1Teleconsultations allow healthcare professionals to conduct remote patient consultations using a means of information communication. [1] Its use in France today is still experimental. Although it is difficult to provide a complete account of the current situation, recent reports [2] mention experiments recorded in France, probably amounting to no more than a few hundred teleconsultations per year. Far from being integrated into hospital practices, teleconsultations are still uncommon and stem from local initiatives. In the absence of specific cost fixing, in particular, the question arises of how they should be paid for.
2The medical teleconsultations we studied took the form of doctor/patient interactions mediated by technology that at first sight resembled videoconferencing (Curien and Gensollen 1985; Relieu 2007) and video telephony (Fornel 1988, 1994; Bonu 2007; Velkovska and Zouinar 2007). This technology can produce remote copresent situations (Fornel, 1992) that are relatively similar to face-to-face interaction, ensuring forms of mutual observation and audibility that are considered satisfactory. Our research is based on the observation of teleconsultations between two institutions belonging to the Assistance Publique-Hôpitaux de Paris (AP-HP): the Hôpital Européen Georges Pompidou (HEGP) and the Hôpital Gériatrique Vaugirard-Gabriel-Pallez (VGP). Bringing together these two institutions in a network in June 2009 through the use of the Cisco Health Presence videoconference platform made it possible to carry out various telemedicine experiments over the course of eight months, in particular teleconsultations and tele-expertise. The technology was retained for use as part of routine treatment. Images filmed in each institution were transmitted live from both ends of the equipment and displayed on high definition screens. The project relied, in addition to the platform, on the availability and subsequent development of tools that are similar to, and most often based on, those used in medicine and that could be connected to the equipment: a dermatoscope, otoscope, stethoscope, ultrasound, an electrocardiograph and a spirometer, to which a portable camera was added. Use of the platform makes it possible to view cardiac and vascular ultrasound results in real time, to view an enlarged image of a small area of skin thanks to a dermatoscope or to hear the amplified sound of heartbeats from a stethoscope at the “other end” of the equipment, that is remotely from the patient and also from the necessary diagnostic devices. The platform also enables sharing of computerised medical records along with photographic and radiographic images.
3Initially, the principal objective of this equipment was to use information and communications technology (ICT), and more specifically high speed networks for remote consultations, in order to avoid a large number of the visits made by elderly patients hospitalised in the VGP when needing to consult an HEGP specialist. Generally, these visits take at least half a day and can prove very tiring, disruptive and even stressful for patients. They require time to prepare patients for the transfer (bathing and dressing) and involve time waiting for an ambulance to take patients there and back, as well as the journey time, not forgetting the time spent in a specialist’s waiting room and the time of the consultation itself. Thus, the stated aims of hospital staff taking part in the experiment is to improve the care of elderly people who are already hospitalised, often fatigable and difficult to move, needing specialist consultations for which they require transportation by ambulance. In the longer term, the goal is also to shorten hospitalisation in the HEGP while enjoying the same quality of care following transfer to the VGP.
4Our objective is not so much to study the medical reasoning in a detailed way, i.e., how diagnoses are made and the various resources on which they depend (Dodier 1993a; Cicourel 1994, 2002), it is to study the way in which use of telepresence technology can lead to adjustments and changes in medical practices so that diagnoses can be made remotely by a specialist doctor. Our theoretical framework draws mainly on the interactionist perspectives of Strauss (Strauss et al. 1963, 1997) and Goffman (1967, 1974) and on Cicourel’s cognitive sociology (1985, 1994, 2002). Employing an interactionist analysis perspective is justified since the use of teleconsultation technology, in a similar way as telepsychiatry (May et al. 2001), “substantially changes the nature of encounters between patients and professionals, in particular from the point of view of interactions” (Akrich and Méadel 2004: 14). Teleconsultations represent a new experiment in triadic consultations that bring together a patient, a specialist and a referring healthcare professional??”in our case this was usually the geriatrician in charge of the patient at the VGP. They differ from multidisciplinary cancer care coordination meetings where the patient is absent (Chardot et al. 1995; [3] Castel 2005), or hospital staff meetings bringing together professionals in the same department to look at a medical case. Teleconsultations also differ from the practices observable in the context of health and care networks, which involve hospital practitioners and care professionals working in independent practices cooperating in the homecare of patients (Bercot 2006). The teleconsultations involve the participation of a specialist doctor on the HEGP side and on the VGP side, the patient and their referring doctor (or a colleague who replaces him), a care assistant or nurse, sometimes a physiotherapist (who are assigned certain tasks delegated by the specialist) and a clinical research assistant (mainly responsible for welcoming, supporting and guiding the telepresence platform users). [4]
5We thus hypothesise that the changes in interactions observable in teleconsultations encourage changes in terms of professional practices themselves, to the extent that these consist of social and interactional practices. From this perspective, interactions are a potentially heuristic analytical starting point for attempting to understand the transformation in work practices that may be at work. The teleconsultation equipment can thus be likened to video telephony, which “implies not only individual action but the joint and continuous action [of several] individuals who are prepared to cooperate to create and maintain a shared interactional space. Such technology is thus not a tool that simply extends perception by providing access to a space but is also an interactional artefact.” This “restructures interactional activity itself, and, as a consequence, the nature of the practical tasks faced by the interlocutors” (Fornel 1994: 126).
6In regard to this, at a very early stage the doctor in charge of the teleconsultation project put in place interaction frameworks aimed at building a common reference frame, in situ, for the various professionals involved, so that they could interact efficiently (Goffman 1974). [5] These framing activities contribute to producing the basic conditions for interaction by guiding the copresent individuals’ perceptions and behaviour using and resulting from the teleconsultation equipment. There were four frame types and the project’s coordinating doctor implemented these quasi-systemically during the first teleconsultations (Esterle, Mathieu-Fritz and Espinoza 2011). The “relational and professional” frame aims to introduce the interlocutors present and defines the bases of a common intelligibility. The “technical” frame, which emerges incidentally during the teleconsultations, relates to the use of the equipment and mainly aims to provide an understanding of the functioning and use of the telepresence platform and its different tools (computerised patient records, x-rays, portable camera, different images sources on the different screens, etc.). The “clinical” frame consists of establishing norms aimed at reproducing common practices in clinical examinations (e.g., presentation of a patient’s record). Finally, the “organisational” frame deals mainly with the scheduling of future sessions, the people to contact and how to fill demand for teleconsultations by providing clinical information about patients.
7A comparison with multidisciplinary meetings or those that take place in healthcare networks shows that the specificity of teleconsultations is linked to the work done to shape interactions by the coordinating doctor in situ??” “framing” work??”, as well as new forms of cooperation based on the use of the technology, notably various forms of task delegation between healthcare professionals.
8Cooperation must also be considered outside the frames, that is beyond the practices allowing the maintenance of a common interactional space. We therefore analysed the “articulation work” done by the actors present, which Strauss showed was important for the care of hospital patients. Its principal aim is that “the staff’s collective efforts add up to more than discrete and conflicting bits of accomplished work” (Strauss et al. 1997: 151). This means making a patient’s treatment coherent, articulating the range of tasks that are sometimes very different in nature: diagnostic, comforting, clinical safety and work on patients’ emotions, discussions linked to the use of machines. This articulation work contributes to enabling various forms of cooperation between the actors present, in order to achieve the goal set by the organisation: “lead to effective diagnoses and treatments” (Cicourel 1994: 447). It is helpful to link the use of “medical technology” to other tasks, the former being a significant source of “disruptions,” in that it entails a “host of conditions that can spawn contingencies affecting the articulation of the trajectory work” (Strauss et al. 1997: 154). The resolution of these problems is part of the “machine work” identified by the author: “when the technology is quite new, especially when a new unit is being set up that embodies novel technology, then there is more likelihood of a blurring in the division of labour …” (Strauss et al. 1997: 157).
9We hypothesise that coordinating action in teleconsultations implies specific articulation work not only between the different protagonists’ “lines of work”??”i.e., the sum of the tasks they do??”, but also between the tasks that make up these lines of work. This hypothesis raises a series of questions: how, and to what extent, does use of teleconsultation technology directly affect the division of medical labour, and, as a result, the relationships between doctors and with paramedical staff? What, beyond the framing, are the activities and forms of cooperation implemented to support the new lines of work that are established as a result of the teleconsultation equipment, notably following the delegation of tasks between health professionals?
10Furthermore, according to Cicourel (1994), the structure of interindividual and interprofessional relationships, as well as forms of symbolic hierarchy, can influence cooperation between actors. In this case, the differences observed will be subtle, since, at first sight, all the doctors present are specialists. However, the HEGP specialists are situated higher in the symbolic hierarchy than the geriatricians practising in the Hôpital de Vaugirard. In some way the HEGP specialists are “more specialised” than the geriatricians, who are more “generalists,” specialising in the pathologies of the elderly (Young 1989). In addition, it is the referring geriatric doctor who calls on the HEGP’s specialist services. It, therefore, seems appropriate to take into account the (potential) effects of position in the medical and institutional hierarchy on professional interactions.
11Our analytical perspective is, moreover, very similar to research in the field of science and technology studies (STS), which has looked at telemedicine and medical technology more generally. Based on a study of interactions, we propose observing not only the adjustments but also the changes in terms of professional knowledge and practices that have taken place in the context of the teleconsultations in comparison to face-to-face doctor/patient relationships (May et al. 2001; Mondada 2004; Oudshoorn 2009; Pappas and Seale 2009). In this regard, as Akrich and Méadel note in their synthesis of research on medical technologies: “we observe that in order for these technologies to work as expected, a series of regulations and adjustments in the organisation, in the division of labour, in relationships with patients and in practices themselves are necessary” (2004: 14). Thus, it is important to take into account the organisational setting into which the equipment is introduced and the new practices involved in carrying out the teleconsultations, in particular the tasks aimed at coordinating the actions of the individuals concerned, as well as the delegation of medical tasks to doctors or paramedical staff (Nicolini 2006). Furthermore, we will show how the different healthcare actors use the equipment??”developing a “theory” of its use, as well as the strategies and new practices that they integrate to a greater or lesser extent into their routines??”and to what extent the equipment can constrain their activities (Fornel 1988; Lehoux et al. 2002; Relieu 2007; Velkovska and Zouinar 2007; Pols and Willems 2011). We will also lift the veil on the various forms of “mutual learning” that can take place between users (David, Midy and Moisdon 2003), and on the changes that can be seen in terms of interprofessional relationships, and even professional roles and identities (Korica and Molloy 2010), as well as forms of reconfiguration of patient care methods that emerge as a result of the various uses of the equipment (Gherardi 2009). [6]
Methodology
In 2011, a year after the experimental phase ended, use of the technology entered a routine phase. We then conducted a dozen semi-structured interviews with the geriatricians in the VGP and observed a dozen teleconsultations.
New forms of relationships between health professionals and patients
Towards new forms of mutualisation of clinical and “theoretical” knowledge between health professionals
12Teleconsultations differ from new relational configurations observable in health networks and “multidisciplinary meetings” [7] (Robelet, Serré and Bourgueil 2005; Bercot 2006), insofar as they are characterised by a relationship between health professionals and with patients. In comparison to the traditional doctor/ patient relationship??”i.e., face-to-face??”, the interactions between patients and medical and paramedical staff are instantly multiplied in teleconsultations. Thus, teleconsultations replace the sequential progression of classical medical treatment, where a geriatric doctor refers a patient to a specialist from whom he expects an opinion. In this traditional organisation, the professionals’ interactions do not take place face-to-face, their relationships being initiated mostly by mail: the referring doctor requesting advice from a specialist, who in turn provides a diagnosis to the referring doctor, who then passes it on to the caregivers (nurses, physiotherapists, etc.).
13Interactions can be focused in various different ways during the teleconsultations. Focused interactions [8] can take place “apart” from the telepresence equipment, for example when the interactions are focused on the VGP hospital side between the patient and his referring doctor or his carers and lead to private conversations, but also “via” the equipment, when focused interactions take place between VGP caregivers or patients and HEGP specialists. Teleconsultations, as practised, open up one-to-one consultations between patients and their doctors to an audience, which can have significant consequences for the content of the exchanges. The patient may be more hesitant than usual to confide themselves in the presence of a team of doctors and caregivers (Fainzang 2006) and for the same reasons, but this time because of the doctors themselves, could become purely and simply a “clinical subject,” that is an individual for whom normal moral and professional obligations are no longer respected (Mathieu-Fritz et al. 2012).
14However, it is common for a patient to intervene in an unprompted way, completing the clinical picture painted by the referring doctor himself, amending certain apparently incorrect points or calling to mind certain aspects of their medical history??”e.g., concerning treatment prior to being cared for in the VGP and various disorders that have not been included in their medical records:
Surgeon: Has she had injections in her knee or not?
Referring doctor: For now, no.
Surgeon: For now, no…
The patient, aged 88, Mrs. H., intervenes: No, I have had some injections, I wanted to tell you, Dr. G. gave me three in my knee and one in my hand.
Referring doctor: But wasn’t that a long time ago?
Mrs. H.: No, a few months ago.
16While specialists set aside that which does not concern them directly during hospital consultations (Lacoste 1993), in the collective setting of teleconsultations, expression is generally freer. Normally, it is the specialist who strongly guides the interactions with patients. During teleconsultations the conduct of the process seems to be more shared between the different parties (Nicolini 2006), because of the presence of the referring doctor, but also because of the sensorial or cognitive difficulties of some patients, which require information to be relayed verbally so that they can take part in the exchanges.
17Before the telepresence equipment was installed, the healthcare professionals from the two hospitals did not meet and their exchanges were not as long. By letting the HEGP specialist “into” the Vaugirard hospital, the use of the technology contributes to creating a new “technical staff” to use a category from medical, or more generally, hospital language. These technical staff may meet together before a patient is brought into the teleconsultation room by a member of the paramedical staff or after the patient has left. During the course of the experimental phase, the systematisation of interaction between health professionals??”in the sense of the implementation of protocols or procedure??”before or after a series of teleconsultations with the same specialist was still not formalised and depended more on the availability of specialists and their own demands concerning the teleconsultations and willingness to share their first impressions of the use of the telepresence equipment. Over time, the relationships between the VGP and HEGP doctors changed, insofar as contacts between them were made not only during teleconsultations but could also take place in an informal way, notably by telephone. The mutual acquaintance thus enabled forms of interprofessional relationships to be established that did not previously exist.
18Generally, the meetings between caregivers and doctors during teleconsultations encourage instant sharing of professional knowledge and know how. The organisation of patients’ medical treatment and healthcare is thus more “integrated.” A physiotherapist, for example, may provide his clinical knowledge of a patient to an orthopaedic surgeon, even though these professionals from the two institutions never have direct or face-to-face contact during the normal care of a patient. A nurse responsible for dressing wounds may offer advice on the development of skin lesions or a nurse may intervene to indicate which drugs are being taken. In comparison to the traditional, discontinuous treatment of patients, which usually works through epistolary relationships based on very synthetic notes, teleconsultations contribute to a deeper understanding of a patient’s case and of his pathology(ies). A large amount of clinical knowledge about them is verbalised and shared. Building a clinical picture frequently leads to an exchange of views and ultimately appears more detailed and precise. Similar to what has been observed in geriatric oncology units (Sifer-Rivière et al. 2011a), teleconsultations also enable specialists to acquire precise information on a patient’s social environment??”e.g., the level of involvement of relatives and family??”as well as a patient’s living conditions (type of housing and facilities), which can be detailed by the referring doctor or the care team when a patient is unable to respond.
19The teleconsultations contribute to the emergence of new forms of interprofessional diagnostic coproduction between doctors from the two institutions. While it is certainly true that the referring doctor’s opinions can play an important role in traditional professional relationships, these opinions only have a marginal place in debates or discussions (by telephone for example) between colleagues and usually amount to an epistolary exchange. In the case of teleconsultations, sometimes the referring doctor actually maintains a contrary point of view, supported by his clinical knowledge of the patient and his expertise in geriatrics, providing new evidence to support his point of view, by reformulating the latter and by expressing his doubts, etc. However, while this form of diagnostic coproduction is possible, in the majority of cases the referring doctor presents the patients clinical record and relies on the specialist’s judgement, only intervening occasionally when the latter asks questions. Moreover, the amount of participation varies greatly depending on the referring doctor: some put themselves forward as the specialist’s interlocutors, while others remain more passive during the teleconsultations (MacFarlane et al. 2006).
20Finally, teleconsultations enable verbal exchanges that, for deontological reasons, cannot take place in epistolary correspondence. Hence, the surgeon who explains that his patient’s operation “is not a great surgical success,” doctors who agree that emergency treatment given in the HEGP was “a bit severe,” and finally the HEGP specialist who provides advice to a referring doctor in the VGP to persuade surgeons to operate on a patient with freshly healed skin lesions. In the latter case, the specialist “lets the cat out of the bag” by explaining that orthopaedic surgeons are above all fearful of prosthesis infections and do not like to take any risks with patients with skin lesions, even benign ones. Thus she provides a range of dermatological advice on rapidly healing any type of lesion likely to concern surgeons.
Various forms of transmission of medical and healthcare knowledge and expertise in addition to sharing
21Knowledge transmission can take place in a totally informal and indirect way. In this case the transmission of knowledge is not the primary goal but is a means to an end, namely to achieving success in diagnosis, treatment and care. Hence, a surgeon explains to a delegate that “it is easier to extend [the leg] if [the patient] is lying,” or provides the precise meaning of the technical term??” “systematisation”??”as applied to painful toes, a term he had just used in a query regarding the facts needed to complete the clinical picture provided by a referring doctor: “Is it more the first toe than the second, more the second toe than the third, and so on?” Furthermore, knowledge transmission can be quite deliberate, sometimes insistent and even firm. This perspective is supported by a geriatrician from the HEGP (called on to take part in teleconsultations in his capacity as a specialist in the treatment of bedsores): “the benefit of this type of consultation is training.” The interprofessional relationship via the telepresence equipment is explicitly defined as being pedagogical by nature and an opportunity to pass on “good practice.” Whilst some specialists prove to be strict, even harsh, with VGP caregivers, a more subtle transmission of knowledge is more commonly observed, even if this is intentional and resolute. Thus a dermatologist can tactfully explain the use of corticosteroids on skin so as not to offend his interlocutor??”i.e., so they keep “face” (Goffman 1967).
22Several months after the experimental phase, the geriatricians reported that the transmission of knowledge had allowed them to better treat their own patients, and in some cases??”notably in dermatology??”, not to seek the advice of a specialist.
“Supervised” task delegation
23In order to make remote diagnoses, teleconsultations entail task delegation, which always takes place under the watchful eye of a specialist. In addition to a greater coordination of action between doctors located at either end of the equipment, teleconsultations are based on a specific form of cooperation. From a general point of view, the delegated tasks vary according to speciality. In some cases, such as in orthopaedics, it is diagnostic palpation and assisted movements??”e.g., flexing and extending limbs??”during physical tests that are delegated. In dermatology, it is the tasks of visualisation and touching certain areas of skin that are assigned to the interlocutor so that he can clinically classify them as “sclerotic,” “nodular,” “tumescent,” “hot,” etc. Furthermore, task delegation is not limited to complex activities, but also concerns those that are more trivial from a medical point of view??”i.e., those that are less specialised or that require professional skills that are very similar to ordinary skills, like removing dressings, cleaning wounds or placing a hand on a patient’s shoulder to comfort them, etc.
24The delegation takes place between individuals at different levels in the medical and paramedical hierarchy. For example, in orthopaedic surgery various types of palpation or movements can be required to complete a clinical picture, to make a diagnosis and ultimately to provide instructions concerning treatment of a pathology. The palpation or movement tasks can be delegated to the referring doctor or even a physiotherapist when a referring geriatrician is present. Thus, an orthopaedic surgeon may ask a physiotherapist to perform rotational movements of the humerus with the aim of testing the setting of a joint following an operation. A dermatologist might also ask a doctor or nurse to touch a skin lesion to ascertain its nature.
Extract from an observation. The delegation of diagnostic tasks to a physiotherapist
…
The clinical research assistant to the coordinating doctor: Is the picture good doctor? Coordinating doctor: Yes, she [the patient] needs to be moved back a little bit.
[At the request of the coordinating doctor (HEGP), the clinical research assistant (HEGP), the referring doctor (a geriatrician) and the physiotherapist (VGP) introduce themselves and greet each other].
Surgeon [who repeats his name at the request of the referring doctor who had not heard it] speaks next: The x-ray shows two identical sides, it’s difficult … [to the patient:] You are Mrs. D., right? Yes? Is it your left shoulder that’s causing you pain?
Patient: Yes.
Surgeon: Yes, that’s quite normal. When was the brace removed?
Physiotherapist replies: We were allowed to remove the brace a fortnight ago, but only during rehabilitation sessions. It was put back on afterwards.
Surgeon: On the x-ray … I’m looking at, I get the still impression that something is going on, eh, there’s some bone callus, I’m not sure that its very strong … [to the patient:] Err, about, about your humerus … can you show me how … how, how you can use it?
Patient: I can’t move it …
Surgeon: Not at all?
Patient: No.
Physiotherapist: She can’t do it except during rehabilitation sessions.
Surgeon: Is she … is she beginning to a little … How long has it been? It’s been …
Physiotherapist: Eight weeks.
Surgeon: Eight weeks … Has she started … has she started to swing it a bit or not?
Physiotherapist: Yes, … and passively, we can raise it quite well, eh, it … there are movements that cause her pain, more behind the arm err … it’s a little bit … random, but err … as for active mobility … it’s not bad, eh … as for swinging, that’s good too.
…/…
Surgeon: That’s not bad … does it hurt her much to swing it?
Physiotherapist: That depends … she swings it, then all of a sudden it goes … Well err, lowering it is harder than raising it, but err … [the physiotherapist pulls a face].
Surgeon [to the patient]: Can you try to show us your arm a little bit, like this [the surgeon makes a gesture].
Physiotherapist: I’m not sure she’ll be able to on her own, eh. [The physiotherapist takes the lead by assisting the patient’s movement and says to the patient:] […] I’ll leave you to it …
Referring doctor [to the physiotherapist]: It’ll have to be done passively…
Surgeon [to the physiotherapist]: We’ll do it passively [to the patient]: Does that hurt?
The physiotherapist points out: She has not warmed up.
Patient [to the surgeon]: Err no, it’s all right …
Surgeon [to the physiotherapist]: Try and hold it in the air like this …
[On the HEGP side, the patient and her movements can be observed (as well as the physiotherapist) from another angle, on a second screen??”placed to the right of the main screen??”showing the picture from a portable camera placed on the left of the patient].
Physiotherapist: She can’t. Surgeon: She can’t at all? Physiotherapist: No, no [shakes her head]. It’s better when abducted.
Surgeon: Try that then, because I really get the impression on the x-rays, eh, it looks like it still moves a little bit, eh …
The project-coordinating doctor sees to the equipment’s framing: She [the patient] needs to be moved back a little … and J. [clinical research assistant], frame it well please [with the portable camera]. That’s it.
[Vertical movement of the patient’s left arm with the physiotherapist’s help stood behind her].
Physiotherapist [to the patient]: I’ll let you do it Mrs. D. [who complains: Ouch!], she has not warmed up since the weekend, its difficult.
Surgeon [to the physiotherapist]: Do you get the impression that it is “directing” her a little, is the humerus directing the humeral head? … It’s difficult to feel … [to the patient:] But, for example, if you put your hand, put you hand in front you … try and rotate it a little… like this [the surgeon moves his fist] to see it is moving at the humeral head [opposite, the physiotherapist: Ah!]; you should really be subacromial [the surgeon tries to guide the physiotherapist’s movement], otherwise you won’t feel it …
Physiotherapist: It’s restricted, it’s a little restricted, I should say … It’s painful everywhere … it can be rotated [the physiotherapist, while continuing her movements, addresses the patient:] There, is that OK?
The patient lets out a little moan: Aaahh [pointing a finger to her left shoulder].
Physiotherapist [to the patient]: It’s pulling here!
Surgeon: It’s normal for it to pull … What I wanted to know is whether it is strong because the x-rays are not …
Physiotherapist: Not great …
Surgeon: … are not reassuring frankly … We can only see two identical sides sadly, it looks like there are two aspects, I’d still do a scan … [The surgeon stops and looks at the physio’s palpation]: Is there a big amyotrophy eh?
…/…
The physiotherapist [continues her movements, questions the patient in almost a whisper, then addresses the surgeon]: Although it’s braced all day and all night, she only works with me for half an hour, so …
Surgeon: Yeah, of course we can get rid of the stiffness, what’s important is that … the fracture has healed, and I get the impression …
Physiotherapist [interrupts the surgeon]: When we use the ball and I get her to roll it like rolling pastry … [the physiotherapist demonstrates the forward and backward horizontal movement with her own arm], she can do it a little with me, she can …
Surgeon: Can she do it then? Does it direct her a bit …
Physiotherapist: She’s, she’s a bit … she’s afraid of it hurting, so it’s true that … and apparently, they’re pretty sharp pains, so, err …
Surgeon: That’s the problem, that’s what makes me think that the pain is from bone rubbing on bone …
Physiotherapist: OK, OK …
Surgeon: … because the stiffness, that’s the tightness you can feel but …
Physiotherapist: As a rule: I can passively raise her arm to 90 …
Surgeon: But the fact is that actively she can’t do anything … Mrs. D, can you swing your arm a little, try to lean a little like this … try to … turn your arm like this …
Physiotherapist [to the patient]: Stand up, stand up to see if you can … [the patient moans a little and slowly falls back into her chair, then manages to get up]. Try to swing your arm like a pendulum.
Surgeon [to the clinical research assistant]: Try to raise the portable camera a little, if possible [the clinical research assistant has difficulty placing the camera correctly and steadying it; the image breaks up on the right-hand screen].
Physiotherapist [to the patient]: Does that hurt Mrs. D.? [She moves her arm by manipulating her shoulder].
Patient: Yes, I can feel it, it’s resisting a little but …
Surgeon: Yes, but it’s not painful is it?
Patient: No.
Surgeon: Even so I’m going to do a scan… to check how it’s healing …
25On other occasions it is a vascular doctor or a cardiologist who delegates the technical tasks, guiding a referring doctor’s actions when doing a vascular “Doppler ultrasound.” In such cases, the issue that arises is more one of confidence in the doctor delegated to (and in their ability to correctly operate an ultrasound) than an issue of medical liability.
26In many situations, the most important medical tasks are therefore delegated to non-specialist doctors, even to people outside of the medical profession itself (Nicolini 2006). It is therefore not a form of “delegation of dirty work” (Hughes 1996), that is tasks that are considered to be infra dignitate, subaltern, but, on the contrary, activities that are intimately linked to what constitutes the heart of the medical profession, namely the production of professional judgements contributing to making diagnoses (Dodier 1993a; Cicourel 2002).
The endeavour to verbalise routine and embodied technical activities
27For delegators, the introduction of teleconsultations is accompanied by another type of transformation of professional practices. This consists of discussing knowledge and tasks that are practically never verbalised in traditional everyday practices and in face-to-face relations between specialist doctors and patients. For specialists, this means shaping the discourse in situ or providing signs that guide a caregiver’s or a delegated doctor’s actions, in particular when this involves the use of technical tools such as an ultrasound or Doppler and hence manipulating the probes associated with these instruments: “higher,” “a little bit more,” “stop,” “OK,” etc. This requires a high level of coordination of action (Dodier 1993b) between the principal parties. The delegator’s endeavours are linked to the explanations he must provide linguistically and paralinguistically when delegating technical tasks to caregivers and doctors who are by the patient’s side. These amount to a verbalisation endeavour contributing to a new form of interprofessional cooperation within the hospital world, based on a??”remote??”delegation of tasks under a specialist’s control.
28This task delegation also directly affects the patient, which can cause new problems. Firstly, the physical examination is not done by the consultant doctor, which can lead to forms of reticence and even refusal on the part of the patient. According to Heath (1993), physical examinations constitute “a precise and systematic interactional organisation” which, in the case of teleconsultations, is changed completely by the intervention of a third party. Specifically, the problem of lateralisation (left, right) linked to the verbalisation of technical actions can arise. When a specialist doctor asks a patient to take part in a flexibility test: “lift your arm like this,” he deviates from the standard practices observed in traditional face-to-face relationships where action consists simply of assisting a patient’s movements.
29Finally, the aims of the delegated tests themselves also need verbalising. Thus, we have an orthopaedic surgeon who very clearly explains the two aims of the technical tests to be performed, both to the patient and the delegated:
We can see that she has a chronically inflamed knee … I’ll tell you what interests me is how much she can bend it and to see if she can straighten it completely. These are the two facts … As for the knee I know it’s swollen, there’s no need to check that. It’s mainly bending and completely straightening.
31The different forms of delegation raise the issue of acceptance by the VGP team, insofar as they imply that the delegate must perform an act of humility and obedience towards the specialist, their margin for personal intervention being very narrow.
Task delegation and the delegate’s “increase in expertise”
32Those to whom the tasks directly associated with making a diagnosis are delegated should be able to replace the remote specialist. Thus, the delegation of ultrasound use??”in order to make vascular and cardiac ultrasounds??”requires VGP doctors to learn new skills. Even for expert doctors with many years in the profession, having a basic knowledge or having taken a course in the past is not sufficient, the technology, techniques and knowledge have changed greatly in the various specialist fields.
33Use of the telepresence equipment and the tools associated with it contributes to changing, in part, the VGP doctors’ professional roles, many of them becoming the privileged interlocutors of the specialists consulted. This all led to the emergence of new work groupings??”which we could call “micro work collectives,” on account their size??”, which operated, at the experimental stage, in a flexible and more affinitive than formal way, while being based on the possession of a minimum of technical expertise or a commitment to training. During the routine phase, some of these micro-groups became established. For example, one of the VGP doctors went to the cardiology department at the HEGP for training in order to carry out the electrocardiograms (EGG) remotely in the “same way” as the head of this department.
34Some geriatricians in VGP highlighted what the issues that participating as delegates in cardiology teleconsultation sessions, and before that the continuous training given by a recognised professor of cardiology from the HEGP represent: “what’s interesting for me, of course, is to be able to …, to use the equipment and all that, but also to learn to interpret … [the cardiac ultrasounds].” The increase in expertise leads, in effect, to “an increase in autonomy” for geriatricians in terms of professional judgement, because a trained geriatrician would now be able to form more sophisticated opinions on some of his patients’ problems, in this case cardiac problems, and on the care to provide them with. However, this autonomisation remains relative, since the delegation is done under the supervision of a specialist doctor, who remains the sole person who can make a diagnosis, write prescriptions and offer guidance during the teleconsultations.
35Finally, this task delegation also raised the issue of delegation of responsibility between specialists and delegates (whether the latter are doctors or members of paramedical staff). At the time of the study, specialist doctors alone assumed legal responsibility, even when delegating some of the tasks performed to make a diagnosis.
The relative increase in domains in which specialists are involved and organisational changes
36In addition to the transmission of professional knowledge, certain ways of organising the healthcare facilities also changed. Previously, the VGP geriatric hospital, in effect, operated in a more isolated way. The increase in exchanges has now forced its doctors into greater reactivity on an organisational level. In the past, consultations were much less regular and (non-urgent) visits by specialists could be as much as several months apart. Since the telepresence technology was introduced, the frequency of (tele)consultations has markedly increased. [9] More specifically, a rise in the average number of teleconsultations per patient was observed. Before the equipment was introduced, elderly patients, who are difficult to move and fatigable, only consulted specialists for problems whose significance or gravity justified transporting them to the HEGP. Usage of the equipment??”in the experimental as much as in the routine phase??”has been accompanied by a recomposition of patients’ trajectories, who consult specialists more frequently than in the past??”principally in orthopaedic surgery and dermatology.
A space between cooperation and subordination
37Whilst telepresence constitutes a new space for cooperation, it can also open up a new space for subordination, where existing hierarchical relationships are affirmed, updated and even amplified. This extension of the area of intervention is characterised by informal control, which is based on a professional world where the hierarchy is very rigid (Cicourel 1994; Pinell 2005). This hierarchy has at least two foundation stones: on the one hand, the doctors’ specialisations and their rank on the statutory scale; on the other, the importance or the reputation of the institution to which they belong.
38Take teleconsultation in dermatology for example. The fact is, it is the referring doctor who requires a specialist’s advice, and the dermatologist will always possess greater specialist knowledge in the field of skin diseases than a geriatrician. The same is true of other medical disciplines, such as orthopaedic surgery, psychiatry, neurology, cardiology or vascular medicine, within their specialist fields. A geriatrician’s knowledge is thus more generalist than that of specialist doctors and it is precisely this degree of specialisation that serves to construct the symbolic hierarchy of the medical world. In addition, some of the HEGP specialists are heads (or assistant heads) of clinics, heads of department, or even university professors-hospital practitioners (Professeurs des Universités-Praticiens Hospitaliers–PU-PH) and well known in their fields. Via the telepresence equipment, the delegation of diagnostic tasks takes place between individuals at different levels of the medical hierarchy. Furthermore, in terms of institutional affiliation, being employed by the HEGP is symbolically more prestigious than practising in a geriatric hospital??”, which is seen more as a satellite institution because of its physical separation from the HEGP. While the professionals involved never lose sight of these symbolic aspects, it is important to assess their reach empirically, and above all to see to what extent the different actors’ power takes shape during the interactions (Fox 1993, 1994) using the telepresence equipment.
39Firstly, whilst technical tasks are delegated, this is always done under the supervision of a specialist, who, what is more, can choose at any time to see a patient face-to-face again if he considers it necessary. Moreover, the teleconsultation technology opens up a new realm for making judgements, that is a new “technical skills arena” (Dodier 1993c, 1995), where delegates offer others??”here their peers in the HEGP??”the opportunity to make value judgements concerning their medical and clinical knowledge, as well as the quality of care provided. [10] A judgement may also be based on diagnostic hypotheses that justified requests from the VGP doctors. For example, a dermatologist refuted the VGP’s diagnoses for a series of patients during the same session, which she did, not only firmly, but also with some embarrassment that transformed into diplomacy.
40The space for cooperation that is opened up by the teleconsultations contributes to making visible a whole range of healthcare practices and routines that take place within a geriatric hospital that have never previously been discussed. Through the interaction via the teleconsultation equipment, the specialists’ scope for intervention is extended, with the latter able to enquire incidentally into the healthcare practices in the geriatric departments in the VGP; we can cite as an example, a teleconsultation during which an orthopaedic surgeon observed??”as an aside??”that nurses were not putting gloves on when replacing dressings or that some patients were not wearing a lumbar support when, from his point of view, it was necessary. With their legitimacy and sometimes with the involuntary assistance of patients who provide clinical information in support of their observations, specialists seek to impose or propose (in a more or less direct way) new healthcare practices:
Surgeon: Does your back hurt?
Mrs. L.: Ah, yes, I have terrible backache! …
The surgeon intervenes: Do you wear a lumbar support … normally? … a lumbar belt …
Madame L.: Yes, I have one.
Surgeon: At home?
Mrs. L.: … I can’t live without it….
Surgeon [smiling] to the referring doctor: … Well then, perhaps she should put it on, if it hurts. Then get her to try a little lumbar rehabilitation… when it’s painful, try to put the belt on sometimes and then when she has a little less pain, when she’s standing, try …
Referring doctor: We have difficulty putting it on … even …
Surgeon [smiling]: I understand… Try putting her in a low seating position perhaps …
Referring doctor: Yeah …
Surgeon: Try lowering the seat back a little, it will put less pressure on …
Referring doctor: But she moves around …
Surgeon: She moves around … Try lying her a little flatter in the chair in her room, perhaps that will improve … her lumbar symptoms.
Mrs. L. addressing the referring doctor: [It hurts] every day, every day, from morning to night, at the top and the bottom …
Surgeon [in an ironic tone]: You are unfortunate Mrs. L.
[The referring doctor smiles turning towards the surgeon].
Mrs. L.: They don’t understand. He [pointing to the surgeon], he understands because it’s his job, apart from him they don’t understand …
Referring doctor [who seems caught in the middle between his patient and the surgeon]:
Yes, why don’t we try the belt again Mrs. L, hey?
Mrs. L.: Oh yes, quickly.
Referring doctor: OK, very good …
42Conversely, healthcare teams can themselves scrutinise the specialists’ practices, whose recommendations sometimes prove contradictory, as evidenced by the completely contradictory advice from two HEGP dermatologists concerning some leg ulcers, one preferring bandages to contention socks, the other advocating precisely the opposite.
43As well as technology for cooperation, telepresence is thus also a technology for informal control of the implementation of medical and healthcare practices. From the VGP professionals’ side, teleconsultations imply a relative loss of autonomy of work, on the one hand, because of a whole range of practices that are made newly visible, contributing to the latter being submitted to the expert judgement of specialists, and, on the other, because these same specialists sometimes seek to impose new ways of practising medicine and healthcare. On several occasions, in response to the specialists’ critical remarks, the VGP doctors and caregivers seem like workers facing hard labour (Ughetto 2007), citing problems linked with looking after the elderly to explain why they do not follow what the HEGP define as “good practices;” they respond to criticism by stating, for example, that “it is difficult to use a urinalysis strip with someone who is incontinent” or that “it is difficult to put a lumbar belt [on a patient].” However, the “sanction” can also be positive and take the form of a “beauty judgement” in the sense used by Dejours ([1980] 1993). This is the case when a specialist doctor recognises the effectiveness of a treatment provided by the referring doctor.
44Finally, in some cases the transmission of medical knowledge is bilateral, or goes in the VGP-HEGP direction, as when a specialist discovers that leukaemia is common in elderly people??”to the great surprise of those on the VGP side, something which could be read on their faces although it was not evident in the verbal exchanges. However, the transmission is still asymmetrical overall and mostly goes in the HEGP-VGP direction, in other words from the specialists to the geriatricians. Clearly, there is also respect on the part of specialists for the VGP geriatricians’ role, for their autonomy as referring doctors. In other words, they are always considered to be the ones who, in the end, will decide on when a patient is to be discharged from hospital. In this sense, cooperation can be founded on what Bergeron and Castel call doctors’ “acquisitiveness:” doctors who consider it “their responsibility to provide or organise each step of the cure alone” are dubbed “acquisitive” (captants), whereas those who “feel, on the contrary, that their participation is limited to one stage of the therapeutic itinerary only” are dubbed “non-acquisitive” (non-captants) (2011: e3). According to the authors, this type of cooperation generally causes fewer conflict situations.
A plurality of forms of resistance to delegation from specialists?
45Beyond the inherent constraints of medical practices in specialities that are likely to require direct clinical examinations (by palpation) to be performed by specialists themselves, we could hypothesise that professional culture constitutes a factor in some cases in opposition to the use of telepresence technology in the medical world. In other words, the usual, very ritualised, way of doing things, which notably offers a means of self-reassurance in terms of one’s effectiveness as a practitioner, [11] could come into conflict with new practices relating to use of the technology. Thus, a cardiologist says that she “likes touching” patients and cites frustration and at not being able to auscultate personally, while at the same time recognising the effectiveness of delegation and teleconsultations more generally. A neurologist states: “we’re perhaps trained that way. It’s true that when there are abnormal movements we need to feel.”
46Also, a desire not to share knowledge and a desire to maintain the opaqueness of their professional practices could equally explain some opposition to teleconsultations??”opposition to the project the coordinating doctor met when looking for specialists to carry out teleconsultations. Not wishing to expose oneself amounts to guarding against negative judgement from peers and other colleagues, and hence constitutes a good way of maintaining autonomy at work. The desire to maintain the opaqueness of professional practices has previously been observed in certain specialities, such as surgery (Katz 1999). It is generally linked to suspicion between doctors (Ménoret and Carricaburu 2005) and to a context of intra- and interprofessional competition specific to the medical world (Castel 2005; Pinell 2005; Bergeron and Castel 2011).
47Finally, delegation can also be seen as a central issue for teleconsultations, insofar as it requires a professional (the specialist) to be prepared to delegate some of his judgement at the time of carrying out diagnostic tests. This space for reflection constitutes professionalism par excellence, that is a space of autonomy of professional judgement, which is not only a culturally, but also a legally protected domain (Freidson 1970; Dodier 1993a). It seems that the desire to preserve this space might, in the future, be a factor in opposition to the installation or use of teleconsultation technology. [12]
48Thus, while the field of activity of the HEGP specialists extends on the one hand, it should be noted that, on the other, participation in teleconsultations requires them to give up some of their practices and to accept delegating some of their judgement and, as a result, give up some of their autonomy of reflection.
49* * *
50The social sciences have still only partially tackled the subject of telemedicine. The vast majority of publications on the subject relate to technical, clinical and economic dimensions, while user satisfaction has been studied using quantitative surveys. These medicotechnical aspects are probably derived from biomedical science, whereas telemedicine cannot be reduced to these aspects alone and is instead a new form of service (May et al. 2003). Literature on the sociological analysis of clinical practice and the use of the teleconsultation technology remains limited (Ekeland, Bowes and Flottorp 2010). Lehoux, Sicotte, Denis et al. (2002) used Giddens’s (1984) structuration theory to study the communication routines between health professionals during teleconsultations, but this was in the context of late-1990s technology, whose performance differed greatly to that of current videoconferencing systems from the point of view of the quality of the transmission of images and sound. Furthermore, the opening sequences of telecommunications have been compared to those of face-to-face consultations (Pappas and Seale 2009) and May et al. (2001) have shown that clinical routines in psychiatry are incompatible with the use of teleconsultations. For our part, the observations made were concerned with the entire consultation in various specialities and we analysed in detail all the transformations in practices and, in particular, the task delegation process. In addition, the technology observed has the particularity of bringing together three parties: a specialist, a patient and caregivers??”including a referring doctor??”, which led us to analyse the interactions between health professionals in addition to doctor/patient relationships.
51We have shown that during teleconsultations, configurations of relationships, subjects for discussion and aspects of knowledge emerge that were not initially foreseen. Use of the telepresence technology contributes, in particular, to the mutualisation and diffusion of medical knowledge (medical knowledge relating to the tasks and actions required to perform diagnostic tests, to instructions for supplementary tests, to the interpretation of clinical signs and to therapeutic decisions) and to healthcare practices (care practices such as changing dressings, for example). Thus, knowledge of various kinds is spread in an asymmetrical way, flowing tendentiously from more specialised professionals to those having more generalist knowledge. Over time, this new knowledge had a durable influence on the geriatricians’ practices, so that they avoided having to seek the advice of specialists in some cases. In other respects, if we pay attention exclusively to the transmission of clinical knowledge associated with patients, the flow of information changes direction.
52In general, the knowledge associated with a patient’s care seems to be deepened in teleconsultations, as shown by the clarifications made to the clinical picture by the various professionals involved. The reorganisation of interprofessional relationships also leads to making them visible, to revealing the professional practices of the various parties present, at the same time encouraging the development of professional judgements of the practices observed in situ. Presenting a patient’s clinical picture and the care being given to him and recalling the diagnostic hypothesis on which a teleconsultation is based, thus entail a referring doctor exposing himself directly to the judgment of peers from further up the symbolic hierarchy, by demonstrating various aspects of his knowledge and also its limits (Cicourel 1985).
53We have also seen that use of the teleconsultation technology has contributed to the emergence of new work groupings, some of which have become permanent since the technology entered its routine phase. Whilst the introduction of teleconsultations had lead to specialists from the HEGP being “let into” the VGP hospital, which sometimes results in the updating of forms of symbolic hierarchy specific to the medical world, doctors from the two hospitals, whose exchanges were previously by mail and were sequential, have woven more direct and closer ties. On the patient side, it has led to a partial restructuring of their treatment, insofar as they have benefitted from a greater number of consultations with HEGP specialists than previously since the introduction of the technology.
54In addition, use of the technology has, at the same time, presented new difficulties, which users seek to overcome: the four interactional frames that make exchanges possible, in particular by establishing new forms of communication between the various participants in the two hospital structures; training of delegates (doctors or otherwise) able to become the hands, eyes and ears of the remotely located specialist; loss of one-to-one dialogue, and the relative loss of autonomy of all practitioners who have to delegate some of their activities or “demonstrate” their expertise.
55The technology’s experimental phase could not have been carried out within a hospital setting without a project manager tirelessly developing various forms of management and relationships to provide organisational and practical coherence to the care of patients needing to consult an HEGP specialist. The introduction of teleconsultations required full-time coordination during the experimental phase, whereas its everyday use required the presence of paramedical staff able to look after patient care while also being able to operate the telepresence equipment (starting it up, shutting it down, connecting instruments, handling devices, etc.) and engaging in various forms of professional cooperation with specialist doctors (Esterle, Mathieu-Fritz and Espinoza 2011).
56Throughout the case study, the teleconsultations raised the question of the relationship between the world of geriatrics and those of other medical specialists. As with recent initiatives that attempt to reduce the gap existing between these areas??”e.g., pilot oncogeriatric coordination groups (Sifer-Rivière et al. 2011b)??”, use of teleconsultations seems to bring about new modes of cooperation and, ultimately, to the establishment of durable collaboration between healthcare professionals. Analysing the changes and the practices that accompany the use of teleconsultation technology thus also raises questions about current developments in the positions of geriatricians within the medical world.
Notes
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[*]
We would like to thank the reviewers from the Revue Française de Sociologie for their comments on later versions of this text, as well as Benoît Lelong, Pascal Ughetto, Ashveen Peerbaye and David Smadja. We would also like to thank the head of the Télégéria experimental project, Pierre Espinoza, for giving us such full access to our field of study. This research was financially supported by the Institut Francilien Recherche, Innovation et Société–IFRIS.
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[1]
Teleconsultation is one of the major categories of telemedicine. In France, according to decree no. 2010-1229, telemedicine is defined as all those medical practices carried out remotely through the use of information and communications technology, also including tele-expertise practices, medical telemonitoring and medical tele-assistance. The practice of telemedicine was recognised in the 13th August 2004 law relating to Health Insurance, consolidated in the Hospitals, Patients, Health and Regions (Hôpital, Patients, Santé et Territoires– HPST) law of 22nd July 2009 and finally included in the Public Health Code (Code de la Santé Publique) in 2010 (decree no. 2010-1229 of 19th October 2010 relating to telemedicine).
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[2]
P. Simon and D. Acker, La place de la télémédecine dans l’organisation des soins, report submitted to the Ministère de la Santé et des Sports (Ministry of Health and Sport) in November 2008; P. Lasbordes, La télésanté: un nouvel atout au service de notre bien-être. Un plan quinquennal éco-responsable pour le déploiement de la télésanté en France, report submitted to the Ministry of Health and Sport in October 2009.
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[3]
See also Plan Cancer 2009-13: http://www.plan-cancer.gouv.fr/.
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[4]
In this respect, teleconsultations differ from the doctor/patient relationship model established by Parsons (1937), which defines the social roles of participants in one-to-one consultations in general practice (i.e., non-hospital).
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[5]
Our use of the concept of framing differs a little from the Goffmanian sense and its conceptual uses. The forms of framing that we have defined evolve over the course of the experimental phase observed and follow a formalisation and standardisation rationale driven by the project’s coordinating doctor, with the aim of standardising the use of the equipment and the course of the teleconsultations. We thus depart, in part, from the constructivism of Goffman’s sociology, but without, however, deterministically conceiving norms that emerge during our observations.
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[6]
On these aspects, see also Gollac (2003).
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[7]
In 2007, 496,000 cases were examined in multidisciplinary meetings on cancer according to a 2007 report from the Regional Cancer Care Network–National Cancer Institute (Réseaux Régionaux de Cancérologie–Institut National du Cancer–RRC–INCA).
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[8]
All face-to-face interactions are characterised by copresence and mutual observability. While all unfocused interactions are reduced to these two characteristics, focused interactions suppose that the actions of the parties taking part are common??”e.g., participation in a discussion (Joseph 1998: 74-5).
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[9]
Several months after moving into the routine phase, two to three half-days of teleconsultations between HEGP and VGP were arranged per week.
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[10]
From this point of view, teleconsultations resemble the multidisciplinary committees observed by Castel (2005) in the field of cancer care, where the exchanges between doctors concerning medical records meant all participants could “demonstrate their expertise,” and be judged by and judge their colleagues, in particular on a technical level.
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[11]
Medical anthropology, in particular the work of Pouchelle (2003) on intensive care, has shown that members of nursing staff had a tendency to increase the volume of signals from the machines attached to patients, thereby making more noise than necessary for the care and wellbeing of patients. Such cultural practices are explained by the desire of caregivers to reassure themselves of the care of patients and ultimately to avert death.
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[12]
The three arguments cited in this sub-section (ritualisation of practice, maintenance of opaqueness, delegation of professional judgement) are based on material collected in fieldwork. They are combined here to support the hypothesis of the specialists’ resulting (future) resistance to teleconsultations. At this time it is difficult to estimate the relative significance of each of these (possible) factors in the resistance to delegation and, as a result, to teleconsultations.
