In reflecting upon their work, the experts raised the idea of inherent, systemic gaps or divides which hindered their ability, beyond scarce resources, to provide the level of care they idealised. These ‘gaps’ or ‘divides’ were developed as categories in the analysis, and infiltrated many characteristic concerns of trauma and emergency - the immediacy, the inability to refuse a patient, and the emotional and psychological challenges for clinician and patients. The two themes found running through the data were (i) the inherent potential for mHealth to bridge these gaps, or conversely, widen them, and (ii) the formalisation of processes and practices that confer these changes. A summary of the final analysis in table format demonstrating the sub-categories, categories and themes is presented below in Fig. 1, followed by elucidation of the categories identified.
In addition, the different perspectives afforded from the two specialties were investigated, and while there was much coherence in opinion found, the focus of the specialties differed on some key areas.
Gold standard practice and achievable practice
The first category on “power and personality” included three sub-categories of ‘Emotional dilemmas’, ‘Sensitivity and ethics’ and ‘Tools for the future’, capturing areas in which a discrepancy was highlighted between a ‘gold standard’ practice, and that which was achievable within the realities of the setting (Fig. 1).
Emotional dilemmas
In a resource poor setting, and in treating patients with traumatic injuries, there can be a gap between the care health professional's wish to provide for their patient, and what they are able to do in practice, for reasons more diverse than the scarcity of resources. These dilemmas and their emotional and psychological impact came up frequently, both for the experts themselves, and as they envisaged from the perspective of the POC doctors.
“I think most of these guys, especially at the primary care facilities, urban and non-urban, are really functioning quite a long way beyond where any human being should be functioning to be, sustainably productive” –ID.2
Pressure to maintain a high turn-over and ‘task fragmentation’ required to address the needs of many patients at once was mentioned as a prominent challenge of the emergency setting. The implications for telemedicine according to the participants were clear; speed, reliability and user friendly design are non-negotiable for success [14, 41]. Such is the relentless intensity of the trauma and emergency field, a system for this arena must be, “analogous to battlefield apps”.-(ID.2), and unreliable service or delayed response could lead to the system being rejected. As one expert described:
“... in an environment like that, you can’t have long delays, you can’t sort of let the patient lie there while you see if the expert replies. So I think rapid, expert feedback is key, because if people use it once and get back a delayed response, they won’t use it a second time.” –ID.4
Trauma and emergency can involve treating terrible injuries, whilst dealing with patients in pain, fearful and vulnerable. In addition, the socioeconomic context of some cases can also be emotionally challenging for the medics, where they occur as a consequence of poverty or violence. In the study setting, as described above, domestic abuse and burns resulting from poor housing conditions were commonly reported mechanisms of injury. Speaking of assessing acute burns patients, one expert commented:
“‘It’s always just that emotional aspect, it’s getting sort of past that, and, sort of the horror of it all, actually having, it’s, I think it’s probably one of the most, em, emotive things that you can see.” –ID.3
For doctors with limited trauma and emergency experience, often ‘out of their comfort zones’ in terms of subspecialty, the demands of treating these injuries can be overwhelming. In the case of burns, some have only one day’s training before taking up post, often alone.
Some experts expressed a belief that the presence of a senior colleague via an mHealth app, albeit remote, constituted a ‘moral support component’ that could be of comfort to inexperienced doctors. All believed that in taking difficult decisions such as to palliate rather than to resuscitate, expert concurrence was valuable both emotionally as well as medically. Decisive instruction, decision support and trustworthy advice facilitated by interaction with experts was seen as key to limiting inherent pressures within trauma and emergency, whilst not being able to eliminate them.
Sensitivity and ethics
All but one expert described how informal ‘telemedicine’ practices were already used extensively, in that images are shared via mobile phone messaging apps in order to consult with colleagues. While confirming the value of image sharing as a concept, some expressed worry around ethical and legal implications in the current system, and saw benefit to a more formalised arrangement. The ability to regulate users for greater security of patient data was one specific advantage listed of such systems, another, the data storage capacity and a legal documentation of having sought help. It was also suggested that using such image records to demonstrate visual improvement to patients, can have a psychological role to play in trauma recovery.
Even in a regulated system however, ethics around photographing injuries, particularly in trauma and emergency where consent may be an issue, are complex. It was suggested that innovations such as apps can exacerbate these issues, making medical practice seem too familiar and removed from the clinical setting.
“..and so it was easier when you had to dig out your big camera, because it kind of forced you into that cognitive space of being aware that you’re taking pictures of people” –ID.1
Effective communication with patients and carers is seen as crucial to remedy such problems. One expert suggested ‘pop-up prompts’ within systems, reminding users to explain various stages of the process before use.
Tools for the future
Many experts saw education as a vital component of their role, and most viewed telemedicine as an opportunity to enhance their capacity as educators. Teleconsultation’s potential for education is well documented, [21, 42] and has been rated in other studies by POC users as one of the most important aspects to influence their satisfaction in its use [3, 16].
The importance of providing feedback on patient treatment and outcome proved a more divisive issue. Many questioned its necessity to job satisfaction at the expert level, and commented that due to the transient nature of the patient journey through EM, feedback is often inevitably lower priority in this specialty. While some did welcome it, many expressed sentiments such as:
“for the experts, as heartless as it sounds, no, because I’ve got my own patient load, I’ve got my own patients that I’m dealing with that are complex and that’s enough for me to handle...” –ID.15
Discrepancies did not lie between specialties, and seemed idiosyncratic or related to personal preference. Other studies have found that expert physicians find patient follow up notifications to be beneficial [25, 43], although these studied experts in HICs providing advice to resource poor settings, potentially acting in a voluntary capacity and through interest or desire for reciprocal learning.
Despite questions raised over the additional workload burden that feedback provision could incur for tele-experts, agreement was complete on its value for POC staff, for their development and encouragement as well as learning opportunities.
Overall, in terms of being able to lift practice from that which was currently achievable to that which was envisaged as gold standard, the potential for telemedicine was believed to relate strongly to educational opportunities, and greater access to support and information, whilst formalising many aspects of technology use already in place through interaction with Whatsapp and other similar services.
Power and personality
The second category on “power and personality” included two sub-categories both capturing hierarchical dimensions of the health care system (Fig. 1).
Hierarchy
Many experts spoke of the hierarchical system that exists within medicine. There was acknowledgment that ingrained systemic fear of seniors could lead to hesitation to seek advice, with subsequent critical delays in patient care, and the effect was imagined to be amplified for nursing and allied health staff. One expert described his first years in medicine:
“That’s part of medical training, you’re made to feel stupid and there’s always someone smarter than you, so it doesn’t create a culture of openness and asking for help... It was very much the sense I don’t want to disturb anyone, what if my question is stupid, what if they ask me something I don’t know.”- ID.11
Telemedicine’s possible contributions in spanning these professional divides included its potential anonymity, reducing anxiety in calling, and an allocated expert per shift reducing the sense of ‘bothering someone.’ One expert clarifies:
“I think it will probably just help in building more positive relationships, because it’s another way of saying we are reachable, you can approach us and I think that helps a lot for doctors who are on the periphery dealing with major problems.”-ID.10
From the expert level, it was proposed that an app could incorporate an allocated ‘shift system’ – with specific time slots during which an assigned expert was responsible for queries directed to them thought the app. This was viewed as potentially more psychologically manageable than the ‘endless on call’ of an informal system, making experts more amenable to queries, and improving communication as a result.
Both EM and burns experts were split in their opinion on whether nursing staff should also be able to seek advice through such a system. Some thought their inclusion to be crucial; in the primary health care facilities nurses tended to be permanent and experienced, in contrast to the short term junior doctors. Many others, however, doubted their ability to engage with such a system, although their reservations related to nurses’ perceived lack of familiarity with smart phone technology rather than ability to use telemedicine per se. A previous study analysing telemedicine referrals from nurses, physiotherapists and other health care workers, found little difference between their responses and those of physicians [29, 44], however, the position of allied staff, their professional standing and potential for role extension varies widely between different countries.
Another related issue that was raised pertained to the idea of hierarchy extending not only to individuals but to institutions and specialties. Some participants queried the relative merits of systems which solely included tele-experts attached to the tertiary burn unit, as opposed to those employing experts from a variety of secondary and tertiary level facilities. Others raised the question of specialty, and on what grounds somebody would be deemed and remain an ‘expert’ within such systems, in terms of credentials or experience.
“I think that it might be, it’s something that, that would need to be quite carefully, trod around, in terms of who’s going to be the experts... I just think it needs to be strategically done. And I was thinking maybe, I mean, maybe there could be like an, exam, or something, some sort of qualification before you actually are allowed to be an expert.”-ID.3
In a system which combines the talents of two specialties, as in many trauma and emergency situations, this is a question which may require consideration at implementation. Simultaneously however, potential was seen to reduce a professional gap at this expert level; greater collaboration between specialties and institutions could enhance partnerships, and foster deeper mutual respect. In general it was perceived that telemedicine could be used to counteract negative effects of a hierarchical system, but would neither dispel nor entrench the hierarchical structure itself.
Experts as gatekeepers
A connected discussion involved issues of communication and trust, in a system where the expert can be viewed as the ‘gatekeeper’ to scarce resources. Related to this was the proposed benefit of images adding ‘proof’ or ‘evidence’ to a query. Many of the experts suspected an exaggeration or underplaying of the severity of cases during telephone consultation by POC staff, in order that the patient would fit the criteria for referral.
“when a burn patient comes in, is this patient going to get that golden bed....like what is it about this patient that I can package them in a way, and sell them in a way to get them into that bed”-ID.11
Many experts expressed empathy towards the motivation behind such misrepresentations of a patient’s condition. Simultaneously, however, many viewed this ‘tactic’ as furthering the crisis in referral and resources, leading to patients directed to inappropriate levels of care. It was thought that the validity and that an app could bring was essential for appropriate disposition, but also for long term relationship building between colleagues and institutions as this ‘evidence’ component eroded previous suspicion and distrust. The possibility was raised however, that such systems could be underused at POC for this exact same reason.
Here, the key elements for interaction with such a technology to effectively elevate practice related to improved relationships, greater transparency of communication a more formalised access to colleagues and definition of their roles.
Physical divides within the trauma journey
One of the greatest divides related to tangible gaps; the physical distance between where trauma cases first present to medical services and where they can best be treated, between the resources and facilities of the primary health care facilities and the specialist tertiary units, and potentially between the experience and skills of their respective staff.
Here, huge potential for diagnostic telemedicine systems to bridge these gaps was anticipated. Suggested benefits pertained to a greater understanding and appreciation of the difficulties and roles between the primary health care facilities and tertiary units, better information exchange leading to enhanced ability to advise, and greater confidence in doing so. Consequential to these crucial enhancements was better initial treatment so vital in trauma and emergency, greater adherence to referral criteria ensuring the right patients selected for transfer, and an overall uplifting of the service. Challenges still remained however related to how new pathways for referral would fit into existing systems, and how inexperienced doctors would respond to greater information. However, the key anticipated areas of potential improvement relating to formalisation of information exchange, and a corresponding increase in the experts’ confidence in their ability to advise were strongly echoed by many of the participants.
Much of the specific information gleaned within this category is beyond the scope of this paper, and has been discussed in greater detail in another work relating to specialists’ expectations of image based teleconsultation [45].