findings suggest there are psychosocial concerns that patients wish to address within orthopaedic surgical consultations. The difference in psychosocial content between the two data sets could be due to several reasons. Firstly, consultations in the current study were longer, allowing for more time for the discussion of psychosocial issues. On average, the length of patients’ second consultations in this study was longer than that of their only consultation in Levinson and Chaumeton’s study. The sample of clinicians used in the current study was small, with only four clinicians and two consultants from one orthopaedic clinic participating in the study. It could be that staff in this particular clinic are more aware of the importance of addressing patients’ psychosocial concerns than in other clinics. The patients attending this clinic were also unique in that they were mostly very physically active or hoping to return to a high level of physical activity. Patients participated in competitive sport or had physically demanding professions, which their hip pain directly affected. Psychosocial concerns such as lifestyle may be more important to this sample of patients than to patients attending other orthopaedic surgery clinics. Finally, the image could have also contributed to the increased discussion of psychosocial issues. The use of the image to communicate medical information to patients may have enabled them to understand their condition and treatment more quickly, thus leaving more time for the discussion of psychosocial issues. Alternatively, the practice of showing patients their images could lead patients to feel that they have greater rapport with their doctor, leading them to raise psychosocial concerns. Carlin et al., (2014), for example,

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found patients felt respected and valued when their clinician showed them their medical imaging results, improving their rapport with their clinician.

When considered alongside the findings of Levinson and Chaumeton’s (1999) study and Levinson et al’s., (2013) systematic review of patient centredness in surgical consultations, these findings suggest that the usual model of patient centredness based on primary care and oncology consultations may be inappropriate for surgical consultations. During consultations about surgery, clinicians tend to be verbally dominant and discuss large amounts of biomedical information with patients. This is likely due to the need to educate patients about surgical treatments including the risks of surgery in order to enable patients to provide informed consent. A model of patient centredness for surgical consultations may therefore differ to that of primary care or oncology consultations in which patients are encouraged to be verbally dominant with discussion focussing on psychosocial issues. It could be argued that a model that focuses on patient education and is therefore, biomedically focused may be more suitable to surgical consultations. Although the aim of surgical consultations may be to deliver biomedical information to patients, a model for surgical consultations should also encourage clinicians to address patients’ psychosocial concerns.

4.4.2. Study strengths and limitations

This study used RIAS, an instrument widely used to assess the content of medical dialogue. RIAS codes are mutually exclusive and exhaustive allowing every utterance of the consultation to be coded and included in the analysis. A proportion of the consultations were also double coded for reliability.

As previously mentioned, the sample size was small with ten patients recruited from one orthopaedic clinic. Patients were typically well educated and had active lifestyles. Consequently, they may not be representative of the general population. The structure of

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these consultations may also differ from other orthopaedic surgery consultations as all but one of the patients had already had a consultation with the clinician earlier in the day. The recorded consultations, therefore, did not include introductions, patient histories and physical examinations, which could all alter the content of the discussion. As a result of these study limitations, these findings cannot tell us about the content of orthopaedic consultations more generally. However, they do provide an interesting description of the communication practices in one orthopaedic surgery clinic and offer insight as to how an image can be incorporated into a consultation.

Furthermore, limitations of the RIAS method have been identified. Mead and Bower (2000), for example, assessed the validity of three measures of patient centredness including RIAS, finding that the correlations between the three measures were low. This suggests that the three measures may not be assessing the same construct and questions the validity of the measures (Mead and Bower, 2000a). A further limitation of the method, as identified by Carrard and Mast (2015), is that it ignores differences in patients preferred interaction style. Adapting the interaction behaviour to the individual patient is central to the patient centred approach, however most methods of assessing patient centredness including RIAS adopt a one size fits all approach (Carrard & Mast, 2015). Despite these limitations, RIAS was selected for use in this study as previous studies have shown the framework to be a reliable method of assessing the content of consultations. Furthermore, RIAS allowed for the inclusion of the image within the analysis and allowed this data to be compared to the results of Levinson and Chaumeton.