Piloting an In Situ Training Program in Video Consultations in a Gynaecological Outpatient Clinic at a University Hospital: A Qualitative Study of the Healthcare Professionals’ Perspectives

Reviewer 1:

Comments

1) You clearly state the phenomenon (i.e. a rise in VCs due to COVID-19), but what is missing is the broader technological or systemic trends pre-COVID that set the stage (e.g., digitalisation in healthcare, pre-existing telemedicine efforts).

Thank you for bringing this to our attention. We have broadened our scope in the introduction (line 38-40), added several references, and we hope you find the changes acceptable.

2) Also, more explicit framing of the problem or research gap — not just that VCs have increased, but that implementation and quality vary, and training has lagged, would have been helpful.

We have revised the introduction accordingly to your comment to further frame the research gap (line 38-42). We hope you find it satisfactory.

3) it is mentioned that 'VCs may not fit all patient groups', but it’s vague. Can you offer examples (e.g., elderly patients, non-native speakers, psychiatric patients)?

We agree upon your comment, and we have elaborated upon what patient groups might not be suitable or requiring additional support to participate in VCs (line 56-58). Hopefully, you find it acceptable.

4) In the methods section, it would have been nice to add a few details on how discrepancies in coding among the researchers were resolved, did you reflect on your biases? how was the interview guide developed? did participants have any relevant or different level of experiences with regards to VCs?

Thank you for focusing on enhancing the methods section and for these comments. We have now added additional information in the method section about the researcher coding progress and how potential bias was addressed, e.g., researcher subjectivity (line 147—152). Moreover, we have elaborated upon the development of the interview guide. Participants’ level of experiences with VCs are described in the Participant section. Our participants had no prior or only minor experience in VC before engaging in the training program (line123).

5) In the discussion, it is best to start by restating the aim of the study. Also, remember that this is a qualitative study. Therefore, phrases like 'implementing CVs is possible' or 'Telemedicine can improve healthcare in several ways.' need to be softer as these were only the thoughts of the participants, not objective data.

Thank you for raising this. As suggested, we have started the discussion section with the aim of the study (line 359-360). Moreover, we have taken attention to not generalizing results but focusing on possible ways to experience and altered the wording according to the suggestion made by you (e.g., line 364, line 366).

Reviewer 2:

General Comments
This manuscript presents a pilot qualitative study exploring the experiences of healthcare professionals (HCPs) with an in-situ training program for video consultations (VCs) in a gynecological outpatient clinic. The study is well-structured, adheres to the COREQ guidelines, and uses Braun and Clarke’s thematic analysis appropriately. It offers practical insights into VC implementation and training design. However, there are several areas where the manuscript could be strengthened.

Strengths
The in-situ training model is highly practical and relevant to clinical settings.

The study offers a well-rounded perspective by combining theoretical training, simulation, and real patient encounters.

Emphasis on both technical and patient-centered communication skills provides a comprehensive approach to VC readiness.

Thank you for commenting on your overall impression of the manuscript.

Major Concerns
1. Limited Sample Size and Diversity
The sample includes only eight participants (four doctors and four nurses) from a single institution. While appropriate for a pilot study, the limited demographic and professional diversity reduces the transferability of findings.

Future research should include a broader range of disciplines, specialties, and cultural contexts.

Thank you for bringing this to our attention. We are aware of the small sample size as this was a pilot of a newly developed training program supporting the implementation of video consultations in a hospital setting. We have now addressed the limitation concerning transferability of the study results in the Strengths and Limitations section, and further broadened the discussion of future research within implementation of video consultations (line 458-465).  We hope you find it acceptable.

2. Potential Bias
Some researchers were affiliated with the same institution, which may have introduced social desirability bias in participants’ responses.

The overwhelmingly positive perspectives on VC suggest possible underreporting of dissenting or ambivalent views. A more deliberate inclusion of negative or neutral opinions would enhance the study’s credibility.

We understand your concern regarding bias in participants’ responses. We sought to minimize this bias by ensuring researchers H.F. and C.L.L. carried out all interviews as well as the analysis, as they were not affiliated with the Department of Gynaecology and Obstetrics piloting the training program but were part of a research unit at the University.  M.M.F. and M.K.T. were first involved in the analysis in the discussion and confirmation of findings. Moreover, qualitative research also involves a conscious effort to identify data that contradicts or question prevailing interpretations or preconceptions of the researchers involved in the study. All to enhance the consistency and validity of findings.

We find that our study results go beyond describing only positive experiences and addresses both concerns of HCPs and challenges during implementation, e.g., theme 3: addressing the logistics in VCs being a challenge in clinical practice as it has to be scheduled for a specific time (line 312-314). Moreover, theme 4: HCPs addressed a need for ongoing support because VCs required new skills not learned in a day and the lack of flexibility in VCs compared to phone consultations diminishes the advantage of VCs (line 334-339). Hopefully, you will find these quotes relevant, providing a nuanced and balanced analysis of HCPs experiences, further supporting the study’s credibility.

3. Lack of Patient Perspectives
While the manuscript notes that patient experiences are reported elsewhere, their exclusion weakens the study’s ability to assess the full impact of VC implementation.

At minimum, a summary or reference to the patient-side findings would strengthen this paper’s conclusions.

The study reporting the patients’ experiences of piloting VCs in gynaecology outpatient clinic is accepted for publication 23.4.2025. Therefore, we are not able to provide a full summary or reference at this point. However, we have added a few remarks on the results from the patient article. We hope for your understanding as the publication process is still ongoing (line 84-87).

4. Limited Clinical Outcome Data
The study focuses on HCPs’ perceptions of training, but not on clinical outcomes such as patient satisfaction, consultation quality, or time efficiency.

A future study should include quantitative outcomes to evaluate the effectiveness of VCs more robustly.

Thank you for bringing this perspective into our considerations. We have revised the Strengths and Limitations section accordingly to your comment, and we hope you find it satisfactory (line 461-465)

5. Ethical and Systemic Considerations Underexplored
Ethical issues such as privacy, data security, informed consent, and patient autonomy are not sufficiently addressed.

Given that some participants expressed concerns about potential pressure from management to adopt VCs, the authors should expand discussion on organizational strategy and ethical safeguards.

This is an important comment and in particular within the field of telemedicine, where the same ethical standards apply regarding research. We have elaborated upon this in the Ethics section, and added further information upon protecting of study participants, data handling and ensuring confidentiality. We hope our revision is acceptable (line 159-171)

Minor Suggestions
Consider improving the visual presentation of the training process (e.g., a more detailed diagram or flowchart).

We have made another suggestion for visual presentation of the intervention process and training program (Figure 1 replaced with new figure 1) illustrating the flow in the intervention set-up. We hope you find it satisfactory.

The expression "Possible, but do not implement everywhere" is vague. A more academic phrasing such as “Feasible with context-dependent considerations” would be clearer.

Thank you for suggesting another phrasing of the theme, which we have revised accordingly to your comment.

Conclusion
This study offers valuable insight into the early-stage implementation of VC training in gynecological outpatient care. As a pilot, it provides a strong foundation for further research. However, broader validation is required, including:

·       Multicenter studies with diverse participants

·       Quantitative outcome measures

·       Ethical and organizational framework development

·       Integration of patient perspectives

With these enhancements, the research has the potential to significantly inform the structured rollout of VCs in specialized care

Thank you for this comment on need for a broader validation and suggestions to improve research within this field. We agree upon your comment, and we have added this in the conclusion of the manuscript. Hopefully, you will find the revision acceptable. (line 485-488), (line 489-495)

Reviewer 3:

1. This study mentioned many barriers in Introduction section, but only one sentence in the literature proves training HCPs in VC and the accompanying technical skills essential to ensure effective and valuable clinical interventions. It's not enough to support the value of your research both theoretically and practically.

Thank you for bringing our attention to this matter. We have revised the manuscript accordingly to your comment, and elaborated upon the importance of skills training in telemedicine and provided more references to support the value of our research. We hope you find it satisfactory (line 67-69).

2. There are very big problems with this research design and results:

·       Only eight healthcare professionals were selected as the sample for the study, which was a small sample size. This may lead to underrepresentation of the findings and difficulty in generalizing to a wider range of healthcare settings and populations.

We understand your concern regarding the sample size. As mentioned under reviewer 2, we have now addressed the limitations of the study’s, transferability and wider use in research in the Strengths and Limitations section (line 458-461). Moreover, the conclusion has been revised accordingly, stressing the need for a broader validation of findings and recommendations for further research in VC training. We hope that our revisions made to the manuscript will be found acceptable by you. Furthermore, as this study serves as a pilot, a total sample of eight HCPs were the amount accepted by the Departments’ management and further being the first department to pilot the newly developed training program. Still, all eligible participants agreed to participate in the study, providing us with the study sample possible. Moreover, to put things further in perspective it was only feasible to train 8 healthcare professionals at a time, as the patient flow in the Department was unchanged during the 1,5 days allocated for piloting the VC training program. We chose to train Friday afternoon, and in situ training with patients in the gynecological outpatient clinic followed the next day (Saturday). The whole set-up required careful planning with triaging of patients, invitation letters sent to patients including a digital consent form, preparation of the rooms in the clinic with screens, planning the theoretical lecture and VC training, aligning with the IT support and making sure the HCPS were updated on start and patient flow. We therefore hope for your understanding regarding the small sample size available for this pilot study.

·       The study did not set up a control group, making it impossible to directly compare the differences between trained and untrained healthcare professionals in video consultations, and difficult to determine the actual effect of the training program.

As this was a qualitative study to explore HCPs experiences of an in situ training program in VCs, an effect measurement was not applicable. We solely report HCPs experiences of the training program and the in situ training of VCs. We agree on your perspective that further research could apply a quantitative approach with a control group to determine the effect of the program versus not applying the program before conducting VCs in outpatient care.

·       The research results are mainly presented in text form, lacking intuitive presentation methods such as tables and figures. It shows that the qualitative design is relatively simple, and the analysis and induction of subjects are lacking.

We appreciate your feedback. In qualitative research using Braun & Clarke it is not usual to present the results through tables and figures. However, we have in the revision of this article added Figure 2 (presentation of themes). Now Table 1 presents the analysis process and Figure 2 presents the themes (results). We have further revised Figure 1 as a flowchart to demonstrate the progress of the pilot test. We hope you find this suitable.

4. From the practical and theoretical level, it is not enough to only explore healthcare professionals’ perspectives, or you need stronger theory and research design to justify this study’s perspective choice. Otherwise, it is recommended to add other more comprehensive perspectives, such as the perspective of patients.

Thank you for your comment on our choice of perspective. As education and training in implementation of VC is an under-researched area in healthcare that requires further attention, we had chosen to focus the analysis, interpretation and reporting on patients’ and HCPs perspectives separately. Thus, our argumentation for taking the HCPs perspective is now incorporated in the manuscript (line 78-84).

We acknowledge the importance of reporting the patients’ perspectives, which are reported in another paper, providing further knowledge and the possibility to compare the findings across the two papers. We hope our perspective and decision on reporting the perspectives of patients and HCPs separately are regarded as satisfactory by you.

5. Although the Discussion section explains the connection with the existing research, it did not state how this research makes up for the problems in the existing research. The significance of your research is not well-reflected.

We appreciate your comment, which we have discussed in the author group. We have rewritten sections of the article, and we have in the discussion section discussed the existing literature on barriers towards VC against the results of this research. We have revised the manuscript accordingly to your comment, and hope you find it satisfactory. (line 360-361), (line 378-381), (line 438-442).