Media and Medicine
Some Implications of Telemedicine by Ben Park and Rashid Bashshur
Health care delivery by two-way television may change roles, authority, and distribution of health-care professionals. The term “telemedicine” was introduced in the last decade to designate interactive, or two-way, television (IATV) in medical practice. Essentially, IATV provides links among individuals and groups at distances ranging from a few blocks to several miles. It can be used for remote diagnosis, consultation, counseling, psychotherapy, and teaching. Telemedicine is being used for these purposes and assessed in a number of health care delivery settings in the United States and Puerto Rico (see 2, 7). It is held to be one possible solution to the problem created by the fact that health professionals and resoiirces tend to be clustered in some areas and in short supply in others. The consequences of human interaction in the telemedicine medium have been suggested but not yet carefully studied. We will discuss two types of consequences: those which may change relationships among health professionals who use the medium, and those which may require change either in the perceptual biases of risers or in the technical equipment so that perceptual bias can be accommodated. Telemedicine uses interactive television technology for communication between providers and recipients of care. The technology, the people who use Ben Park is Director of Communications Research at the Alternate Media Center, School of the Arts, New York University Rashid Bashshur is Associate Professor of Medical Care Organization, Schoool of Public Health, University of Michigan, and co-author of the recently published book Telemedicine. Both authors have been studying the new field of telemedicine with the help of grants from the Rockefeller Foundation (to Park) and the National Science Foundation (to Bashshrir)
161
Journal of Communication, Summer 1975
it, and other aspects of the environment constitute a communication system. We would not stress what may be obvious if we did not have ample evidence that many users consider telemcdicinc a mcrc technical addition to existing arrangements and fail to take into account its unique interpersonal and systemic attributes. Thus it appears useful to examine telemedicine both in terms of what we will call the internal situation (what happens in transactions within the twodirectional television system) and in terms of the external situation (the effects of telemedicine on the larger health care system).
Professionals’ roles are a$ected by the ways in which interactive channels are used. In a typical use of telemedicine, a nurse practitioner is providing primary medical care at an outreach clinic and requests a consultation via two-way television from a physician at a distant hospital in order to diagnose the problem of a patient who is with the nurse at the clinic. The system of health care within which the television channels are used has a strict hierarchy: the nurse is subordinate to the physician and will, as a direct outcome of the transaction, execute the physician’s instructions about the patient’s care. During the transaction, the physician can ask the nurse for the patient’s history and for information about X-rays and electrocardiograms; can hear heart, lung, and bowel sounds via a remote stethoscope placed where the physician wants it; and can ask the nurse to describe such things as the color, tone, or three-dimensional aspects of surface lesions. Frequently, the physician has remote control of a camera scanning the patient, and the nurse will position the patient so the physician can get the best view. It is apparent that the roles of nurse and physician in this example are not those customary in the face-to-face setting. The nurse must perform many tasks that ordinarily would be performed by the physician’s hands and some of those that would be performed by the physician’s eyes. In other words, the physician gives up certain customary diagnostic tools and receives indirect information relayed by the nurse and/or the medium. The basic characteristics of the emergent role relationship can be described as follows: (1)The physician has to relate to the nurse directly, ask her (or him) questions, depend on her judgment, and use her observations to perform clinical activities. (2) The physician has to deal with the nurse, at least in part, on her own terms, because the nurse is the real contact with the patient. The physician has to accept the nurse as a partner in providing clinical services to the patient. (3) Because of these changes, there seems to be a need to develop an explicit definition of the nurse’s role in terms of the specific clinical functions the nurse can perform that are beneficial to the patient, and to facilitate remote diagnosis by the physician who is not physically present during the clinical encounter. Similar role shifts might occur when a generalist calls for consultation with a specialist. Ordinarily, the generalist would send the patient to the specialist’s
162
Media and Medicine 1 Telemedicine
office and in due course get a brief report on the patient’s problem. In the telemedicine setting, the generalist is an active party to what previously may have been understood only sketchily.
The new roles enacted via telemedicine can be expected to have significant effects on the entire system of medical care delivery. If nurses assume more responsibility for patient care in telemedical situations, how long will it take them to perceive the changes in their new roles and to insist upon them? A slightly different, but more interesting, way of putting it is: Whose patient is it? If the nurse were another physician asking for assistance, there would be no question whose patient it was. Can a patient ever “belong” to a nurse, in the sense that he or she “belongs” to a physician? In the telemedical situation, it seems to be the case that the patient often does. We have also observed that in telemedical transactions there is a tendency to shift away from some of the deferential behaviors characteristic of face-to-face encounters in hierarchical organizations. It has been suggested that there may be a greater degree of symmetry in the telemedicine setting and hence less need for the rituals commanded by the physician’s superior role in face-to-face encounters. The physician seems to need deference rituals to preserve his or her role as authority in the traditional office or hospital setting; but, although telemedical transactions allow a more relaxed and informal atmosphere, there is no evidence that the physician’s authority is threatened by the softening of ritual. Physicians will find themselves having not only to relax certain rigidities in dealing with patients, but also to develop a peer relationship with the other health care professionals on the “team.” However, once they get used to the new medium, physicians may resort to their habitual behavior and rise the medium to reinforce their traditional authority. Telemedicine’s potential depends largely on the degree to which interactive television is capable of responding to the trained perceptions of health professionals and, conversely, on the degree to which physicians are able to reorder their perceptual needs in ways which take into account the visual and auditory capacities of televison. Most of the technical equipment used for IATV has been adapted and combined from components intended for one-way television. Although much of it has been adapted with skill, it shows its heritage and is inherently clumsy. Cameras and remote controls that are quite adequate for surveillance and monitoring of industrial plants and highway traffic possess neither the fluidity of head motions nor zoom lens ratios that enable a physician to inspect a patient with ease and finesse. Ideally, remotely controlled cameras, coupled with devices by which the physician can position the patient precisely, would enable a physician to see the
163
Journal of Communication, Summer 1975
At the Wagner Child Health Station in New York City, community health worker examines a child, while Dr. Nicholas Cunningham, the clinic’s co-director, looks on from his office more than a mile away in Mount Sinai Hospital.
patient easily from any angle and to view any size ratio up to 15-times close-up. Microphone transports would be designed to enable attention to sounds of any dimension from any source, the way physicians employ their own ears in the natural setting. In order for such equipment to be properly designed, however, there must be studies of the precise sounds and sights which physicians need for their diagnostic evaluations, of characteristic sequences which physicians follow in looking and listening, and of methods by which technology can either respond to physicians’ perceptions or change their perceptual biases. Andriis and Bird ( 1 ) have shown that physicians viewing X-rays via television can actually receive images superior to those available on direct view, but must retrain themselves to scan the X-rays in a systematic pattern different from the habitual scanning pattern of most radiologists. A different medium will require adjustments in perception in response to its different contingencies. It may be argued that technology should be devised which requires least adaptation or shift from one’s perceptual bias. But if adaptation can give new meaning to the observation, adaptation should also be encouraged. Major questions remain. If telemedicine proliferates widely, will it decrease the pressure on large centralized hospital outpatient departments? Will it decentralize patient care? Can patients be discharged earlier from hospitals because supervision and monitoring are available? Will ready access to consultation and professional peer interaction via IATV encourage health personnel to
164
Media and Medicine / Telemedicine
Dr Cunningham interacts with another community health worker and child at the Wagner Child Health Station
return to the medically indigent urban ghettos and rural areas which telemedicine is designed to serve? There is as yet only a small body of literature dealing with human communication via interactive television. Reid (9) noted the need for awareness and careful study of unanticipated impacts, and stressed that two-way communications should not be treated as simulations of face-to-face contact. Short (10) pointed out the difficulties which ensue when outsiders impose technology on the people who are to communicate with it. He proposed that potential risers be involved in the planning and implementation of its use, and that no one should use the new technology unless he or she is interested in what is to be accomplished with it. Pool (8) stressed the basic tenet that both acceptance and use are dependent on those involved in the interaction. Champness (5) underscored the point that users’ previous attitudes will to a large extent predetermine their acceptance of new communication technology. Bretz (4) listed both information-centered and person-centered goals underlying the desire to interact via telecommunications, stressed the need for informality and flexibility in interaction, and proposed a shift from broadcasting terms and definitions to words and concepts derived from the language of human interaction. Park (7) suggested certain physical and psychological properties of the television medium and of the cnltural context which may influence interaction via IATV. Telemedicine is in its infancy in terms of technology, clinical applications, and operational standards. Its real potential can best be achieved by understanding the intricate relationship among these phenomena and IATV’s unique attributes in communication.
165
lournal of Communication, Summer 1975
REFERENCES 1. Andrus, W. Scott, and Kenneth T. Bird. “Teleradiology: Evolution through Bias to Reality,” CHEST 62, Dec. 1972, pp, 655-657. 2. Bashshur, Rashid, Zakhour I. Youssef, and Patricia Armstrong (Eds.) Telemedidne. Springfield, Illinois: Charles C. Thomas, 1975 3. Bird, Kenneth T., Milton H. Clifford, Thomas F. Dwyer, and John G. Clark. Teleconsultatlon: A New Health Information Exchange System. Annual Report, July 1, 1969-June 30, 1970. Boston: Massachusetts General Hospital, May 15, 1970. 4. Bretz, Rudy. Two-way TV Teleconferencing for Government: The MRC-TV System. Santa Monica, California: The Rand Corporation, April 1974. 5. Champness, Brian G. The Measurement and Prediction of Acceptability. London: Communications Studies Group, Joint Unit for Planning Research, University College, January 1971. 6. Freidson, Eliot. Personal communication, July 1973. Relevant Reference: Profession of Medicine: A Study of the Sociology of Applied Knowledge. New York: Dodd, Mead and Co., 1970. 7. Park, Ben. An Introduction to Telemedicine: Interactive Television for the Delivery of Health Seruices. New York: The Alternate Media Center at New York University School of the Arts. June 1974. 8. Pool, Ithiel de Sola. “Citizen Feedback in Political Philosophy.” In I. de S. Pool (Ed.) Talking Back: Citizen Feedback and Cable Technology. Cambridge and London: The MIT Press, 1973, pp. 237-246. 9. Reid, Alex. New Dlrectlons in Telecommunications Research. New York: Alfred P.Sloan Foundation, January 1971. 10. Short, John A., in Elton, Martin C. J., “The Use of Field Trials in Evaluating Telecommrrnications Systems for Use in the Delivery of Health Care.” London: The Communications Studies Group, Joint Unit for Planning Research, University College. Unpublished Manuscript, 1973. 11. Thayer, Lee. “Communications Systems,” in E. Laszlo (Ed.)The Relevance of General Systems Theory. New York: George Braziller, 1972.
A physician at Massachusetts General Hospital views a close-up of an intraoral cavity being transmitted from Bedford Veterans Administration Hospital, 30 miles away.
166
Some Implications of Telemedicine by Ben Park and Rashid Bashshur
Health care delivery by two-way television may change roles, authority, and distribution of health-care professionals. The term “telemedicine” was introduced in the last decade to designate interactive, or two-way, television (IATV) in medical practice. Essentially, IATV provides links among individuals and groups at distances ranging from a few blocks to several miles. It can be used for remote diagnosis, consultation, counseling, psychotherapy, and teaching. Telemedicine is being used for these purposes and assessed in a number of health care delivery settings in the United States and Puerto Rico (see 2, 7). It is held to be one possible solution to the problem created by the fact that health professionals and resoiirces tend to be clustered in some areas and in short supply in others. The consequences of human interaction in the telemedicine medium have been suggested but not yet carefully studied. We will discuss two types of consequences: those which may change relationships among health professionals who use the medium, and those which may require change either in the perceptual biases of risers or in the technical equipment so that perceptual bias can be accommodated. Telemedicine uses interactive television technology for communication between providers and recipients of care. The technology, the people who use Ben Park is Director of Communications Research at the Alternate Media Center, School of the Arts, New York University Rashid Bashshur is Associate Professor of Medical Care Organization, Schoool of Public Health, University of Michigan, and co-author of the recently published book Telemedicine. Both authors have been studying the new field of telemedicine with the help of grants from the Rockefeller Foundation (to Park) and the National Science Foundation (to Bashshrir)
161
Journal of Communication, Summer 1975
it, and other aspects of the environment constitute a communication system. We would not stress what may be obvious if we did not have ample evidence that many users consider telemcdicinc a mcrc technical addition to existing arrangements and fail to take into account its unique interpersonal and systemic attributes. Thus it appears useful to examine telemedicine both in terms of what we will call the internal situation (what happens in transactions within the twodirectional television system) and in terms of the external situation (the effects of telemedicine on the larger health care system).
Professionals’ roles are a$ected by the ways in which interactive channels are used. In a typical use of telemedicine, a nurse practitioner is providing primary medical care at an outreach clinic and requests a consultation via two-way television from a physician at a distant hospital in order to diagnose the problem of a patient who is with the nurse at the clinic. The system of health care within which the television channels are used has a strict hierarchy: the nurse is subordinate to the physician and will, as a direct outcome of the transaction, execute the physician’s instructions about the patient’s care. During the transaction, the physician can ask the nurse for the patient’s history and for information about X-rays and electrocardiograms; can hear heart, lung, and bowel sounds via a remote stethoscope placed where the physician wants it; and can ask the nurse to describe such things as the color, tone, or three-dimensional aspects of surface lesions. Frequently, the physician has remote control of a camera scanning the patient, and the nurse will position the patient so the physician can get the best view. It is apparent that the roles of nurse and physician in this example are not those customary in the face-to-face setting. The nurse must perform many tasks that ordinarily would be performed by the physician’s hands and some of those that would be performed by the physician’s eyes. In other words, the physician gives up certain customary diagnostic tools and receives indirect information relayed by the nurse and/or the medium. The basic characteristics of the emergent role relationship can be described as follows: (1)The physician has to relate to the nurse directly, ask her (or him) questions, depend on her judgment, and use her observations to perform clinical activities. (2) The physician has to deal with the nurse, at least in part, on her own terms, because the nurse is the real contact with the patient. The physician has to accept the nurse as a partner in providing clinical services to the patient. (3) Because of these changes, there seems to be a need to develop an explicit definition of the nurse’s role in terms of the specific clinical functions the nurse can perform that are beneficial to the patient, and to facilitate remote diagnosis by the physician who is not physically present during the clinical encounter. Similar role shifts might occur when a generalist calls for consultation with a specialist. Ordinarily, the generalist would send the patient to the specialist’s
162
Media and Medicine 1 Telemedicine
office and in due course get a brief report on the patient’s problem. In the telemedicine setting, the generalist is an active party to what previously may have been understood only sketchily.
The new roles enacted via telemedicine can be expected to have significant effects on the entire system of medical care delivery. If nurses assume more responsibility for patient care in telemedical situations, how long will it take them to perceive the changes in their new roles and to insist upon them? A slightly different, but more interesting, way of putting it is: Whose patient is it? If the nurse were another physician asking for assistance, there would be no question whose patient it was. Can a patient ever “belong” to a nurse, in the sense that he or she “belongs” to a physician? In the telemedical situation, it seems to be the case that the patient often does. We have also observed that in telemedical transactions there is a tendency to shift away from some of the deferential behaviors characteristic of face-to-face encounters in hierarchical organizations. It has been suggested that there may be a greater degree of symmetry in the telemedicine setting and hence less need for the rituals commanded by the physician’s superior role in face-to-face encounters. The physician seems to need deference rituals to preserve his or her role as authority in the traditional office or hospital setting; but, although telemedical transactions allow a more relaxed and informal atmosphere, there is no evidence that the physician’s authority is threatened by the softening of ritual. Physicians will find themselves having not only to relax certain rigidities in dealing with patients, but also to develop a peer relationship with the other health care professionals on the “team.” However, once they get used to the new medium, physicians may resort to their habitual behavior and rise the medium to reinforce their traditional authority. Telemedicine’s potential depends largely on the degree to which interactive television is capable of responding to the trained perceptions of health professionals and, conversely, on the degree to which physicians are able to reorder their perceptual needs in ways which take into account the visual and auditory capacities of televison. Most of the technical equipment used for IATV has been adapted and combined from components intended for one-way television. Although much of it has been adapted with skill, it shows its heritage and is inherently clumsy. Cameras and remote controls that are quite adequate for surveillance and monitoring of industrial plants and highway traffic possess neither the fluidity of head motions nor zoom lens ratios that enable a physician to inspect a patient with ease and finesse. Ideally, remotely controlled cameras, coupled with devices by which the physician can position the patient precisely, would enable a physician to see the
163
Journal of Communication, Summer 1975
At the Wagner Child Health Station in New York City, community health worker examines a child, while Dr. Nicholas Cunningham, the clinic’s co-director, looks on from his office more than a mile away in Mount Sinai Hospital.
patient easily from any angle and to view any size ratio up to 15-times close-up. Microphone transports would be designed to enable attention to sounds of any dimension from any source, the way physicians employ their own ears in the natural setting. In order for such equipment to be properly designed, however, there must be studies of the precise sounds and sights which physicians need for their diagnostic evaluations, of characteristic sequences which physicians follow in looking and listening, and of methods by which technology can either respond to physicians’ perceptions or change their perceptual biases. Andriis and Bird ( 1 ) have shown that physicians viewing X-rays via television can actually receive images superior to those available on direct view, but must retrain themselves to scan the X-rays in a systematic pattern different from the habitual scanning pattern of most radiologists. A different medium will require adjustments in perception in response to its different contingencies. It may be argued that technology should be devised which requires least adaptation or shift from one’s perceptual bias. But if adaptation can give new meaning to the observation, adaptation should also be encouraged. Major questions remain. If telemedicine proliferates widely, will it decrease the pressure on large centralized hospital outpatient departments? Will it decentralize patient care? Can patients be discharged earlier from hospitals because supervision and monitoring are available? Will ready access to consultation and professional peer interaction via IATV encourage health personnel to
164
Media and Medicine / Telemedicine
Dr Cunningham interacts with another community health worker and child at the Wagner Child Health Station
return to the medically indigent urban ghettos and rural areas which telemedicine is designed to serve? There is as yet only a small body of literature dealing with human communication via interactive television. Reid (9) noted the need for awareness and careful study of unanticipated impacts, and stressed that two-way communications should not be treated as simulations of face-to-face contact. Short (10) pointed out the difficulties which ensue when outsiders impose technology on the people who are to communicate with it. He proposed that potential risers be involved in the planning and implementation of its use, and that no one should use the new technology unless he or she is interested in what is to be accomplished with it. Pool (8) stressed the basic tenet that both acceptance and use are dependent on those involved in the interaction. Champness (5) underscored the point that users’ previous attitudes will to a large extent predetermine their acceptance of new communication technology. Bretz (4) listed both information-centered and person-centered goals underlying the desire to interact via telecommunications, stressed the need for informality and flexibility in interaction, and proposed a shift from broadcasting terms and definitions to words and concepts derived from the language of human interaction. Park (7) suggested certain physical and psychological properties of the television medium and of the cnltural context which may influence interaction via IATV. Telemedicine is in its infancy in terms of technology, clinical applications, and operational standards. Its real potential can best be achieved by understanding the intricate relationship among these phenomena and IATV’s unique attributes in communication.
165
lournal of Communication, Summer 1975
REFERENCES 1. Andrus, W. Scott, and Kenneth T. Bird. “Teleradiology: Evolution through Bias to Reality,” CHEST 62, Dec. 1972, pp, 655-657. 2. Bashshur, Rashid, Zakhour I. Youssef, and Patricia Armstrong (Eds.) Telemedidne. Springfield, Illinois: Charles C. Thomas, 1975 3. Bird, Kenneth T., Milton H. Clifford, Thomas F. Dwyer, and John G. Clark. Teleconsultatlon: A New Health Information Exchange System. Annual Report, July 1, 1969-June 30, 1970. Boston: Massachusetts General Hospital, May 15, 1970. 4. Bretz, Rudy. Two-way TV Teleconferencing for Government: The MRC-TV System. Santa Monica, California: The Rand Corporation, April 1974. 5. Champness, Brian G. The Measurement and Prediction of Acceptability. London: Communications Studies Group, Joint Unit for Planning Research, University College, January 1971. 6. Freidson, Eliot. Personal communication, July 1973. Relevant Reference: Profession of Medicine: A Study of the Sociology of Applied Knowledge. New York: Dodd, Mead and Co., 1970. 7. Park, Ben. An Introduction to Telemedicine: Interactive Television for the Delivery of Health Seruices. New York: The Alternate Media Center at New York University School of the Arts. June 1974. 8. Pool, Ithiel de Sola. “Citizen Feedback in Political Philosophy.” In I. de S. Pool (Ed.) Talking Back: Citizen Feedback and Cable Technology. Cambridge and London: The MIT Press, 1973, pp. 237-246. 9. Reid, Alex. New Dlrectlons in Telecommunications Research. New York: Alfred P.Sloan Foundation, January 1971. 10. Short, John A., in Elton, Martin C. J., “The Use of Field Trials in Evaluating Telecommrrnications Systems for Use in the Delivery of Health Care.” London: The Communications Studies Group, Joint Unit for Planning Research, University College. Unpublished Manuscript, 1973. 11. Thayer, Lee. “Communications Systems,” in E. Laszlo (Ed.)The Relevance of General Systems Theory. New York: George Braziller, 1972.
A physician at Massachusetts General Hospital views a close-up of an intraoral cavity being transmitted from Bedford Veterans Administration Hospital, 30 miles away.
166
