Video Consultation for Overseas Patients

1.      Introduction

Continuous care, especially for terminal illnesses, is essential for improving the patient’s health. The concept of teleconsultation has been proposed as a possible solution for enhancing consultation services for patients living far from the care facility. According to Deidar et al. (2016), teleconsultation refers to the use of information communication technologies to bridge the geographical gap between healthcare providers or between the healthcare provider and the patient. In an attempt to explore the efficiency of teleconsultation across international borders, I considered the position of patients in Kazakhstan and Russia seeking medical assistance from Singapore. Bridging this geographical gap using video consultations would be beneficial for both the physician and the patients (Armfield et al., 2015). A notable barrier to this alternative is cultural differences that resulted in language barriers as well as different levels of awareness and acceptance for said technologies (Legido-Quigley et al. 2014). Bali (2018) also mentions the role played by legal issues affecting the use of teleconsultation services.

1.1.Problem statement

Medical tourism is continually gaining popularity as an alternative for acquiring quality healthcare in locations that have advanced and relatively cheaper systems. In the case of patients from Kazakhstan and Russia seeking help from doctors in Singapore, the option of video consultation may help to eliminate the barrier caused by the geographical distance. However, before endorsing this option, it is necessary to find out how patients feel about this option. Breaking down the attitudes of both patients and practitioners would be a good foundation for understanding and overcoming the barriers that challenge teleconsultation.

• Research Aim

This dissertation aims to critically assess overseas patient’s experience-seeking medical care from Singapore doctors via Video Consultation media.

1.3.Research questions

The study will aim to answer the following research questions:

1. What role does video consultation play in enhancing primary health care provider to overseas patients?
2. What is the experience of doctors in Singapore concerning the provision of healthcare service to patients in Kazakhstan and Russia over Video-consultation?
3. What are the experiences of Kazakhstan and Russian patients in seeking clinical care via video-consultation?

1.4.Objectives

The objectives of the dissertation will include;

1. To understand the use and benefits of video consultations for patients separated from their physicians by vast geographical differences.

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2. To evaluate the challenges facing the use of video consultations in providing care for Kazakhstan and Russian patients by practitioners in Singapore.
3. To analyze overseas patient’s views on the effectiveness of using Video-consultation over physical clinical visits.
4. To evaluate the medical infrastructural developments in Singapore that support telemedicine and make the region a medical tourism hub.

2.      Literature Review

2.1. Remote consultation

Beavis et al. (2019) observe that the term teleconsultation is a concept under remote consultation that is meant to facilitate either diagnostics or treatment across vast geographical distances. The National Information Board (UK) (2014) supports this view and adds that the communication channels technology provides are essential avenues for revolutionizing healthcare provision. However, Greenhalgh et al. (2015) do not support this idea, noting that remote consultations come with clinical risks as well as limiting the level of accountability of the medical practitioners. Legido-Quigley et al. (2014) share Greenhalghs’s views by highlighting the lack of formality in e-consults.

2.1.1. Video consultation

In a study evaluating the quality of care given to patients with diabetes and cancer, it was observed that out of the 78 patients for whom Skype consultations were offered, those that did use the service (34 patients) reported a higher level of satisfaction and needed fewer unscheduled clinical visits (Greenhalgh et al., 2015). A follow-up study performed by Buvic, 2019, involving 228 participants confirmed the findings of the first, where the service costs were lower because fewer hospital visits were needed. Buvic et al. (2019) examine three substantial costs; implementing and running the telemedicine service, value of travel, and production losses. The study considers the case of videoconferencing and Skype for business and summarizes the expenses in the group below:

Figure 1: Graph of the cost of video conferencing and clinical visits

According to the graph, the initial cost for installing equipment and software for facilitating teleconsultation is significantly higher than that of the face-to-face consultation. This is because it requires little to no initial cost (Buvic et al., 2019). Greenhalgh et al. (2015) provide similar views, noting that the main challenge of using video consultations is that they are expensive to set up initially. Both studies agree that the incremental travel costs of physical consultations eventually overcome the cost of video consultations.

2.2.The case for medical tourism for Kazakhstan and Russian patients

Despite Russia being one of the largest and developed countries in the world, the state of its healthcare system is not quite advanced. Baybarina et al. (2016) observe that there were low preparedness in pediatric healthcare as well as ineffective diagnostic and painful treatment methods. In support of this view (Vertakova & Vlasova, 2014), observes that Russia does not invest in its healthcare as much as other developed nations do, which shows in the fact that doctors’ salaries tend to be equivalent to the nation’s minimum salary level. However, the country does have a higher ratio of doctors per 10,000 population as compared to most European countries (Vertakova & Vlasova, 2014).

Comparatively, Kazakhstan is investing significantly in its healthcare sector, intending to make it more world-class (Sharman, 2014). However, its current disease-centric medical system limits the opportunity to improve the whole industry (Sharman, 2014). Devi (2014) supports this view by observing that the country has made significant developments to enhance the treatment of some diseases like tuberculosis, despite there still needing to improve treatment for cancer. Both sources also observe that a system of specialization has dominated the country’s healthcare, thus stunting the development of public healthcare systems.

Phua (2016) observes that the rise of medical tourism is based on the need to develop better methods of improving economic development, hence its popularity in developing nations like Singapore. Both Kim et al. (2019) and McArthur (2015) support Phua’s view and add that this popularity is also increased by the cheaper cost of healthcare in developing nations. For instance, a heart bypass costs $133,000 in the US and $16,300 in Singapore (Kim et al., 2019; McArthur, 2015)

2.3.Outstanding Themes in Literature

The primary theme that resonated with all the sources was that of feasibility. In each instance, the promise of efficiency as far as video consultation is concerned was evaluated in terms of the benefits or shortcomings of using remote consultations for both the patient and the physician. The most dominant finding was that remote consultations were not only cheaper for the patient, but also time-saving and less strenuous. Some sources, including McArthur (2015), also found that they provided more flexibility for both the patient and the physician. The primary shortcoming was associated with the lack of accountability that was caused by the rather informal feel to this method of consultation.

2.4.Themes not addressed in Literature

One major theme that has the potential to affect the efficiency of video-consultations but is rarely discussed in the literature is cultural barriers. Such aspects as language and norms that tend to differ in from one culture to the other. In the case of patients from Kazakhstan and Russia seeking medical treatment in Singapore, this aspect would be of great significance concerning the impact on remote consultations. Bridging the cultural gap between the countries is crucial in improving the efficiency of video-consultations as well as enhancing both the patients’ and the practitioners’ experience.

2.5.Literature review methods

The preferred method of literature review for this study was the systemic review. According to Ferrari (2015), this approach evaluates existing information in a given field while formulating a well-defined question whose answer can be derived from assessing existing evidence on a specific topic. This approach was selected because it helps to minimize bias and follows a comprehensive plan (Uman, 2011). In doing so, it synthesizes and appraises different sources, after which a meta-analysis helps to provide a conclusion that is reflective of the details provided in these studies.

2.5.1.      Overview of Articles Found

The sources needed to select not only gave sufficient descriptions of the topic but also provided the most comprehensive and unbiased information. Thus, each source had to satisfy three criteria first before its content was evaluated and determined to be sufficient. These criteria were: Scholarly sources where each source had to be peer-reviewed, and thus suitable as a source of reliable information, relevance that demanded each source to contain information relating to remote consultation, and the different terminologies used to refer to the same and recent— all the sources that qualified for use in this study had to have been published no earlier than 2014.

After this initial screening, the sources that qualified for use would be evaluated in terms of the content they provided. While the relevance to the topic has significant weight, studies that included statistical evaluations of the topic, especially with regards to the feasibility of using remote consultations- and later video consultations- were given more precedence. Further breakdown of the sources used can be found in Table 1 in the Appendix section.

The following PRISMA diagram shows how the sources used in the meta-analysis were selected:

Figure 2: PRISMA diagram

3.      Methodology

A literature review was conducted to inform the research topic and methods.  A mixed-method approach was used.  Two groups of patients and a group of medical professionals were interviewed, and a survey was conducted on video-consultation by healthcare providers in Singapore. The groups were, three patients who received initial treatment in Singapore and commenced subsequent consultations via video-consultation, three patients who consulted doctors in Singapore only via video-consultation, 3 Singaporean doctors with experience using video-consultation and 17 participants in a survey about video-consultation in Singapore

3.1.Research design

a.      Literature review

1. Method

A systemic review was used to conduct the literature review. This option was considered since it provides an organized overview of the topic. As a result, it is easier to structure the paper according to the goals of the paper (Ferrari, 2015). The research conducted was as objective as possible to reduce instances of bias as well as ensure the study was as comprehensive as possible.

1. Sampling of sources

A predetermined criterion was used to filter the sources that would be most relevant to the study. For one, all references had to be academic, and, therefore, verified. Besides, no source would be earlier than in 2014. Later, they would be filtered further according to the suitability of the content they provided.

• Procedure

An internet search was conducted on various online databases, including Google Scholar, JSTOR, and Research Gate. The critical words sought were “teleconsultation,” “remote consultation,” “video-consultation,” “medical tourism,” “medical tourism + Singapore.” After finding no sources discussing Kazakhstan and Russian patients seeking treatment abroad, an effort was made to understand the nature of healthcare in these countries, which would be motivators for engaging medical tourism. In this regard, internet searches were done for the following key terms “healthcare in Russia” and “healthcare in Kazakhstan.” The sources were then sorted according to the criteria discussed above in the “Sampling of sources” section

1. Challenges of using a literature review

The primary problem of using this method is that the research is susceptible to the errors made by the different materials consulted. It is for this reason that this method required insights into various sources.

1. Ethical consideration

An unbiased search was conducted on sources associated with the key topics. Besides, once consulted, each source would be accredited in the study via an appropriate citation.

b.      Interview

1. Method

A survey was conducted to find out the attitudes of the patients and practitioners towards video-consultation, as is used to connect patients with practitioners across international borders.

1. Sampling of participants

Nine participants were sought for the interview. The first group of three patients were individuals who had received treatment in Singapore and then travelled back home to either Kazakhstan or Russia. The second group consisted of three patients who engaged in a video consultation with practitioners from Singapore for six months without an initial clinical visit. The third group consisted of three medical practitioners in Singapore, who had experience dealing with video-consultations.

• Procedures

A survey was conducted for patients and practitioners that engaged in video-consultation and medical tourism. Each participant would answer interview questions that targeted their experience during the exercise as well as their attitude towards this method of consultation. The practitioners would respond to question about their professional opinions on video-consultations.

The first group of participants would receive treatment in Singapore and then travel back home to either Kazakhstan or Russia. For the next six months, they would engage in video consultations with their physicians. They would then take part in the interview. The second group would interact with the physicians via video-consultation only without an initial clinical visit. The physicians answered the interview questions based on their experiences with video-consultation as well as their professional opinions on consultation practices.

1. Ethical considerations

The anonymity of the participants needed to be preserved at all times. Therefore, the interview slips would only contain indexes assigned to each participant. The primary challenge with the survey was the probability that the participants would be biased in their responses. There was no option to help avoid this bias. Therefore, the research would have to assume that every answer was truthful.

1. Shortcomings of the interview

It was challenging to evaluate the truthfulness of the patient’s responses. Therefore, the research findings had to be made under the assumption that all responses were unbiased.

c.       Survey

1. Method

A survey was also conducted in which patients 17 participants answered several survey questions on video-consultation for overseas patients.

1. Sampling of participants

The participants were chosen randomly to minimize bias. There were no specific qualifications sought before an individual could take part in the survey.

• Procedures

The participants were first informed of the purpose the survey was to play. Afterwards, they were asked questions regarding their awareness of video-consultations for overseas patients. They were also asked questions about their attitudes towards this form of consultation.

1. Ethical considerations

The participants needed to be allowed to answer the survey in their own accord and without any influence from the researcher. Furthermore, their identities were protected at all times by ensuring the survey was anonymous.

1. Challenges with the survey

There is a likelihood that some respondents would give biased responses. Furthermore, relying on responses from people who had not had any experience with video-consultations made their responses somewhat speculative, as their opinions may be quite different otherwise.

4.      Findings and discussions

4.1.Findings and analysis

i.                    Literature review findings

Buvic et al. (2019), Greenhalgh et al. (2015), Ledigo-Quigley et al. (2014), and the National Information Board (UK) (24) supports the argument that video-consultation is more convenient than repetitive clinical visits. That is especially for cases where patients are seeking help from foreign practitioners. Telemedicine can, however, not replace physical clinical visits entirely, as suggested by the National Information Board (UK) (2014). Remote consultations have their shortcomings that include the fact that they not always inspire trust. Because of that, they are used as a supplement to clinical visits as echoed by Ledigo-Quigley et al. (2014). The option to use video-consultations for Kazakhstani and Russian patients offers them an opportunity to explore the potentials of medical tourism.

McArthur (2015) considers popular medical tourism destinations, especially in developing countries, as cheaper. This option is reasonable considering that Russia’s healthcare system is not well developed, as is noted by Baybarina et al. (2016) and Vertakova & Vlasova (2014). Similarly, Kazakhstan’s healthcare system is improving but still lacking, as Devi (2014) and Sherman (2014) observe. Seeking healthcare in Singapore, which invests in making its medical tourists comfortable, according to Kim et al. (2019), can help patients from these European countries to better chances for treatment and recovery. Furthermore, such international interactions can improve relations between countries engaging in medical tourism. For the destination states, medical tourism can act as economic boosters, although such growth can come at the expense of investing in improving the efficiency of the healthcare systems meant for the local population as observed by Phua (2015).

ii.                  Interview findings and analysis

Three patients from the first group and two from the second took part in the interview. Notably, the patients seem to have different attitudes towards video consultations, which is reasonable considering that it is a relatively new practice. For individuals who have been exposed to an ordered approach to teleconsultation, the level of trust and satisfaction is quite high. This observation is especially prominent for instances where telemedicine is used alongside physical clinical visits. This view can be traced from the fact that the patients who had an initial appointment before using video-consultation subsequently all reported having higher trust and satisfaction levels while those that relied on remote consultation alone were not satisfied, as is observed in Table 1 below.

However, remote consultation does offer many conveniences as compared to clinical visits. The fact that patients do not need to use much time and effort to make consultations makes video consultations very preferable. In this regard, all the patient respondents agreed that the convenience offered by remote consultations was unarguable, as can be observed in figure 3 below. Also, in terms of comfort, the cost of the consultation is seen as a significant motivator for patients seeking to use video-consultations when pursuing treatment from foreign medical centres. This cost advantage is primarily supported by the fact that travel and accommodation costs associated with visiting international doctors for consultations are eliminated. This observation was supported by all respondents, although Patient 2 in group 2 seemed to feel that the cost of video consultations was too high, considering that the doctors could not do as much as they would during clinical visits. From a professional point of view, the need to promote patient-doctor trust is also viewed as an essential aspect to consider when engaging in video consultations. Notably, the doctor should always consider using telemedicine only when it is suitable for the patient’s treatment process. In this regard, the doctor interviewed observed that it is necessary to have an initial clinical visit to get a feel of the patient’s condition as well as build initial trust that could help promote better communication and understanding in later consultations. The doctor also noted that not all diseases could be managed using video consultations.

Figure 3: Summary of the patient’s positive reception towards video-consultation

 Table 1: Summary of the patient’s positive reception towards video-consultation

The interview findings can be evaluated from five necessary measures that determine the patient’s perception- convenience, trust, cost satisfaction, and reliability. Three patients in group one and two in group two took part in the interview. All the patients found video consultations convenient. However, only those in group one trusted online interaction. Notably, all patients in group one thought video consultations were cheaper than clinical visits, while one patient in group two thought the cost was unreasonably high since the practitioner could not do much over the video calls. In this regard, all the patients in group one we’re satisfied with the online interactions and found the approach reliable. However, patients in group two were not satisfied and did not find video-consultations reliable.

iii.                Survey findings and analysis

All 17 respondents actively answered the survey questions except for question 4, in which two participants skipped. The results revealed that only 11.76% of the respondents trusted video-recommendations by remote physicians via video-consultations. Most of them moderately trusted these consultations (70.59%), while 17.65% had little trust in them. None of the respondents distrusted this form of consultation. These findings were strange, considering that only a few of the respondents had used video-consultations (5.88%), and none was very familiar with it. Only 23.53 % were somewhat familiar with it, while 35.29% did not know of the video consultation.

It was also observed that most patients would prefer video-consultations when a tremendous geographical distance was to be covered. Thus, most patients preferred clinical visits when done locally (69.23%). In comparison, most patients would prefer video-calls (66.66%) when the doctor was in Singapore. In this regard, the inconvenience of travel, as well as the associated costs, was an excellent motivator for preferring video-consultations to clinical visits. Also, most patients, 76.47%, found video-consultations convenient and accessible when dealing with foreign doctors. Thus, it only reasonable that most patients (88.24%) of the respondents would have preferred to have a video-consultation first before flying to Singapore to seek medical consultation.

4.2.Discussions

4.2.1.      Viability of Video-consultation

Video consultation is based on the need to improve convenience, especially in the case of medical tourism (Armfield et al., 2015). This convenience is considered necessary by the patient, as is evidenced by 76.47% of the respondents in the survey deeming video-consultations accessible and convenient. All the interviewees found that the reduced need for clinical visits translated into lower costs. However, the second group of interviewees observed that trust was challenging to build trust without an initial clinical appointment. The potential for the doctor-patient trust to be lost in video-consultations makes it incapable of being a complete substitute for face-to-face consultations. This view is matched by that of Greenhalgh et al. (2015), who proposed that teleconsultation should instead be treated as alternatives that can only supplement clinical visits. Notably, most of the respondents from the survey (82.4%) were okay with starting with video-consultations. However, these observations cannot be taken to mean that they are for the idea that clinical visits should be entirely replaced by telemedicine. Physicians supporting this idea, opined that it was necessary to have an initial face-to-face visit- something that Buvic et al. (2019) also supported in their research.

4.2.2.      Patient’s attitude towards video-consultations

Patients from Russia and Kazakhstan seemed okay with the idea of video-consultation. Even without any previous interaction or awareness of telemedicine, respondents in the survey (76.47%) thought it was more accessible and convenient that clinical visits, especially for international cases. Thus, it was not surprising that participants of the survey (88.24%) preferred to have video-consultations as opposed to flying out for medical consultations in Singapore. However, the suspicion that surrounds computer technologies will always come to play when implementing them in sensitive fields like medicine, which, to some extent, overshadowed the convenience these remote consultations can provide. Legido-Quigley et al. (2014) observed that some of the theoretical interpretations surrounding video-consultations arise from the perceived lack of formality surrounding these sessions. The interview findings partially agree with this observation, with half of the patients finding them okay while the other being unsure of it, yet most participants in the survey (70.59%) had moderate trust towards it. Only by working towards building the patients’ trust in video-consultations can this technology garner enough support from the public.

For any patient-doctor relationship, the level of trust shared plays a significant role in how much the doctor’s opinions are trusted and followed by the patient. The value of this relationship, which relies significantly on how the physician and the patient communicate, is a critical factor for the success of such an initiative. Views by Legido-Quigley et al. (2014) that cultural differences could also affect the effectiveness of video-consultations seemed insignificant for the cases in the survey. The fact that none of the participants in the survey expressed complete distrust in video-consultations, despite only 5.88% having any experience with it, shows a growing tolerance for new technology. It is also worth noting that patients need close and further directions and explanations about such issues as technical terms. That would be possible only through frequent clinical visits.

Overall, the potential usability of video-consultations in medical tourism did not seem unreasonable. The survey and interviews prove that it does have its advantages. However, the patients’ and physicians’ attitudes towards it relied on how it was implemented. Not only is it convenient, but these remote consultations are also cheaper and save on time. Furthermore, they encourage international partnerships, as the physicians from Singapore have to liaise with the local practitioners to help optimize the treatment patients recovers.

5.      Conclusion and Recommendations

5.1.Conclusion

Both the survey and the interviews show that video consultation can create convenience for the patient. Therefore, it should be considered as a future alternative for clinical visits. Nonetheless, as the literature review suggests, this importance should not be misconstrued to mean that remote consultations are substitutes for clinical visits. Occasionally, some conditions would be best managed if the patient and the doctor interact face-to-face. In cases where video-consultations are used, especially in the case of medical tourism, as was shown by the Kazakhstani and Russian patients, it is necessary to build better relationships between the doctor and the patient. Furthermore, these two parties should share a deeper level of trust that ensures communication would be open, thus facilitating more accurate conclusions from the practitioner.

5.2.Recommendations

In the case of patients from Kazakhstan and Russia, seeking treatment in Singapore will come at the risk of incurring significant charges having to travel back and forth for clinical consultations. The option of video-consultation makes it such that this need for constant travel is reduced significantly. However, for this option to work, it is necessary to ensure that it appeals to both the patient and the practitioner. It is for this reason that the practitioner should try to implement effective communication techniques to not only improve the patient’s experience but also to build trust between them. An initial clinical visit is essential for building trust and deciding whether remote consultation is suitable for the patient’s condition. However, further research is needed into what factors to consider when determining whether video consultation is ideal for a given scenario.

References

Armfield, N., Bradford, M., Bradford, N., and Gentles, R. (2015). The clinical use of Skype—for which patients, with which problems and in which settings? A snapshot review of the literature. International Journal of Medical Informatics, 84(10), pp.737-742.

Bali, S., 2018. Barriers to the development of telemedicine in developing countries. [Online] Available at < https://www.intechopen.com/books/telehealth/barriers-to-development-of-telemedicine-in-developing-countries> [Accessed 21 Feb. 2020].

Barbara, E. N., Baranov, A. A., Namazoca-Baranova, L. S., Piskunova, S. G., Besedina, E. A., Sadovshikova, A. N., Yuldashev, O. R., Mukhortova, S. A., Artemova, I. A., Chernikov, V. V., Kharkin, A. V., Chistyakova, E. G., Vologdina, E. L., Kaputskaya, T. N. & Kiripova, R. F., 2016. Pediatric health quality health assessment in different regions of the Russian Federation. Annals of the Russian Academy of Medical Sciences, 71 (3).

Buvic, A., Bergamo, T., Bugger, E., Smaabrekk, A., Willsgaard T., Olsen, J. A., 2019. Cost-effectiveness of telemedicine in remote orthopaedic consultations: a randomized controlled trial. Journal of Medicine in Internet Research, 21(2).

Deidar, K., Bahaadinbeigy, K. & Mahmood, S. T., 2016. Teleconsultation and clinical decisionmaking: A systemic review. Journal of Academy of Medical Sciences of Bosnia and Herzegovina, 24(4), pp. 286-292.

Devi, S., 2014. Reforming health care in Kazakhstan, World Report, 383 (9936), pp. 2197-2198.

Ferrari, R., 2015. Writing narrative style literature reviews. Medical Writing, 24(4), pp. 230-235.

Greenhalgh, T., Vijayaraghavan, S., Wherton, J., Shaw, S., Byrne, E., Campbell-Richards, D., Bhattacharya, S., Hanson, P., Remoter, S., Guttering, S., Hopkinson, I., Collard, A. and Morris, J., 2015. Virtual online consultation: advantages and limitations (VOCAL) study. BMJ Open, 6(1).

Kim, S., Arcadia, C. & Kim, I., 2019. Critical success factors of medical tourism: The case of South Korea. International Journal of Environmental and Public Health, 16(4964).

Legido-Quigley, H., Doering, N. & McKee, M., 2014. Challenges facing teleradiology services across borders in the European Union: A qualitative study. Health Policy ad Technology, 3(3), pp. 160-166.

McArthur, B., 2015. Medical tourism development, challenges, and opportunities from Asia. Almatourism Journal of Tourism, Culture, and Territorial Development. 6(12), pp. 193-210.

National Information Board (UK) (2014). Radical health and social care changes needed, say UK report. PharmacoEconomics & Outcomes News, 711(1), pp.7-7.

Phau, K.,2015. The promotion of cross-border medical tourism in developing countries: Economic growth at the expense of healthcare system efficiency and cost containment? The Open Public Health Journal, 13(2020), pp. 98-105.

Sharman, A., 2014. A paradigm of primary health care in Kazakhstan. Central Asian Journal of Global Health, 3(1), pp. 186.

Uman, L. S., 2011. Systemic reviews and meta-analysis. Journal of Canadian Academy of Child and Adolescent Psychiatry, 20(1), pp. 57-59.

Vertakova, J., Vlasova, O., 2014. Problems and trends of Russian healthcare development. Procedia Economics and Finance, 16(2014), pp. 34-39.

Appendices

Appendix 1

Table 1: Breakdown of sources used in the literature review

Appendix 2

1. Personal Reflection

Stephen Covey’s texts (7 Habits of Highly Effective People), observes that the first step is to be proactive to increase one’s circle of influence. He writes about two things; solving (tackling) ‘areas of concerns’ concerns that include health, family, work-related problems, national, international problems, or threads (epidemic). On the other hand, in contrasts with the ‘circle of influence,’ concerns which we have, but about which we can do something, or in other words, matters which we can influence and deal with.

Moreover, Covey says that improving one’s influence requires a proactive approach, which he describes: “As human beings, we are responsible for our own lives. Our behaviour is a function of our decisions, not our conditions. We can subordinate feelings to values. We have the initiative and the responsibility to make things happen” (Covey,1989:141). However, sometimes we try to deal with the concerns that we cannot control and neglect issues that we can address individually.

To support my leadership role, I refer to the NHS leadership model identified in module1. During the research period, my substantial parts, such as connecting service, engaging the team, and accountability, improved. Moreover, all these dimensions could be linked with some aspects in section 4 (FOUR GOLDEN THREADS). For instance, I developed a better awareness of connecting different medical services, such as Technology and Creativity. At this stage, my project could combine aspects of both technologies as well as creativity as are applicable in healthcare.

Moreover, I chose to take the lead in raising awareness for the potential video-consultations have in improving the provision of medical care in the country, thus enhancing my leadership qualities. This initiative would get more people on-board the idea of using telemedicine. However, the size of the research was not sufficient to make significant claims. Regardless, the findings did have some importance within my circle of influence. I refer to Ingli’s extraordinary realistic self-image (ERSI) framework, as outlined in Megginson and Whitaker (2003), which was a beneficial exercise.

Regarding the Emotional Intelligent assessment, I worked on my self-awareness and confidence. I decided to focus on my positive thinking and self-confidence, particularly in the meeting. I used Parker Glen’s framework to be more familiar with meetings, especially when organizing the video- meetings for consultations. No doubt, the limitation of the technology, such as video-call by phones and Skype, reduced the sufficiency and professional nature of the video-consultation. In this regard, I observed that there are various areas to improve and make l vide-calls more accessible. For instance, individual apps or programs could make these remote consultations more professional.

International perspective: My work bridges patients from developing countries with healthcare providers in a developed country. At this stage, my leadership role would take different angles, such as negotiation skills, skills as a translator, as well as working according to the situation (last-minute cancellation, dealing with cultural difference expectation, time limitation). According to the Inglis framework, I am a combination of pragmatist and activist styles, which means that I learn best from real-life assignments, trying new things, and helping to develop new ideas. Therefore, my strengths help me to works promptly and sufficiently. However, as the level of trust in SG doctors was not sufficient for the new patients, I had to put significant effort into advertising them. Besides, my self-employed status prevented me from being recognized and trusted.

Patient-centred: putting patients at the centre was the most challenging part. The challenges come with the question: what is more important to promote new technology, or to put on priority patients’ preferences? Based on the results, vide-consultations seem to be used only with the experienced patient. However, with new patients, it is very uncomfortable to use them. My role as a leader was to change the patient’s perspectives to make them more accepting of it as well as educating them on the challenges of which they had to be aware of. However, whether the findings would be different if the project were extended to a more prominent coverage was not clear. My medical background played a significant role at this stage. I understand, as a leader, medical doctor, people in my country need more awareness of the efficacy, accessibility, low cost of telemedicine.

1. My performance and principal analysis according to 9 dimensions of NHS leadership model

Appendix 3

Interview questions

Written interviews

Group 1.

Patient1. Fifty-five years old, man. On 19.04.2019. He was operated on for umbilical hernia at Mount Elizabeth clinic. He was discharged on the same day. After two days, he got his consultation and went home. By the doctor’s recommendation, patients should seek consultation with local doctors.  After a few months, the patient intended to explore the second consultation by the Singapore doctor. The doctor was informed and agreed. Both sides appointed a convenient time, and the consultation was successful and satisfied by both parties.

Interviewer: How do you find the video consultation?

Patient: I find it very convenient and helpful.

Interviewer: Why do video-consultation was helpful for you?

Patient: I think yes, I find it very helpful and accessible and save much time.  One of the things which makes video-consultation comfortable is the fact that this doctor operated me, so he is more familiar with my case and body, so consequently, he will give me good advice, and I trust him.

Interviewer: Were there any difficulties in video-consultations, such as technologies, connections, quality of connections, visibility, overall satisfaction?

Patient: no, I find it very convenient, as we agreed on timing. The visual part was clear, and the connection was okay.

Interviewer: do you find video-consultation is a low-cost service?

Patient: well, I paid the same amount of money that I paid when I was in Singapore. However, I save a lot of money cos do not spend on tickets, hotels, and so on. So, yes, it costs me less.

Patient 2.  65 ye female, was operated her eye in Singapore eye surgery clinic. She had a cataract issue. This video-consultation was appointed for the different eye issues cause.

Interviewer: How do you find video-consultation?

Patient: I find it a very convenient and accessible way to get the second consultation by the doctor, who operated me without need to fly to the destination—I safe much money on it.

Interviewer: Were you comfortable with that?

Patient: yes, I do

Interviewer:  Were there any difficulties?

Patient:  Well, I feel comfortable with that because I knew this doctor and trusted her. Moreover, she is my doctor and an excellent professional. It was okay until I ask her about other health issues. My visuality becomes worse, and she said that it is not the cause of the side effects after the operation, these issues could be something else. To test it, I need to do some diagnostic analysis, either in my place or better, to revisit her.

Interviewer: Was it helpful for you?

Patient:  yes, I think her medical advice was constructive regarding my resistant case; even though with my new issues, she told me what kind of analysis I need to do. But, the fact that she couldn’t do it makes a bit sad.

Interviewer:     Do you find video-consultation is a low-cost service?

Patient: DEFINITELY, YES

Patient 3. I had done the medical check-ups and has chronic arterial hypertension. The purpose of the video-consultation was the correction of the treatment. Results. The patient was satisfied and followed the instruction.

Interviewer: How do you find video-consultation?

Patient:  In my case, I think it is very helpful and convenient. I asked the doctor a few more questions related to my issue and received the desired answer.

Group 2.

Patient 1. 45 ye female, had stomach pain for over one year. She addressed this issue to several specialists, but the pain remains. She was looking for the SG doctor and wanted to fly for medical check-ups. I suggested to her to have a video-consultation first before she flies to SG. After the conversation with the doctor, she made several analyses before planning to visit SG.

Interviewer: How do you find video-consultation?

Patient: yes, I find it very convenient. Doctor, share with me what might be the cause of my health issue and suggested doing a few analyses, which I find very helpful and sufficient.

Interviewer: Were you comfortable with that?

Patient: yes, somehow. But, to have a medical consultation by video, it seems to me very new and a bit confusing.

Interviewer:  Were there any difficulties?

Patient: Well, maybe not difficulties, just my general understanding of medical consultation, that doctor should examine you first, then ask questions, after some recommendation. But, here, he just said what I could do. I feel not fully satisfied.

Interviewer: how do you think, what was the reason for your conclusion?

Patient: maybe, cost VC was new for me, and I don’t know the doctor.

Interviewer: do you find video-consultation is a low-cost service?

Patient: in some sense, yes, it cost me not so much. However, I think, as I get not sufficient medical consultation, I found the cost is moderate.

Patient2.

26 ye. After the pelvic ultrasound, it was discovered a tumour on her ovary. The local doctor suggested an urgent operation. She uses video consultation by Singapore doctor for the alternative medical conclusion. After the conference, she was advised to do the MRI and several hormone tests first.

Interviewer: how do you find video-consultation?

Patient: yes, it is quite helpful, but don’t think it will be commonly used in our country.

Interviewer: why do you think so?

Patient: cost, it’s a new way of getting a consultation, and, for me, I wanted to have more face-to-face conversation, preferably by online, despite the fact he calms down me, and advice to do more tests before deciding to do the surgery.

Interviewer: do you find video-consultation is a low-cost service?

Patient: I think, no. It’s a bit overcast just for the vide-consult. I don’t think its proper medical consultation, even though it’s a highly recommended, qualified doctor.

Group 3

Doctor

Interviewer: How do you find video-consultation?

Doctor: it could be convenient for overseas patients to get medical consultation by foreign doctors. And this way of consultation becomes very useful.

Interviewer: How do you think, what kind of consultation should be by video- calls. Are there any limitations?

Doctor: well, I think the best option is, of course, is the second consultation, where you have a patient’s trust, familiar with his/her history, or do some medical manipulation. In these cases, video consultation worthy for both sides. However, when the case is new, there might be some problems.

Interviewer: like what?

Doctor: well, online medicine it’s kind of new for the patients, and not all feel comfortable. They think it is not efficient and very superficial.

Interviewer: so, in what manipulation will you recommend VC?

Doctor: mostly, second consultation and alternative opinion of the controversial health issues.

Appendix 4: Analysis of Survey