Virtual clinics in foot and ankle surgery: patient and clinician perceptions

Abstract

Background

The worldwide COVID-19 pandemic has led to the popularisation of ‘virtual’ clinics. In orthopaedics, little is known about the use of virtual clinics within foot and ankle surgery, specifically.

Methods

A cross-sectional observation study of patients and clinicians in response to virtual clinics in foot and ankle surgery. Patients seen in a virtual clinic were contacted by telephone from two weeks after their consultation and asked to complete a 12-point questionnaire. Demographic information was also collected. Clinicians in foot and ankle completed a 10-point questionnaire.

Results

One hundred patient responses were collected. Patient satisfaction with virtual clinics was positive, with 65% of respondents reporting they were very happy (Likert scale rating 5). More than 90% of patients felt they received enough information, felt involved, felt the virtual clinic was helpful and knew who to contact if there was a problem. However, 79% would still prefer a face-to-face consultation, and 22% would have preferred a video consultation. Clinician responses were more cautious, with 60% stating they were neither happy nor unhappy (Likert scale rating 3). Virtual clinics may be faster for the clinician.

Conclusions

Virtual clinics may be more convenient for patients, with high satisfaction levels reported, but represent significant clinical challenges for foot and ankle surgeons. Elements of virtual clinics may persist post pandemic, particularly in routine follow-up. Virtual clinics are not appropriate for new patient referrals.

Introduction

The SARS-CoV-2/COVID-19 pandemic has been an unprecedented national emergency in the UK and worldwide. It has resulted in the development of safe ‘hospital distancing’ care for many trauma and elective services within orthopaedics within a short space of time. One way of achieving this is through the growing trend for ‘virtual’, ‘video’ or ‘telecommunication’ clinics, as supported by updated guidelines from the British Orthopaedic Association¹ and NHS England² in response to the pandemic in the UK.

Telemedicine has been around since the early 1990s and was initially used in remote locations.³ Virtual clinics have been used for some time by other medical specialities in the UK, such as renal medicine, gastroenterology and ophthalmology, but their uptake in trauma and orthopaedics has been slower.^4–6 Since 2011 in the UK, virtual clinics in orthopaedics have been more focused on trauma services, commonly known as ‘virtual fracture clinics’.⁷

Within elective orthopaedics, the use of virtual clinics was previously associated with hip or knee arthroplasty^8–12 with a focus on cost saving.

Within the foot and ankle subspeciality, we identified a published abstract from the 2017 American Orthopedic Foot and Ankle Society meeting¹³ that reported on the use of telemedicine in elective orthopaedics. However, the results were not differentiated, and it was not possible to determine foot and ankle results separately.

More recently, the British Orthopaedic Foot and Ankle Society (BOFAS) discussed the implications of virtual telephone and video clinics during the pandemic in their webinar series.¹⁴ BOFAS suggested virtual clinics may be more appropriate in routine postoperative follow-ups but are not recommended for new patients, who should be seen face-to-face.¹⁴

There remains little published research on this subject within the foot and ankle subspecialty, despite the growing importance of virtual clinics as the pandemic continues in the UK and worldwide.

The aim of this paper was to evaluate a novel elective foot and ankle virtual clinic, set up during the COVID-19 pandemic from a traditional face-to-face service. To do this, patient and clinician perspectives were assessed, and a narrative review of the literature was conducted.

Methods

Data collection

Patients seen in a virtual foot and ankle elective clinic at The Robert Jones Agnes Hunt Orthopaedic Hospital (RJAH) between 8 April and 12 May 2020 (34 days) were identified using hospital records (Table 1). This period corresponded to a change in practice to virtual clinics within the foot and ankle department as the pandemic evolved. All virtual clinics in our foot and ankle department were conducted by telephone.

Table 1 .

Patient inclusion and exclusion criteria

Inclusion criteria	Exclusion criteria
Patients seen successfully in a virtual clinic (telephone, video)	Did not attend virtual clinic appointment
Patients seen between 8 April and 12 May 2020	Declined to participate in study
Patients seen by consultant A, B, C or D
Both new and follow-up patients
Patients attending for a recognised foot and ankle condition
Age 18+
English-speaking or family interpreter present

Basic clinical information was collected from the patient’s electronic patient record (EPR) and is shown in Table 2.

Table 2 .

Basic clinical information collected from electronic patient records of patients successfully completing the questionnaire

1.	Consultant (divided anonymously into A, B, C and D)
2.	Reason for their clinic appointment (monitoring of condition, postoperative, discussion of results)
3.	Operation and date (if undergone a procedure in the last 12 months)
4.	Consultation type: telephone, video or mixed
5.	Date of birth

A questionnaire was devised to ask patients about their experience in the new virtual foot and ankle clinic as shown in Table 3.

Table 3 .

Patient questionnaire used to assess the patient’s response to virtual consultations

1.	Were you given enough information about your condition?
2.	Did you receive enough information about the management plan?
3.	Did you feel involved in the consultation?
4.	Was there enough time for the consultation?
5.	Was the consultation helpful?
6.	Do you think there is a role for teleclinics?
7.	Would you have preferred a video call?
8.	Do you know who to contact if you have clinical concerns?
9.	Would you have preferred a face-to-face consultation?
10.	What is your overall rating of the consultation? (Likert scale 1–5)
11.	Would you recommend the virtual clinic?
12.	Do you have any further comments regarding the virtual clinics?

Patients were selected from an anonymous list and contacted over a two-month period (12 May to 12 July 2020) at a minimum of four weeks after their virtual consultation. This corresponded to the end of the consultation period when virtual clinics were carried out. Patients were contacted by telephone between the hours of 0900 and 1700 to complete the questionnaires. Verbal consent was gained over the telephone and it was explained that the questionnaire was for research purposes and that the assessor was not a foot and ankle consultant to reduce bias. Questionnaires were administered by three independent assessors (JHR, AD, ER). There was no set time limit for discussing the questionnaire, but most discussions lasted 5 to 10 minutes. Basic clinic information was added retrospectively to successfully completed questionnaires from the patient’s EPR. Attempts were made to contact each patient at least once with the aim of successfully completing 100 questionnaires.

To assess clinician responses to the new clinic format, a secondary questionnaire was constructed and sent to all foot and ankle department consultants at RJAH (following collection of patient data at the end of the study period). The consultant questionnaire is shown in Table 4.

Table 4 .

Consultant questionnaire

1	Did you do remote clinics before lockdown?
2	What are the advantages of remote clinics compared with face-to-face appointments?
3	What are the disadvantages of remote clinics compared with face-to-face appointments?
4	How would outpatient service delivery be changed if most clinics became remote?
5	Do virtual clinics run faster or slower than normal clinics for you? (Likert scale 1–5)
6	Do you feel there is an advantage to video-remote clinics compared with telephone remote clinics? (Likert scale 1–5)
7	Do you think remote clinics should continue post pandemic?
8	If you think it should continue, then why?
9	How can remote clinics be improved?
10	How satisfied are you with the virtual foot and ankle clinic? (Likert scale 1–5)

Patient and clinician satisfaction levels with the service were assessed using a five-point Likert scale (1 = very unhappy; 2 = unhappy; 3 = neither happy nor unhappy; 4 = happy; 5 = very happy). Other questions assessed using Likert scale corresponded to: 1 = strongly disagree; 2 = disagree; 3 = neither disagree nor agree; 4 = agree; 5 = strongly agree.

Data analysis

Patient data was anonymised and recorded in Microsoft Excel^®. Figures and tables were created using the same software.

Results

Demographics

Some 310 patients were identified as having been seen virtually by a foot and ankle consultant during the study period (Table 5). One hundred of these patients were successfully contacted by telephone and included in the study. These patients were distributed between four consultant clinics, with small variations in the final number of patients included per consultant because some patients could not be contacted.

Table 5 .

Demographics of included patients

Sex	75% female, 25% male
Mean age (SD), years	56.1 (16.57)
Age range, years	21–85
Ethnicity (%)
Caucasian	97
Chinese	1
Middle Eastern	2
Language spoken	100% English
Interpreter	None required
Patients requiring assistance (dementia, family assistance, language barrier, etc.)	0%
New or follow-up patient	100% follow-up

Patient responses

The majority of patients (64%) attended the foot and ankle clinic for monitoring of their condition, 33% attended postoperatively and only 3% attended for discussion of their results (Figure 1).

Figure 1 .

Patient reasons for attending the clinic

Although most patient responses were positive, the majority (79%) would still prefer a face-to-face consultation given the choice. In addition, 22% would have preferred a video consultation, rather than a telephone consultation. Nineteen per cent of patients did not feel there was a role for teleclinics (Figure 2).

Figure 2 .

Patient responses to the questionnaire

Patients were asked to give a Likert scale response (1–5) of how satisfied they were with their virtual clinic consultation, with 1 being the least positive and 5 being the most positive. The results are shown in Figure 3.

Figure 3 .

Patient satisfaction with virtual foot and ankle clinics (Likert scale 1–5)

Clinician responses

Questionnaire data were collected successfully from all five consultant foot and ankle surgeons at RJAH. In addition to written comments, clinicians were asked to give a Likert scale rating in response to the following questions: ‘Do virtual clinics run faster?’, ‘Do you feel there is an advantage to video-remote clinics compared with telephone remote clinics?’ and ‘Do you think remote clinics should continue post pandemic?’ (Figures 4 and 5). Prior to the pandemic, no consultant had experience with virtual clinics.

Figure 4 .

Clinician responses to virtual foot and ankle clinics (Likert scale 1–5)

Figure 5 .

Clinician satisfaction with virtual clinics

Discussion

Patient perspective

The main findings were that patients were satisfied with the ‘virtual foot and ankle clinic’ set up during the pandemic, with 65% of patients very happy (Likert 5), and 97% of patients saying they felt their consultation was ‘helpful’. The majority of the other responses were also positive: 100% of patients felt they were involved in the consultation and had enough time; 98% felt they were given enough information about their condition; 96% felt they were given enough information about their management plan; 95% felt they knew who to contact if they had a clinical problem; and 85% of patients would recommend the clinic to others.

Positive comments that corresponded to these findings included patients who lived far from RJAH or who were shielding and were grateful for a remote option. Other positive comments included those who felt they had ‘normal’ or ‘routine’ progress and were therefore happy to be consulted remotely. Given that the majority of patients in this study who were seen virtually were routine follow-up, it may be that virtual clinics are more appropriate in this category compared with new patient referrals.

One patient explained that they had sent photographs of their wound by email prior to the telephone clinic and felt this was an excellent way to be contacted. Email consultation has been previously recognised as a desirable method to augment virtual clinics in some populations.¹⁵ Day et al developed a service for their virtual clinics in foot and ankle surgery in which patients could email imaging prior to a consultant-led telemedicine clinic.¹⁶

In other patient comments it was felt the virtual clinic was ‘faster’ and more efficient with less waiting around. This is supported by Ahmed et al who reported on a foot and ankle virtual clinic set up during the pandemic which led to decreased waiting times for patients and consultants, meaning that more patients could be seen virtually in a consultant-led clinic than in a face-to-face consultation.¹⁷

In the other responses, 19% of patients felt there was not a role for virtual clinics in the future and 79% would still prefer a face-to-face consultation given the option.

Negative patient comments related to these findings commonly stated that a virtual clinic was acceptable only in the context of the pandemic and they hoped that normal face-to-face consultations would resume following the pandemic. Other comments related to the fact that patients felt trust and rapport with the clinician were important, together with ‘eye and body contact’. It is clear that given the choice, overall, the majority of patients would still prefer a face-to-face consultation.

During the pandemic, some patients did not receive a routine radiograph postoperatively and these patients felt more negatively towards their consultations. However, curtailing of routine radiographs postoperatively in the pandemic is in keeping with new guidance² and has been reported by other foot and ankle units internationally.^18,19 Recent evidence within foot and ankle surgery has also supported this. In 2018, Van Gerven et al found that only 1.2% of 1,174 radiographs booked routinely for 528 patients post ankle Open Reduction Internal Fixation resulted in changes to management.²⁰

Clinician perspective

In contrast to patient responses to virtual clinics, clinician’s responses were more cautious: 60% were neither happy nor unhappy (Likert scale 3) and only 20% were happy (Likert scale 4). When clinicians were asked whether they think virtual clinics should continue post lockdown, the mode and median Likert scale response was 3 (neither happy nor unhappy). The inability to clinically examine patients themselves was consistently cited as the biggest disadvantage. In addition, patients not answering their telephone was cited as a problem for clinicians. Errors in triage and wrong referrals have also begun to be reported with virtual clinics during the pandemic.¹⁷ This suggests that virtual clinics present unique clinical and professional challenges not necessarily present in a face-to-face consultation.

If the clinics were to continue, the consultant body felt that it would be appropriate only for specific, screened routine follow-up patients and not new patient referrals. This is similar to other current literature.^14,21 There may be scope to decrease the need for follow-up appointments further by using patient-reported outcome measures data submitted by patients. The patient’s condition can be monitored remotely and those failing to improve or with an increase in symptoms could trigger a face-to-face review.²² This is not without its challenges, patient-reported outcome measures are reliant on accurate data collection²³ and timely reporting. To improve the virtual clinic service further, clinicians felt there would need to be significant investment in the infrastructure with high-definition video and an ability to record consultations.

There was a suggestion among clinicians that virtual clinics may be faster, with written comments commending this aspect. Although the virtual consultation may have been quicker, it is possible some patients seen virtually still required a further face-to-face consultation which could have increased the total time of consultation. Flexibility was cited by clinicians as another positive attribute of virtual clinics.

Video consultations and multimedia messaging

When selecting a telemedicine system, it is mandatory to respect the General Data Protection Regulation (GDPR 2016/679)²⁴ that provides data privacy and security provisions for safeguarding medical information. Personal and contact data should be password protected.

During the pandemic, foot and ankle surgeons have tried familiar multimedia apps, such as WhatsApp,²⁵ that have previously shown promise but concerns remain regarding end-to-end encryption and patient confidentiality.²⁶ Foot and ankle surgeons in Italy have used ‘iMeApp’ to share clinical pictures, videos and other information with patients during the pandemic²⁷ and surgeons in New York have used ‘Zoom’ video consultations.¹⁶

Although all consultations in this study were conducted via telephone, 22% of patients indicated that they would have preferred a video consultation. It is likely that overall patient satisfaction would increase with a fully video-integrated service across all patients. In a systematic review of video conferencing compared with telephone consultations in healthcare, video was found to have advantages including greater diagnostic accuracy and reduced re-admission rates, although patient outcomes were similar.¹²

Concern has also been expressed by some foot and ankle surgeons regarding video consultations during the pandemic. Marks et al noted that video conferencing was insufficient when ‘dealing with diabetic ulcers where probing of wounds is vital’.²⁸ Some foot and ankle surgeons have emphasised the importance of keeping all wound reviews as face-to-face consultations.^19,29 Part of the reasoning for this is due to the technical difficulties of conducting a clinical examination in foot and ankle surgery through telecommunication, as well as the awkward anatomy. Another reason is that potential complications may be missed or left too late. Ovaska et al found that only 37% of wound complications presented with an unscheduled visit.³⁰ In addition, patients may be reluctant to report new problems and instead remain at home due to risks of the virus.²⁹ Other subspecialities such as upper limb may lend themselves more naturally to virtual clinics due to the ease of access and examination.

During the pandemic, new protocols have been developed for routine wound review assessments using video consultation, through an intermediate nurse outpatient clinic to guarantee a consistent quality in video telecommunication as well as clinical care.^19,29 New methods to clinically examine the foot and ankle patient virtually, have also been reported.³¹

Other ‘virtual clinic’ literature

In the wider literature, other benefits of virtual clinics include the previously mentioned cost savings.¹² Despite concerns that virtual clinics may reduce learning opportunities for trainees, there is evidence that the extra time available to consultants as a result leads to a better learning environment that is less stressful than traditional models.³²

However, there are also concerns with virtual clinics regarding patients’ lack of internet access. In one study, 72% of patients reported having internet access, with lack of access associated with socio-economic deprivation and older age.³³ A lack of internet access, particularly in the elderly population, highlights that a traditional model is still required as a backup in conjunction with newer telemedicine models. Telephone, particularly landline, in the older population is still an important technological modality to be used for ‘virtual’ follow-up. There are also concerns that virtual clinics could lead to a rise in medicolegal cases.

Study limitations

The main limitations of this study are that it was not a true prospective study and the results are based on a clinic that was set up to cope with the new guidelines and the COVID-19 pandemic and was therefore a ‘live’ patient study. It does not represent a fully matured model for virtual clinics and is more of a snapshot taken during exceptional circumstances. Further prospective research is required to evaluate whether patient responses have changed as the pandemic lengthens and as virtual clinics have evolved. There was an element of study bias in telephoning patients directly even though this was carried out by clinicians with no conflict of interest. Finally, owing to the limited number of consultant foot and ankle surgeons within our department conducting virtual clinics, we were only able to include questionnaires from five clinicians.

Conclusion

Virtual clinics in foot and ankle surgery are an acceptable format during the pandemic. Our results suggest that virtual clinics may be more convenient for patients who reported high satisfaction levels but represent significant clinical challenges for foot and ankle surgeons. Beyond the pandemic and into the new ‘normal’ it may be acceptable that elements of virtual clinics persist, particularly in routine follow-up patients, creating a hybrid model, although not be appropriate in new referrals. Virtual clinics may be faster for the clinician. Patients and clinicians feel strongly that they would like to maintain a face-to-face format for the majority of consultations.