JMIR Preprints Stommel et al

The impact of video-mediated communication on

closed wound assessments in post-operative
consultations: a conversation analytical study of
video-mediated and co-present consultations.

Wyke Stommel, Harry van Goor, Martijn Stommel

Submitted to: Journal of Medical Internet Research

on: January 13, 2020

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Table of Contents

Original Manuscript....................................................................................................................................................................... 5

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The impact of video-mediated communication on closed wound

assessments in post-operative consultations: a conversation analytical study
of video-mediated and co-present consultations.

Wyke StommelPhD, ; Harry van GoorPhD, ; Martijn StommelPhD,

Corresponding Author:
Wyke StommelPhD,
Phone: +3124-3612482
Email: w.stommel@let.ru.nl

Abstract

Background: While studies of physically co-present, face-to-face physician-patient interaction are abundant, relatively little is
known about medical encounters conducted through video-mediated technology. Previous research indicated that particularly
physical examination in the video setting poses challenges for the participants. However, we know little about how specific
medical activities such as wound assessment compare between the face-to-face and video-setting.
Objective: The objective of our study was to examine and juxtapose assessments of post-surgery wounds through a video
connection and in the consultation room.
Methods: We recorded 22 post-operative video consultations and 17 post-operative face-to-face consultations. The primary
purpose of the consultation was informing the patient about the final pathology results of the resected specimen and the
secondary purpose was checking on the patient’s recovery, including an assessment of the closed wound. The recordings were
transcribed in great detail and analyzed using methods of Conversation Analysis.
Results: One of the particularities of the video-consultations compared to face-to-face consultations is the way in which an
assessment of the wound is established. In the consultation room, wound assessments overwhelmingly involve wound showings
in the context of which surgeons report their observations formatted with evidentials (“looks neat”) and subsequently assess what
these observations imply or what can be concluded from them. In contrast, wound assessments in video-consultations do not tend
to involve showing the wound and, given the technological restrictions, do not involve palpation. Rather, the surgeon invites the
patient to assess the wound, which opens up a sequence of patient and physician assessments in which diagnostic criteria like
redness or swollenness are made explicit. In contrast to observations in regular consultations, these assessments are characterized
by epistemic markers of uncertainty (“I think”, “sounds… good”) and evidentials are absent. Only in case of a potential problem,
the surgeon might request the patient to demonstrate part of the body on camera.
Conclusions: Arriving at a conclusive wound assessment in a videoconsultation requires more interactional work than in face-to-
face consultations and patients have a fundamentally different role, providing their own, “lay” observations. Hence, it appears
that in video-consultations physicians are dealing with a disadvantage compared to physical examination in face-to-face
consultations, while patient participation is increasingly important.
(JMIR Preprints 13/01/2020:17791)
DOI: https://doi.org/10.2196/preprints.17791

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Original Manuscript

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ORIGINAL PAPER
SUBMITTED TO JOURNAL OF MEDICAL INTERNET RESEARCH, JANUARY 2020

The impact of video-mediated communication on closed wound assessments in post-operative

consultations: a conversation analytical study of video-mediated and co-present consultations.

Authors: Wyke Stommel1, Harry van Goor2, Martijn W.J. Stommel2

1. Centre for Language Studies, Radboud University Nijmegen, Nijmegen, 6500 HD,
Netherlands
2. Department of Surgery, Radboud University Medical Center, Nijmegen, 6525 GA,
Netherlands

Corresponding Author:
Wyke Stommel
Centre for Language Studies
Radboud University
6500 HD Nijmegen, Netherlands
w.stommel@let.ru.nl
+31-24-3612482

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Abstract
Background: Research on the use of video-mediated technology for medical consultation is
increasing rapidly. Most research in this area is based on questionnaires and focuses on long-term
conditions. The few studies that focused on physical examination in video consultations indicated
that it poses challenges for the participants. The specific activity of wound assessment through video
in post-surgery consultations has never been studied yet. Also, comparative analysis of the face-to-
face and video-setting on the moment-to-moment organization of such an activity is original.
Objective: The objective of our study was to examine the impact of video technology on the workings of
assessments of post-surgery wounds and its limits.
Methods: We recorded 22 post-operative video consultations and 17 post-operative face-to-face
consultations. The primary purpose of the consultation was informing the patient about the final
pathology results of the resected specimen and the secondary purpose was checking on the patient’s
recovery, including an assessment of the closed wound. The recordings were transcribed in detail and
analyzed using methods of Conversation Analysis.
Results: The way in which an assessment of the wound is established in video consultations differs
from the procedure in face-to-face consultations. In the consultation room, wound assessments
overwhelmingly (15 out of 17) involve wound showings in the context of which surgeons report their
observations formatted with evidentials (“looks neat”) and subsequently assess what these
observations imply or what can be concluded from them. In contrast, wound assessments in video
consultations do not tend to involve showing the wound (3 out of 22) and, given the technological
restrictions, do not involve palpation. Rather, the surgeon invites the patient to assess the wound,
which opens up a sequence of patient and physician assessments in which diagnostic criteria like
redness or swollenness are made explicit. In contrast to observations in regular consultations, these
assessments are characterized by epistemic markers of uncertainty (“I think”, “sounds… good”) and
evidentials are absent. Even in case of a potential wound problem, the surgeon may reside in
questioning the patient rather than requesting a showing.
Conclusions: The impact of the videotechnology on post-operative consultations is that a conclusive
wound assessment is arrived at in a different way compared to face-to-face consultations. In video
consultations, physicians enquire and patients provide their own, “lay” observations, which serve as
the basis for the assessment. This means that in video consultations patients have a fundamentally
different role. These talking-based assessments are effective unless, in case of a potential problem,
patient answers seem insufficient and a showing might be beneficial.

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Key words
Video consultation – remote/tele consultation – physical examination – assessment – patient-
physician relationship – conversation analysis

Introduction
Video consultations are generally found promising for use in the medical domain, especially due to
advantages like remoteness, convenience for patients and informal caregivers, and reduced anxiety
[1-4]. However, implementation of video consultations into real-world settings is complex. Most
research in this area focuses on long-term conditions and is based on questionnaires to elicit patient
and clinician experiences, reporting both positive and negative experiences with video consultations.
The experiences often seem to depend on the context, e.g., a long-term condition in which the
clinician and patient have a pre-existing relationship and whether both parties are confident with
technical issues [5,6]. Adaptation to the context can be accomplished by involving the patient in the
choice of consultation modality. In a comparative study on video versus face-to-face consultations in
follow-up care after colorectal cancer surgery, video consultations based on patient preference were
shown equivalent to face-to-face consultations in terms of patient satisfaction and perceived quality
of care [7]. Which patients might be most suitable for video consultations is unclear, but it is
recognized that patients’ reasons and ability to use video consultation may change over time and with
experience [8]. One of the advantages of the video format is that it affords visual access, which at
least in theory enables physicians to visually assess what patients show. Nevertheless, physical
examination has been regarded problematic in the video setting [9]. Patients’ self-examinations in
front of the camera such as measuring weight, blood pressure, heart rate, and rhythm and oxygen
saturation appeared to be challenging in various respects [10]. One of the challenges was that
patients had to do a physical examination while simultaneously making it visible to the clinician.
Hence, visual access may not be just an advantage; it also creates new problems.
Conversation analytical studies of medical video consultations are beginning to uncover
micro-level dimensions and challenges of video-mediated consultations [10-12], sometimes
explicitly in comparison with co-present consultations [13]. Pappas and Seale [11,12] analyzed
medical video consultations with a primary care physician/nurse and a patient at one end of the
connection and a consultant (a medical specialist) at the other. The professional who was with the
patient and therefore had direct perceptual access to the patient’s body made an assessment of the
patient’s foot and used the visual channel to demonstrate the assessment to the physician on the other
end [12: p.116-117]. Seuren and others [10] identified various challenges of video consultations in

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secondary care related to instructions for patients to self-measure oxygen level and to the patients’
manipulation of the camera and the body to capture what should be viewed by the physician.
So, a key domain of interest to medical video consultations is physical examination, which
requires the physician’s visual access to the patient’s body. Visual access is an affordance [14] of
video-mediated interaction, despite the “fractured ecologies” [15] of the patient and the physician
inherent to the interaction. It has been found that doing physical examination, the remote physician
transposes observational authority to the patient’s site [12]. Relatedly, examination conducted by
patients themselves may enhance their autonomy with regard to their own health [10]. Hence,
physical examination in video consultations may have the potential to instigate a shift in the
physician-patient relationship, or more broadly, in the way in which medicine is practiced.
When physicians examine patients they may communicate the findings of their observations
to the patient [16-18]. Simultaneously with the act of examination, physicians may produce talk
which is subordinated to the examination, which is called online commentary. There is usually no
mutual gaze and no response from the patient due to a lack of shared access to the object of
evaluation (e.g., a physician inspecting a patient’s ear). Alternatively, patients may be invited to
provide an initial self-assessment as long as they have access to the object of examination.
There are two primary formats for communication along with physical examination, namely
reports of observations and assessments of what is observed [16, 19]. In case of an observation
report (e.g., “I don’t see”), the conclusion such as “looks good” should be drawn by the patient. With
assessments of what is observed (e.g., “that looks good”) it is the physician who presents a
conclusion. Essentially, the power of both formats lies in the physician’s epistemic “ecological
advantage” [16, p.16] to be able to perceptually (seeing, hearing, feeling) assess the state of the
patient’s body. The criteria or “codes” for the evaluation that are discursively constructed in the
interaction serve as an apparatus of the physician’s professional vision [20]. The ecological
advantage thus encompasses rights with regard to both examination and constructing observation in
certain assessment categories.
Assessments are evaluations of objects and events in talk-in-interaction [21]. Assessments can
be elicited both by verbal actions (questions, prior assessments) and by embodied conduct or
experience [cf. 21, 22]. Goodwin and Goodwin [23] discern assessments on distinct levels of
organization, with assessments activities as one such level. Assessment as an activity refers to
multiple participants jointly producing an assessment in multiple turns, using intonation, overlap,
intensifiers, nods and other resources. Relevant to such assessment activities is that the participants
have differential access to the assessable, which is reflected in their talk. For instance, saying “that

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sounds good” attends to the fact that the assessable was available through a co-participant’s
description [23, p.165]. Displaying agreement on, or producing concurring assessments is important
in assessment activities. The same speaker can repeat an assessment although subsequent
assessments may display diminished participation and thus bring the activity to a close. Overall, an
activity of assessment is a structure which participants collaboratively bring to a climax and which
they then withdraw from.
A specific occasion for the occurrence of assessments are “informative showings” [24], which
involves showing something ‘new’ such as the current state of the wound and a recipient who is
informed by the showing. In the medical context, a showing enables the physician’s professional
vision [20] as a basis for assessment rather than that joint visual perception is achieved by the
showing [cf. 25-27].
The question this article addresses is how assessments of a surgical closed wound are
collaboratively produced in video consultations in which the physician lacks direct perceptual access
to the assessable, which is available in the face-to-face setting. This question provides insights in the
ways in which video technology as a mode of communication affects clinical practice.

Methods

The data consist of 39 video recordings of follow-up consultations after abdominal cancer surgery,
including 17 co-present consultations (average 13min40) and 22 video consultations (average
12min20). The data were collected in the context of a study comparing the conversational
organization of video-mediated consultations with regular consultations at the outpatient clinic
during the first post-operative consultation after discharge [13]. The first post-operative consultation
was chosen because of the potentially considerable burden of a visit to the outpatient clinic and thus
potential advantage of video consultation in this phase. Inclusion criteria were patients ≥18 years old
after abdominal cancer surgery. Exclusion criteria were inability to give informed consent and lack of
proficiency in Dutch. The participants were 39 patients (21 female and 18 male) often accompanied
by one or more family members and 3 male surgeons who were experienced in video-consulting
before the start of the study. The type and complexity of the surgery was comparable for all patients,
although some were laparoscopic operations which involved three or four small incisional wounds
for the trocars, rather than one large wound. At discharge, the patients were informed about the
follow-up consultation scheduled approximately two weeks after the operation. The goal of the
follow-up consultation was explained as discussing the final pathology results and checking on
recovery. The results sometimes involved bad news, but were mostly brought off as a confirmation of

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what was expected. The question about recovery, including the wound assessments, usually came as
a second order of business for the consultation [13]. The patients were offered to have the follow-up
consultation through video or as a regular consultation at the hospital. After they chose either of
these options, they were informed about the study and asked to participate. They all gave their
consent, although one patient requested us at a later time not to use the recording or transcript in any
scientific publication or presentation of the study.
A waiver for medical ethical approval was obtained from Radboud Medical Center Ethical
Committee in June 2017. The data were collected in June-July 2017 and March-June 2018. Each
consultation was recorded using two camera’s, one directed mainly at the surgeon and one at the
patient and accompanies, either in the consultation room or on the surgeon’s desk top computer. The
recordings thus reflect the real life circumstances of the surgeon, who does not have access to
whatever the patient sees or hears including delays, perturbations, sequential mismatches etc. [cf.
28]. The particulars of the ecological set-up at patients’ homes may have influenced some practical
choices, for instance re-adjusting their body to the screen to make them visible rather than turning
the camera towards the spot, which is another way to show things in video communication [29]. For
the hospital recordings, the surgeons sometimes turned away the camera or even turned it off during
the physical examination for ethical reasons; these recordings were not excluded from the data set,
although they were inevitably inapt for detailed analysis of the examination. The consultations were
transcribed based on conversation analysis conventions [30, 31] and all names were replaced by
pseudonyms.
In order to juxtapose assessments in co-present and video-mediated consultations, we first
identified all wound assessment activities in the data and whether it involved a showing or not. The
next step was to examine each case microanalytically using multimodal conversation analysis [32,
33]. These analyses were inherently comparative, resulting in an understanding of the methods used
for doing wound assessments contingent on the medium. In the next section we discuss five
illustrative cases of wound assessments, two in the co-present setting, and three in the video setting,
that are representative of our findings.

Results
We found that in the co-present setting, wounds were generally (15 out of 17) assessed on the basis
of a showing of the wound. On the contrary, in the video-mediated setting showings were rare (3 out
of 22). See table 1 for an overview of the occurrence of wound assessment, wound assessment
including showing and no wound assessment.
Showing-based Talk-based wound No wound
wound assessment
https://preprints.jmir.org/preprint/17791 assessment assessment[unpublished, non-peer-reviewed preprint]
Co-present (n = 17) 88% (15/17) 6% (1/17) 6% (1/17)
Video-mediated (n = 22) 17% (3/22) 51% (12/22) 32% (7/22)
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Table 1. Frequency of showing-based and talk-based wound assessment in co-present and video-mediated consultations

In the following, we first analyze the face-to-face default method and then the default video-
mediated (VMC) method. We found no communicative differences between laparoscopic wounds
and other wounds. The two assessment procedures are mostly initiated by the physician who enquires
about how the wound is healing. Finally, we discuss one video consultation in which wound
assessment is initiated by the patient who reports a potential problem. This allows for an in-depth
understanding of the intricacies of wound assessment through video.

The face-to-face default method: Showing-based wound assessments

Showing-based wound assessments are characterized by a relatively stable structure. It is initiated by
the physician asking whether the wound(s) is (are) healing well. The patient’s answer is a tentatively
positive evaluation of the wound, upon which the physician expands the sequence with a request to
show the wound or an invitation to undress behind the curtain for physical examination. During the
showing or examination, the physician produces observation reports using evidentials and
evaluations (“looks neat”, “looks uneventful”). The evaluations tend to be rather brief and general
descriptors like “neat”, “good” and “uneventful”. Excerpt 1 is an example of a co-present showing-
based wound assessment. The physician is enquiring about the patient’s recovery, having asked about
fever and illness (data not shown) and then about the wounds (line 1).
Excerpt 1 (Reg 25 5:50)
1 DOC: =zijn de wondjes goed genezen?
=did the small wounds heal well?
2 PAT: volgens mij *wel.
Doc: *firm nod
according to me yes.
I think so.
3 DOC: oke: kunt u *ut- ut #^hemd even omhoogtrekken (.) dat ik kan kijken?
#figure 1
Doc: *points to Pat’s belly and moves forward
Pat: ^---------------------------------------------
okay: can you- briefly pull up the- the shirt so that I can have a look?
4 (2.0)^#
Pat: -----^stands up and takes out shirt
5 DOC: ohja *>nou<^ dat ziet er keurig uit ^*(.) ja;
oh yeah >well< that looks neat (.) yeah;
Doc: *bends forward
Pat: ^------------------------^turns hips, showing belly
Doc: *leans back in chair
6 PAT: ^volgens mij wel heh,
according to me it does huh,
I think so huh,
Pat: ^--------------------
7 DOC: jaha:: (.) zeker ja;
yea::h (.) it certainly does yeah;
Pat: -------------------

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8 *(0.5)
Doc: *nods
Pat: ------
9 DOC: °ziet er rustig uit°.
°looks uneventful.°
°healing well.°
Pat: ---------------------
10 DOC: ja;*^
yeah;
Doc: *looks at pc screen
Pat: ----^puts shirt back into jeans

#Figure 1 (5:59)

The showing-based wound assessment activity begins with the physician’s yes/no-question (line 1),
asking whether the small wounds healed well. The patient confirms with an epistemic downgrade
(“according to me” line 2), thus making an independent assessment by the surgeon a relevant next
action. The request to show the wound “can you- briefly pull up the shirt” (line 3) displays a
relatively high entitlement [34], thus building on the structure of wound assessment as projected by
the patient’s previous turn. The patient complies immediately (see line 3, figure 1), aligning with the
activity. As soon as the wound is visible, the physician reports that it “looks neat” and confirms the
patient’s initial evaluation (“yeah” line 5). Note that physician uses an evidential (“looks”) to present
a conclusion rather than an observation report, later rephrased as “looks uneventful” (line 9), which
is produced softly and thus displays diminished participation and an orientation to activity closing
[23].
Giving visual access in the showing-based assessment activity does not need to be requested
explicitly, as it was in Excerpt 1. The activity structure in the co-present setting allows for more
subtle collaborative orientation to the relevance of showing, as can be seen in Excerpt 2.

Excerpt 2 (Reg 36 7:37)

1 PAT2: =dus:=
=so:=
2 DOC: =.hh* en hoe is de wond genezen meneer [van dijk;
=.hh and how is the wound healing mister [van dijk;
Doc: *points briefly at Pat belly

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3 PAT2: [KEUrig.
[neatly.
4 PAT: nou die is °netjes°
well that looks °neat°
5 DOC: ^ja?
yeah?
Pat: ^#---
#figure 2
6 PAT2: vinden wij wEl,
we do think so,
Pat: ---------------
7 PAT3: ja das echt mooi.
yeah that’s really pretty.
Pat: -----------------^#stands up and pulls up shirt
8 DOC: Oh ja (.) ja dat# ziet er netjes uit.
Oh yeah (.) yeah that looks neat.
#figure 3
9 PAT2: keurig (heh),*
neat (huh),
Doc: *nods
10 DOC: °hartstikke goed°* (.) ja hoor
°really good° (.) yeah (hoor)
°that’s great°
Doc: *nods

#Figure 2 (7:38) #Figure 3 (7:41)

While asking how the wound is healing (line 2), the physician points at the patient’s belly, indirectly
orienting to the show-ability of the wound. After a single item, positive assessment by the patient’s
partner (line 3) and one from the patient (line 4), the patient rises to initiate a showing (Figure 2).
Hence, he expands the initial positive assessments allowing the physician to independently self-
assess the wound to arrive at a concurring assessment. Put differently, the patient’s claim about the
showable wound makes relevant the showing as a way of facilitating independent access [cf. 24].
While the showing is emerging non-verbally, the physician produces a checking question (“yeah?”
line 5) which elicits an epistemically downgraded assessment from the patient’s partner (“we do
think so” line 6) and an upgraded one from the patient’s daughter who sits off-camera (“really pretty”
line 7). Then, the physician receives the now perceptually available wound as newsworthy (“oh”,

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[35]) (line 8), touches the belly just over the scar with two fingers (Figure 3) and assesses the wound
using the same lexical form as the patient (“looks neat”). Hence, the structure of a wound assessment
activity in the consultation room is opened with a physician question, expanded with a showing
which then leads to a concurring assessment by the physician. The physician assessment is formatted
with an evidential (“looks”) displaying direct access to the assessable.

The VMC default method: Talk-based wound assessments

The VMC default method is talk-based assessment which are characterized by a different structure
and different epistemic marking compared to showing-based assessments. These sequences also
typically begin with the physician asking whether the wound is healing well. Excerpt 3 is an example
of a talk-based wound assessment typical for the video setting.

Excerpt 3 (Vid 16 3:53)

1 DOC: en U:UHM zijn- is de WOND goed genez↑en (.) de wondjes,
and U:UHM have- has the WOUND healed well (.) the small wounds, (0.9)
2 PAT: JA (.) honderd procent;
YEAH (.) a hundred percent;
3 (0.8)
4 DOC: geen uh ROODheid of ZWELling,
no uh REDness or SWELLing,
5 (1.2)
6 PAT: nee nee nee nee nee (.) ik kan niks opnoemen;
no no no no no (.) I can’t name anything;
7 (.)
8 DOC: N↓EE (.) okE (.) perfect;
NO (.) okAY (.) perfect;
9 (1.1)
10 .hh u::hm (.) NOU dat klinkt allemaal heel erg GOED;
.hh u::hm (.) WELL that sounds all really very WELL;

The assessment activity opening question received a positive assessment from patient, in this case
with an the epistemic upgrade “a hundred percent” (line 2), which formulates the confirmation as an
extreme case and thus legitimizes it [36]. The physician does not continue with a showing request
nor does the patient initiate a showing. Rather, the physician poses a subsequent question to verify
the patient’s answer. This question explicates two diagnostic criteria for wound assessments, namely
“redness” and “swollenness”, and makes relevant a confirmation of the absence of these symptoms
from the patient. The patient then responds with multiple “no’s”, not only responding to the
immediately preceding question, but to the physician’s course of action checking recovery [37]. This
is elaborated with a more explicit assessment by the patient (“can’t name anything”) which again
legitimizes the multiple saying “no” [cf. 36]. The physician accepts and evaluates this answer
(“perfect”), upon which he explicitly closes the “recovery”-sequence with a qualified assessment:
“.hh u::hm (.) WELL that sounds all really very WELL”. Note that this qualification displays the

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differential access [23] by the patient and physician to the wound (“sounds”) and acknowledges the
patient’s evaluation(s) as the epistemic basis for this closing assessment. Hence, a talk-based wound
assessment in VMC is an assessment activity similar to a showing-based assessment, but it involves
questioning rather than showing and its climax assessment reflects differential access and is thus
epistemically weaker than in a showing-based assessment.
Even when patients produce slightly less overtly rhetoric wound assessments than “hundred
percent”, showings are not oriented to as relevant next actions. This can be seen in Excerpt 4, in
which the patient reports a potential minor problem with the wound (“only near my navel).

Excerpt 4 (Vid 12 3.10)

1 DOC: de WONDjes zijn ook goed geNEzen,
did the little WOUnds also hEAl well,
2 (0.7)
3 PAT: ja (.) ja de blauwe PLEkken zijn weg (.) BIJna=
yeah (.) yeah the bruises are gone (.) ALmost=
4 DOC: =oke=
=okay=
5 PAT: =en uh de wondjes zijn uh↓ (.) zijn ook GOED aan het genezen
=and uh the little wounds are uh (.) are also healing WELL
6 dus dat zie je BIJNa niet meer sommige zie je niet meer;
so you almost don’t see them anymore some you don’t see anymore
7 (0.3)
8 DOC: [okee]
[okay]
9 PAT: [al ]leen bij mijn NAvel;
[on ]ly near my NAvel;
10 (0.3)
11 DOC: ja=
yeah=
12 PAT: =die is nog IEtsjes maar de RESt is weg;
=that one is still a BIt but the RESt is gone;
13 (1.2)
14 DOC: nou dat is allemaal FIJN om te HOren (.) [u:hm]
well that is all NICE to HEAr (.) [u:hm]
15 PAT: [ja]
[yeah]
16 DOC: dus uh ja dan is het toch allemaal GOED verLOpen;
so uh yeah then it did all go WELL;

In response to the activity opening question (line 1), the patient first confirms, produces a general
description of what can be seen on the body (“bruises are gone (.) almost”) and then an explicit,
verbal confirmation that the wounds are healing well. This is elaborated with a formulation of the
visual observation of the wounds as the epistemic basis of this claim (“you almost don’t see them
anymore some you can’t see anymore“ line 6). Note that the patient uses the impersonal “you”,
designing this claim as objective rather than as epistemically marked as her own observation.
Then, the patient expands the positive assessment with a minor problem (“only near my navel” line
9, “that one is still a bit” line 12), although this is contrasted with an overall positive assessment
(“but the rest is gone” line 12) which proposes closing of the assessment. The physician responds
with the qualified assessment “well that is all NICE to HEar”, not orienting to the minor problem

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report but rather treating the patient’s wound assessment as relatively unspecific (“all”) and as news
which he had no direct independent access to. The presented conclusion which follows (“so uh yeah
then it did all go WELL”) is built on this general, positive news receipt and covers the whole surgery
process, thus moving out of the activity of wound assessment.
In sum, talk-based wound assessment sequences include the specification of diagnostic
criteria (“redness”, “swollenness”), perceptual basis (“some you don’t see anymore”) and/or
reference to a location on the body (“near my navel”). These may be elicited by the physician or
volunteered by the patient. Centrally, in such VMC talk-based assessments physicians arrive at
qualified wound assessments, marking them as epistemically grounded in the patient’s evaluation
rather than in their own observation or examination.

Patient-initiated wound assessments in VMC

In the examples so far, the assessment sequences were initiated by the physician enquiring about the
wound. However, wound assessments may also be initiated by patients rather than physicians with a
report or question addressing some sort of trouble with regard to the wound. Although wound (or
location) showings do occur (3 out of 22 video consultations), even patient-initiated sequences which
make relevant a wound assessment may unfold as talk-based assessments in video consultations. In
such cases, the interaction tends to be stretched over several sequences. The possibility to show the
wound is disregarded, despite the fact that visual access is available through the video connection.
Excerpt 5 is an example of a lengthy talk-based wound assessment in the video setting. In response
to the question how the patient is doing (line 1), she reports pain related to the wound as a first
concern [cf. 13], which opens up the wound assessment activity.

Excerpt 5 (Vid 1 1:54)

1 DOC: hoe gaat ‘t met u;
how are you doing;
2 (2.0)
3 PAT: op zich gaat het prima?
in general it’s going fine?
4 (0.5) e:h <ik heb alleen sinds gistere'> heb ik problemen
(0.5) e:h <only since yesterday I have> I have problems
5 als ik buk dat de wond zeer doet.
when I bend over that the wound hurts.
6 (0.6)
7 DOC: ja (0.2) okee.
yeah (0.2) okay.
8 (0.9)
9 mm hm,
mm hm,
10 (0.7)
11 → en e:hm (0.4) eh ZIET u ook iets aan de wond of niet.

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12 and e:hm (0.4) do you also SEE something at the wound or not.
13 PAT: (1.5)
*nee.
Pat: no.
14 *----
15 DOC:→ (0.4)
‘t is niet rood,=
Pat: it’s not red,=
16 PAT: -----------------
=ºneeº.*
Pat: =ºnoº.
17 -------*shakes head
18 DOC: (1.6)
nee.
19 PAT: no.
neu niet dat ik e:h dat ik ‘et extra rood vind [ofzo.]
20 DOC: no not that I e:h that I find it extra red [or something]
[nee. ]
21 → [no. ]
EN DAT IS DAN DAT GROOTSTE WONDJE WAT-
22 → AND THAT IS THE LARGEST WOUND WHICH-
BIJ U: EH BEETJE *MIDDE’ OP DE buik zit zeg maar;*
Pat: WITH YOU: IS A BIT IN THE MIDDLE OF THE belly so to say;
23 DOC: *-------------------------------*nods
(.) heh?
24 (.) huh?
•hh *wat we gebruikt hebben om* eh om het zakje met eh
Pat: •hh which we used to pull the little bag with eh
25 DOC: *-------------------------* nods
‘et stukje lever eh: door naar *↓buiten te halen↓.*
Pat: the piece of liver eh out.
26 *------------------*nods
27 PAT: (0.2)
ja.
28 yeah.
29 DOC: (0.7)
[ja. ]
30 → [yeah.]
[en en] *ziet u d- of voelt u* dat daar ook een zwelling zit of niet?
Pat: [and and] do you see- or do you feel that it is swollen there or not?
31 *--------------------*nods
32 PAT: (1.6)
*nee d’r zit geen zwelling daar,*
Pat: no it is not swollen there,
33 *-------------------------------*shakes head
34 DOC: (0.3)
nee
35 no
36 PAT: (0.4)
e:h ‘t is wat (.) hard;
37 e:h it is a bit (.) hard;
38 DOC: (0.5)
ja? (0.3) okee.=
39 PAT: yeah? (0.3) okay.=
40 =maar*
Pat: =but
41 *shrugs
DOC: (0.4)
ja (0.4) ja
42 PAT: yeah (0.4) yeah
43 dat is eigenlijk alle'.
that’s all actually.
44 DOC: [86 lines omitted]
ºdus ikº •h beschouw dat (0.5) e::h in eerste instantie echt
45 ºso Iº •h consider that (0.5) u::h at first really
als onschuldig. dat dat e:h eh zo pijnlijk is voor u,
as innocent. that that u:h uh is so painful for you,

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To begin with, the patient refers to the viewable wound in her problem presentation (lines 4-5),
which creates an opportunity for the physician to request a showing (a so-called “touched-off”
showing, [38]). However, rather than requesting the patient to show the wound, he accepts this initial
problem account (“yeah (0.2) okay” line 7), which arguably projects history taking as a next activity
[39]. Nevertheless, the physician does not take a turn, remains silent for 0.9 second and then
produces a continuer (“mhmm”, line 9), creating a context for the patient to elaborate on the
complaint. In the silence that follows (0.7s), the patient does not continue, upon which the physician
initiates the talk-based assessment activity. Hence, the initial problem report by the patient seems to
create an interactional limbo in the structure of the assessment activity in which an opportunity to
request a showing has passed.
The physician, asking whether the patient also sees something at the wound, orients to the
viewability and thus potential show-ability of the wound. The patient denies something can be seen,
upon which the physician expands by making explicit what could be seen, namely redness (line 15).
This further question also receives a “no”, but this time one that is elaborated with an account which
implicitly proposes a scale of redness indicating the wound is not “extra red” (line 19). “Not extra
red or so” implies the wound is (a bit) red, which may flag trouble to the physician. Saliently, the
patient produces this assessment without direct visual access, i.e. she is not simultaneously
inspecting the wound. Moreover, it is marked with an epistemic downgrade (“I find” line 19), thus
designing this observation as not only rooted in her earlier observation but also as subjective (or
“subject-side”, [40]). A showing could have resolved these issues, but this is not what happens.
Rather, the physician checks whether the complaint is about the largest wound (line 21) and indicates
roughly where this is located on the patient’s belly (line 22). This way, again, a viewable (location on
belly) is talked about without being shown. After the participants have reached agreement about
which wound is being discussed (line 27 and 29), the physician launches another diagnostic question:
“[and and] do you see- or do you feel that it is swollen there or not?” . The seeing as a source of
observation is repaired to feeling regarding the diagnostic criterion of “swollenness” (line 30).
Hence, the patient is not invited to look “through the doctor’s eyes”, but to touch “on behalf of the
physician”. This implies showing is now less relevant, as a show might be perceptually inadequate to
assess swollenness.
From this point onward, the patient reports tactile observations including that it is “not
swollen there” (line 32), followed by a further potentially troublesome description “it’s a bit (.) hard”
(line 36), which introduces yet another category. Nevertheless, the sequence is collaboratively closed

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with an orientation to the problem as minimal (“that’s all actually” line 43) and thus not in need of
further talk. Then, the physician starts a new (but related) sequence on the patient’s activities during
the past weeks (data not shown), which eventually leads to his wound/pain assessment as “innocent”
(line 45) with multiple disfluencies and hedges (“uh’s”, “at first really”) and epistemic downgrade (“I
consider that”). Hence, a talk-based assessment in case of potential trouble may reside in talk to
avoid a showing request. It includes the explication of multiple diagnostic criteria, it may involve
reference to various sensorial observations by the patient and it eventually leads to a qualified wound
assessment.

Discussion

Principle results
Our primary finding is that video consultations differ from co-present consultation with regard to
wound assessment. Talk-based wound assessment is the dominant trajectory in video consultations,
while showing-based wound assessment is the dominant method in co-present consultations. While
both trajectories are generally initiated with an informing question by the physician, the subsequent
steps differ. Either the activity continues with a showing/examination of the wound, or with one or
more questions enquiring the absence of specific diagnostic criteria (redness, swollenness). Showing-
based assessments work towards evidentially grounded general assessments (“neat”, “good”,
“uneventful”), while talk-based assessments arrive at qualified assessments which display a lack of
direct access to the assessable (“sounds”, “I consider that”). Hence, wound assessments in video
consultations are grounded in patient assessments, which implies a shift in clinical practice from
primacy of the doctor’s gaze to the patient’s evaluation of how the wound(s) are healing. Even in
case of potential wound trouble in video consultations, physicians may reside in talk and avoid to
request a showing of the wound despite its apparent relevance. Such talk-based assessment
sequences can be stretched substantially, with physicians bringing up multiple questions to enquire
symptoms and observations from the patient, both visual and tactile. Hence, despite the possibility of
visual access and the interactional relevance, the participants display an orientation to avoiding
showing in video consultations.

Comparison with prior work

We may speculate about the reason(s) for the avoidance of showing closed surgical wounds in video
consultations. A general reason could be that asking a patient to undress or show part of the nude

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belly or torso while being in the private sphere (usually the living room) with potentially others
present and/or showing part of the nude body on camera is a delicate thing to do. In contrast, the
hospital’s consultation room is marked with clinical set up and assets (physician wearing white coat,
curtain, examination table, medical instruments etc.), creating a context in which showing the body
and physical examination may become relevant or may be expected by patients and/or physicians.
Possibly, as participants’ experience with video-interaction evolves, showing practices may occur
more naturally. The avoidance of showings in video consultations, and thus direct visual access by
the physician, implies that the “ecological advantage” [16] of physical examination may not, or does
not naturally apply to the video setting.
This means that physicians have less authority in diagnosing the wound and that instead,
patients are more agentive and epistemically amplified compared to face-to-face consultations.
Similarly, Seuren and others [10] suggested that physical examination in video consultations may
enhance patient autonomy as patients become (more) active participants in the examination, having
to handle instruments (e.g., to measure oxygen in blood) or to modify the camera. Nevertheless,
physicians’ qualified assessments indicate a degree of uncertainty as a result of the restrictions of the
medical ‘armentarium’ inherent to the medium (e.g., the impossibility of palpation) and reliance on
patient reports and observations [cf. 12]. This might explain why prior studies on physicians
perspective on applicability of video consultations revealed anticipated need for physical
examination as a main reason not to opt for video consultation [1, 6]. The question is, however,
under which conditions it is necessary to conduct a physical examination. In the majority of cases
talk-based assessment was sufficient to assess wound-healing, which implies the early post-operative
phase is a context in which video consultations appear effective.

Limitations
A limitation of our study is that we cannot exclude that the patients who chose a hospital consultation
were more insecure about their recovery including the wound(s) than those who opted for a video
consultation. In that case, our findings could not (only) be explained by the medium of
communication. However, examining the data we found multiple cases of patients in the hospital
setting who did not present any insecurity with regard to their recovery and we also found cases of
potential insecurity (patient reporting pain) in the video data. Another limitation is that the observed
phenomenon may be related to the specific goal of the consultation. In our data, the reason for the
consultation was the news delivery of the pathology results and an examination of the wound was not
explicitly announced. However, in the face-to-face consultations showings and the physicians’

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invitations to “have a look” were utterly unproblematic. Nevertheless, it is possible that in video
consultations in which the goal of the interaction is more closely linked to examination medically
relevant showings are more common and are also volunteered by patients [cf. 10, 12]. Patients may
then even close the curtains or do the video consultation from their bedroom. Hence, medical
assessment practices are likely to further evolve with participants’ growing familiarity with video-
mediated interaction.

Conclusions
Overall, it has become clear that video-mediated and co-present medical interaction differ with
regard to assessments of medical assessables such as wounds. It was particularly the comparative
perspective that yielded new insights, providing evidence of normative orientations with regard to
showing that intersect the medical dimension of the talk ánd the medium of communication. This
underscores the relevance of the communication channel for the organization of (institutional) talk-
in-interaction [41] and that juxtaposing equivalent interactions through different media is
worthwhile, particularly when the choice for the one or the other medium is an ‘emic’ choice for both
the patient and – in a different way – the physician. New communicative affordances, such as
patients sharing images of their body (parts) with their phones, are likely to further affect medical
interactions.
A practical implication of our study is that physicians may have to do “extra work” in video
consultations to facilitate showing-based assessments. Furthermore, they should consider under
which circumstances (e.g., closed wound inspection) a hospital visit is more suitable than a video
consultation. Another practical implication is that talk-based assessment seems to reduce the
physician’s medical authority as it ascribes more authority to the patient. This reliance on patient
observation and judgement is in line with increased self-management as a form of patient
empowerment in video consultations [42,10], which is generally regarded beneficial. It nevertheless
seems important that practitioners are aware of potentially shifting authority.

Acknowledgements
We would like to thank Christian Licoppe for a data session at Télécom Paristech and the
participants of data sessions at Copenhagen University and at King’s College London for their
valuable input to the analysis of our data. We are also grateful to Willem van de Heuvel and the CIS
MA students for their initial transcriptions of the videos, to Anita Pomerantz for her feedback on an
earlier version of the manuscript and to two anonymous reviewers for their valuable comments.

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Conflict of interest
None.

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Transcription conventions
Data are represented in two-line transcripts, occasionally three lines. The first represents the original
utterance in Dutch; the second line gives the English translation word by word, staying as close as
possible to the Dutch. Where relevant, a more understandable/idiomatic English translation is given
in the third line, in italics.
[ A left bracket indicates the onset of overlapping talk.
] A right bracket indicates the end of overlapping talk.
= Equal signs ordinarily come in pairs and indicate that the second line was “latched” to the
first.
(1.0) Numbers in parentheses indicate silence represented in seconds.
(.) A dot in parentheses indicates a “micropause” of less than 0.2 seconds.
:: Colons indicate prolongation of the immediately prior sound.
- A hyphen indicates a cut-off.
hh The letter “h” indicates audible outbreath. The number of “h”s represents the length of the
outbreath.

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.hh The letter “h” preceded by a dot indicates audible inbreath. The number of “h”s represents the
length of the inbreath.
yes Underlining indicates emphasis.
YES Upper case indicates that a word or utterance is markedly loud.
ºyesº A word or utterance enclosed by two degree signs is markedly quiet or soft.
. A dot at the end of an utterance indicates strongly falling intonation.
; A semicolon at the end of an utterance indicates falling intonation.
? A question mark at the end of an utterance indicates strongly rising intonation.
, A comma at the end of an utterance indicates slightly rising intonation.
* Asterisks indicate bodily behaviors.

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