A qualitative study exploring the experience of viewing three‐dimensional medical images during an orthopaedic outpatient consultation from the perspective of patients, health care professionals, and lay representatives

RATIONALE, AIMS AND OBJECTIVES Three-dimensional (3D) medical images are shown to patients during clinical consultations about certain health conditions. However, little is known about patients' experience of viewing them. The aim of this qualitative study was to explore the impact of sharing 3D medical images with patients during a clinical consultation about hip surgery, from the perspective of patients, health care professionals, and lay representatives. METHOD Interviews were conducted with 14 patients who were shown their own 3D medical images during their clinical consultation and four health care professionals conducting consultations within one orthopaedic outpatient clinic. In addition to interviews, 31 lay representatives participated in six focus groups. The focus groups aimed to gain a broader understanding of the advantages and concerns of showing patients their medical images and to compare 3D and two-dimensional (2D) medical images. Interviews and focus groups were audio-recorded, transcribed verbatim, and analysed using thematic analysis. RESULTS Three themes were developed from the data: (a) the truthful image, (b) the empowering image, and (c) the unhelpful image. Focus group participants' preference for 3D or 2D images varied between conditions and groups, suggesting that the experience of viewing images may differ between individuals and conditions. CONCLUSIONS When shown to patients during an orthopaedic clinical consultation, 3D medical images may be an empowering resource. However, in this study, patients and focus group participants perceived medical images as factual and believed they could provide evidence of a diagnoses. This perception could result in overreliance in imaging tests or disregard for other forms of information.


| INTRODUCTION
Patient involvement in managing their own health and making decisions about their care is increasingly encouraged. 1 Patient activation, a measure of patient's knowledge, skill, and confidence in managing their own health, is associated with better health outcomes across all specialities. 2,3 To participate in their care, patients need to understand the information health care professionals give them. 4 Communication about surgery can be particularly challenging as surgeons must explain procedures that are technical, that are often complicated, and that may have risks and potential complications. 5 Fossum et al 6 found during orthopaedic consultations that patients had difficulty understanding what the clinician asked, said, or did. They also experienced a lack of empathy from the clinician. Pictures, 7,8 photographs, 9 and twodimensional (2D) radiological images such as ultrasound, X-ray, computed tomography (CT), and magnetic resonance imaging (MRI) images (hereafter referred to as medical images) [10][11][12] have been found to help patients understand medical information and promote behaviour change when shown to patients during clinical consultations or when accompanying medical information leaflets. However, sharing 2D medical images with patients has also resulted in false optimism 13 and anxiety. 11,14 Little, if any, research has explored the impact of sharing medical images with patients during consultations about orthopaedic surgery. However Carlin et al 11 15 This is supported by Phelps et al, 16 who found that when medical information was accompanied by a 3D image, healthy participants reported greater understanding, trust, and satisfaction compared with when there was no image. These studies suggest that 3D images might be beneficial to patients as they may aid understanding of medical information. However, patients' experience of viewing their own 3D images has not yet been studied.
Our aim was to understand patients' experiences of viewing their own 3D medical images during an orthopaedic consultation and health care professionals' experiences of sharing medical images with patients. A hip clinic specializing in femoroacetabular impingement (FAI) was used as a case study. FAI is a condition in which the shape of the hip joint is abnormal, and this can limit the range of movement that a patient can make before the acetabulum (hip joint socket) impinges with the head of the femur (ball). This can cause damage to the cartilage and labarum within the joint as well as pain during certain movements or at rest. 17 Active individuals may be more likely to suffer from FAI due to the way in which they use their hips. 18 Treatments include adjustments to lifestyle, physiotherapy, hip arthroscopy (a key hole operation to alter the shape of the bone), and total hip replacement. Six focus groups with lay representatives from local public, patient, and student groups were also conducted in order to gain a wider perspective on the advantages and concerns of sharing medical images with patients. The use of focus groups enabled us to gain feedback on a wider selection of 3D images that might not be shared with patients at present.

| METHODS
This study was conducted as part of a mixed-methods doctoral research project, which aimed to explore the impact of 3D medical images when used during a clinical consultation about orthopaedic surgery. This article presents the analysis of qualitative data collected as part of the project. The quantitative analysis from the project is published elsewhere. 16 The qualitative aspects of this project drew upon principles of phenomenology to allow an in depth understanding of the participants' individual experiences and the meaning they ascribe to them. 19,20 A hip clinic was used as a case study. We sought further clinics to study including two knee clinics and a shoulder and elbow clinic. However, the use of 3D images was less widespread than expected at the start of the project. Clinicians were interested in using 3D images and some were already using 2D X-ray images and diagrams during some consultations. In these clinics, patients tended to have CT scans after their clinic appointment, and so it would not be possible for a 3D image to be available at the time of the consultation.

| Interviews with patients and health care professionals
Patients and health care professionals were recruited from a tertiary care orthopaedic hip clinic in the UK NHS between September 2014 and June 2015. Patients attending this clinic tended to be young and active and were often diagnosed with FAI. During consultations to discuss diagnosis and treatment, medical images including 3D images were often shared with patients.

| Participants
A convenience sample of 14 patients and 4 health care professionals were interviewed. Patients aged 18 years and over, who were having a CT scan before their clinic appointment, were invited to participate.
All patients who participated in the study were shown their medical images during their consultation. Patients attending for follow-up after treatment were excluded. Potential participants were sent an information pack from the clinics consultants, which included: a letter of invitation, a participant information sheet, a reply form, and a stamped addressed envelope. Potential participants had at least 2 weeks to decide about participation. Patients who expressed interest in participating met the researcher on the day of their appointment in the clinic and had the opportunity to ask questions and discuss the study before giving informed consent to participate.
Health care professionals who conducted consultations with recruited patients were invited to participate.

| Images
During consultations, patients were often shown a selection of images, which included X-rays, MRI images, 2D CT images, and 3D images.
Three-dimensional images are generated from the digital data of CT scans. They can be rotated to view the hip from different angles. In this clinic, the 3D images showed only the bone and were used to show patients abnormalities in the shape of their bones and where the shape of the bones could be revised through surgery. An example 3D image is shown in Figure 1. Figure 2 shows an example 2D CT image.

| Data collection
Interviews were semistructured and used a brief topic guide. The Interviews with patients covered their experience of (a) their condition, (b) their consultation, and (c) viewing their medical images.
Interviews with patients were conducted face-to-face, by telephone, or via Skype depending on the patient's preference.
Interviews with health care professionals explored the use of 3D images within the clinic and with each participating patient. Interviews  with health care professionals tended to be conducted face-to-face, immediately after each clinic session in which one of their patients was participating in the study.

| Focus groups
Focus groups are used within exploratory research to elicit a collective view of a phenomenon from a group of individuals. 21 The aim of the focus groups was to gain a wider perspective on the potential impact for patients of viewing their own medical images by understanding: (a) whether there are potential advantages or concerns about sharing medical images with patients; and (b) how 3D images compare with 2D images.

| Participants
Thirty-one participants were recruited to six focus groups from two community orthopaedic patient groups, two local public groups with an interest in science, and two groups were formed of students from the University of Warwick Psychology Department. Kruger and Casey 21 recommend conducting three or four groups with a target audience. The student focus groups were conducted first, allowing the materials to be piloted. They did not generate rich data, so a further four groups were conducted. Groups included four to eight participants. Small groups were selected as they have been argued to allow for greater discussion and diversity of opinions as participants may have more confidence to disagree with one another, enable quieter participants to speak up, and prevent one participant becoming too dominant. 22 Participants were recruited by email for four of the six groups, and the other two groups were recruited at regular group meetings. These groups were selected to achieve variation in characteristics of the focus group participants. Students were selected, as they are a similar population to those who may experience FAI along with orthopaedic injuries. Orthopaedic patient groups were made up of patients with different orthopaedic conditions to the patients seen within the clinic but who may be shown or be interested to see their own medical images in the future. Two local public groups were also included to access the views of potential patients who may not have a specific focus on orthopaedics.

| Data collection
During the focus groups, participants were shown a selection of anonymized 2D and 3D images. They were first shown orthopaedic images specifically 2D and 3D images of FAI, avascular necrosis (AN), and a hip fracture. Then they were shown 2D and 3D images of soft tissues, specifically images that did or could present gastrointestinal cancers. This included a 2D image and a 3D image that presented liver cancer and a 3D virtual colonoscopy, which showed no pathology but was used to present how bowel cancer could be presented in the image. For each condition, participants were shown 2D and 3D images and were provided with an explanation of the images and the condition (eg, the symptoms a patient with this condition may experience and possible treatments). Materials for the focus groups were prepared with assistance from a Consultant Radiologist .

| Data analysis
Nvivo 10.0 was used to manage the data. Interview and focus group data were initially analysed seperately. Interview data were analysed using thematic analysis as described by Clarke et al. 23 This method included familiarizing oneself with the data and coding the data inductively line-by-line based on meaning. Semantic and latent codes were derived from the data, and coding was an iterative process with new codes added and existing codes developed as more data were added.
Codes were compared and organnized into groups to develop catergories. Themes were developed by exploring the categories indepth and by comparing within and across transcripts. Categories and themes were revised and defined through discussion. E.E.P. coded the data and codes; categories and themes were discussed and examined by E.E.P. and F.G. throughout analysis.
Multiple methods were used to analyse the focus group data.
First, each group's preference for 2D or 3D images for the four clinical conditions was quantified. Qualitative analysis used both inductive and deductive coding. 23 This involved: (a) searching the data for sentences or paragraphs relating to the initial codes developed from the interview data to check for similarities and differences, and then (b) coding the data inductively using thematic analysis.
In order to develop and refine the initial themes and categories developed from the interview data, the two data sets were combined.
Categories developed from the interview data were compared and developed with categories from the focus group data. This aided the development of conceptual themes, which are evident in both data sets.
Several strategies were adopted to ensure rigour and transparency.  immediately after their consultation, and two patients were interviewed face-to-face 13 and 20 days later (one in their own home and one when they returned to hospital for treatment). Five patient interviews were conducted over the telephone or skype up to 7 days after their consultation.

| Health care professionals
Four health care professionals were interviewed. One was a physiotherapist and three were doctors who were nearing completion of their specialist training in orthopaedics. All were male. Interviews with health care professionals were conducted face-to-face immediately after the clinic session, where possible. In two cases, this was not possible, with one interview conducted 2 weeks after the consultation and the other completed in writing within 3 days of the consultation.

| Focus groups
Thirty-one individuals participated in six focus groups. This included 12 students, 9 participants from community patient groups, and 10 participants recruited from local groups with an interest in science.
Focus group participant characteristics are included in Table 1. Six participants spoke about their own experience of viewing their medical images or their relatives' images during the focus groups.  Table 2 presents the three themes with descriptions and categories.

| The truthful image
Patients and participants spoke of "the truthful image." They perceived the images as evidence that they could trust but there were concerns from focus group participants that this perception could result in an overuse of imaging.
The image as evidence Focus group participants explained that by viewing their image, patients would know that their clinicians have quality information and that their condition is being looked at properly. They explained that "it's (the image) also a demonstration that they know precisely what's wrong and where rather than saying we think we have got the problem" (FG3) and that they might question "how do you know exactly?" (FG3) if they had not seen an image.
Furthermore, one group explain that the image allows patients to "to see it with your own eyes and not having the doctor put a spin on it" (FG2). This suggests a belief that health care professionals may intentionally mislead patients and that the image can in some way prevent or challenge this.

Overuse of imaging
One focus group were concerned about the potential for overuse of imaging and the high levels of ionizing radiation required to produce 3D images arguing that "if people became aware that pictures of your insides can be taken they may choose to disregard the radiation aspect" (FG4) and ask for more CT scans.
There was also concern that health care professionals might request more imaging tests for patients if they believed that sharing images with patients might make them appear more patient friendly.

| The empowering image
Viewing their own 3D image could be empowering for patients, helping them to make sense of their condition, giving them confidence in the decision they made about treatment, and helping them to move forward.

Making sense
Viewing their own 3D images helped the majority of patients to make sense of their condition. The images helped patients to understand and visualize why they were experiencing certain symptoms.

Moving forward
For patients who were shown a 3D image that depicted an abnormality during their consultation, the experience was "brilliant" (Patient 14) and "fascinating" (Patient 1). Viewing their image could help patients Focus group participants felt that viewing their image could be comforting for patients as they may feel "relieved there was a reason for your pain" (FG6) and could help them to accept their limitations such as limitations to daily activities and move on.

| The unhelpful image
At times, the use of images might be unhelpful to patients. They could cause distress or inadvertently disempower patients. It was not always clear to health care professionals when the image was helpful or not as health care professionals at times underestimated the impact of the image for patients.
For a minority of patients, the image could cause distress. One patient felt more anxious after viewing their image and the extent of their abnormality and questioned "whether it is better to be in the dark about that or not" (Patient 10). Another patient hypothesized that their image may have made them more anxious should their condition have been more serious.
Focus group participants believed that while viewing images of bones might be a helpful experience for some patients, there might be a difference in emotional impact between viewing images of orthopaedic conditions and other conditions. The question whether viewing images of cancer or viewing images when there was no curative treatment available example may evoke a sense of vulnerability or have a long lasting impact: would patients say "I keep waking up and seeing that picture?" (FG3).

Focus group participants' responses when viewing the images
suggest that some orthopaedic images may also be distressing for patients to view. A 3D image depicting AN was described as frightening and upsetting by some participants, with one participant explaining that "I think that some probably would be distressed to see that-it has a cancerous look about it"(FG3). Another participant said they would feel disheartened to see the image of AN. This image was described as "horrendous" (FG5), "terrible" (FG6), and "revolting" (FG6) in comparison to the 3D image of FAI, which was described as fantastic" (FG6) and "amazing" (FG6).

Disempowering patients
Medical images were not considered helpful in all contexts and there were circumstances in which they could disempower patients. One patient found his 3D image unhelpful as there was no known abnormality and nothing to see in the image.
Three focus groups discussed the use of medical images to persuade patients to have a recommended treatment and participants tended to support this use. Participants spoke of the image making patients' condition more real and frightening them into reality. Using the image to pressure and evoke fear in patients even if it led them to have a recommended treatment could be disempowering. One group described feeling "nervous about it (the image) being used as a shock tactic" (FG4), which they felt was "brow-beating the patient" (FG4) if they do not follow the suggested treatment.
Three focus groups believed patients should decide if they wish to view their images and emphasized the importance of respecting patient's wishes. However, one group argued doctors have a duty to explain medical conditions to patients in a way that they understand and an image may be needed to achieve this.
I think the healthcare professional has some sort of duty to make sure they understand… so the mere fact that someone says "I don't want to know" isn't necessarily the end of the consultation… and pictures might help (FG3).

Underestimating the impact
At times, health care professionals underestimated the impact of the image, identifying a concern, such as the size of the abnormality or quality of the image, which they felt could make the 3D image less helpful to patients.   This study highlighted the importance of considering the context in which the images are shown. We found that for some conditions, 3D images were considered "amazing" by lay representatives, whereas for others they provoked fear or concern and were described as "hor- Patients and lay representatives perceived 3D images as evidence. This perception has been previously described by Joyce 26,27 who examined the depiction of MRI (the technology and the images)

| Strengths and limitations
Qualitative data collection methods were used to allow participants to describe their experience and views in their own words. Interviews with patients and health care professionals provided two accounts of the consultation from both parties participating in the interaction. Gaining feedback from six focus groups with lay representatives allowed corroboration of ideas. As participants volunteered to participate, there may be a degree of self-selection bias, with participants more interested in viewing medical images potentially more likely to participate.

| Future research
This study focused on consultations about hip surgery. As the impact for patients of viewing their own 3D images may differ depending on the nature and severity of the condition, future research should explore the impact of sharing 3D medical images with patients in different clinical contexts. Furthermore, investigating the impact of viewing 3D images during a consultation on health outcomes such as patient activation should be considered.

| CONCLUSIONS
When presented alongside a diagnosis about hip problems, 3D images may be an empowering resource for patients. They could help patients to make sense of their condition, which may enable patients to participate in shared decision making and be more involved in their care. Patients trust 3D images, with some patients considering them to be evidence of the information they are given. This could increase their confidence in their diagnosis, treatment, and health care professional. However, as medical images are susceptible to interpretation errors, health care professionals should be careful when communicating with 3D images to avoid presenting them as certain. Furthermore, in some contexts, viewing an image might be unhelpful or distressing. Before sharing images with patients, health care professionals should consider whether the use of images is appropriate for their patients and consider seeking consent from patients first.