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Video Elicitation and the Study of Doctor-Patient Interactions:

Poor Acting and Mixed Reviews

Candidate: Rachel Evans

Module Tutor: Professor David Clarke

Module: C83 PAD

Degree: BSc Psychology (International Study),

University of Nottingham

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Contents

1. Introduction

2. Doctor-Patient Interactions

2.1. The Nature of DPI

2.2. Why Study DPI?

2.3. Approaches to the Study of DPI

3. Video Elicitation

3.1. History

3.2. Principles

3.3. Methodology and Recommendations for those Conducting VE Studies

3.4. Further Considerations for those Using VE to study DPI

3.5. Limitations of the Suggested Approach

3.5.1. context is disregarded.

3.5.2. data quality.

3.5.3. practical issues.

3.5.4. ethical issues.

4. Conclusion

5. References

Abbreviations

DPI= doctor-patient interaction

SDM= shared decision making

VE= video-elicitation

Word count= 3 946

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1. Introduction

Improving patient satisfaction and health outcomes is understandably a priority for

health care organisations. As medical consultations constitute a large proportion of patient

contact with health care providers, improving the effectiveness of doctor-patient

interactions (DPI) can make a valuable contribution to achieving this aim (Ogden et al.,

2004). However, the DPI is the result of complex interpersonal processes, which can be

understood on multiple levels (Saba et al., 2006). As such, a special Issue of Patient and

Education Counselling (Volume 83, Issue 3, 2011) discusses the need to apply integrative

approaches to enable a deeper understanding of interaction in health care settings. In

keeping, the current paper explores the use of video elicitation ([VE] also termed video-

stimulated-recall) as a method to collect behavioural data (i.e. a video of the DPI) to be

analysed by an observer, as well as subjective reports from participants in the DPI (Henry &

Fetters, 2012). Moreover, although data is collected in a qualitative format it may be

analysed by quantitative methods. These possibilities mean that VE has face validity as a

useful approach for investigating what makes an effective DPI. Nevertheless, caveats to the

application of VE to study DPI are also noted.

2. Doctor Patient Interactions

2.1. The Nature of DPI

For the purposes of this paper DPI will be regarded as face-to-face interactions

between a patient and a single health care provider, be this their local GP, a specialist

doctor (e.g. oncologist), or surgeon etc. In these circumstances there is a mutual influence

between individuals (Melbourne et al., 2011). This may be shown between speech turns, for

example, question-and-answer sequences. Although, cross-contingency may also be shown

over the whole consultation, for example, how the patient’s presentation of their symptoms

influences the questions that the doctor asks to try and determine the diagnosis (Connor,

Fletcher, & Salmon, 2009). Interpersonal processes within DPI are clear from anecdotal

experience (Rao et al., 2010). But stronger evidence from statistical sequence analysis and

micro- analysis of doctor-patient verbal communication confirms the reciprocal nature of

DPI (Bensing, Verheul, Jansen, & Langewitz, 2010; Eide, Quera, Graugaard, & Finset, 2004;

Heritage & Maynard, 2006).

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However, the medical consultation involves more than verbal communication.

Whilst important functions of the DPI can be achieved by verbal means, such as information

exchange and medical decision making, these processes also involve non-verbal cues and

subjective experiences (Pawlikowska, Zhang, Griffiths, van Dalen, & van der Vleuten, 2012;

Zimmerman, Del Piccolo, & Finset, 2007). This can be seen in research which shows that

patients can experience task-focused behaviour, such as bio-medical information provision

by doctors, as caring and relationship building (Young, Ward, Forsey, Gravenhorst, &

Salmon, 2011). This highlights the inter-subjective nature of DPI and development of the

therapeutic interpersonal relationship between doctors and patient (Radley, 1994).

Moreover, it also demonstrates that behaviour can be multidimensional, with the doctor’s

information giving utterance in the example above serving both instrumental and socio-

emotional functions. The complex nature of DPI, therefore, has implications for how DPI

should be studied.

2.2. Why Study DPI?

It is important to investigate DPI because how these individuals interact can impact

upon the course and outcomes of the medical consultation in a positive or negative manner

(Ong, de Haes, Hoos & Lammes, 1995). For example, unvoiced patient concerns can give rise

to misunderstandings, incorrect diagnoses and poor patient satisfaction (Bensing et al.,

2010). As a result researchers are interested in what constitutes an effective DPI and how

this can be promoted in medical practice. In contrast to the ‘authoritarian doctor’

perspective prominent before the 1990’s (Marks, Murray, Evans, & Estacio, 2011), which

assumed that the doctor held power over the consultation, many researchers and policy

makers now emphasise the importance of ‘patient-centred’ care and ‘shared decision

making’ (SDM; Hall, 2003; Kaba & Sooriakumaran, 2007). This means that doctors should

aim to create a therapeutic relationship with the patient based on mutual trust and patient

involvement in treatment decision making (Mead & Bowers, 2000). However, training

programmes to improve doctor communication and shared decision making have produced

observable improvements in patient-centred behaviours that have not been mirrored in the

views of patients towards the interaction (Davis et al., 2003; Rogers, Kenny, Nelson &

Robinson, 2005). Together with evidence that doctors and patients often have different

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views of the same interactions (Kenny et al., 2010; Young et al., 2011), this suggests that

further research is necessary to uncover what makes a successful DPI.

2.3. Approaches to the Study of DPI

Research surrounding DPI has differed in its epistemological underpinning (Salmon,

Mendick & Young, 2011). Two distinctions have been made, based on the source of

knowledge and the format of data collected (see Table 1). Firstly, researchers often choose

between self-reports from those involved in the interaction (emic) or an observer’s (etic)

classification of the event (Saba et al., 2006). For example, a post-consultation questionnaire

completed by a patient, versus, analysis of a video-recorded DPI by a researcher. Secondly,

data has been collected in a quantitative (i.e. number-based) or qualitative (i.e. language-

based) format (Neumann, Kreps & Visser, 2011). For example, analysis of a video-recorded

interaction by counting the number of utterances in a coding category, versus, identification

of the main themes within the DPI reported as a written description.

Historically these approaches have been applied independently (Bryman, 2006; Zoppi &

Epstein, 2002). However, this limits the conclusions that can be drawn from the study. It has

already been shown (in sections 2.1. and 2.2.) that self-reports of the DPI from the doctor

and patient do not always agree with each other or with etic classifications (e.g. Kenny et

al., 2010; Saba et al., 2006; Young et al., 2011). Researchers approaching the study of DPI

from only one perspective would, therefore, fail to collect important data, which may have

important theoretical and practical implications. This suggests that multiple data sources

and formats should be used within the same study to generate comprehensive data.

Table 1. Approaches to the study of doctor patient interactions, varying in terms of the data

source and format of data collection.

Source Format

Self-report Observer

Quantitative E.g. questionnaire, with likert-type scale (i.e. not written answers)

E.g. coding utterances from a video of a DPI and counting the number in each category

Qualitative E.g. interview with open questions to allow participants to talk about DPI

E.g. analysis of the main themes within a video of a DPI, reported as a written description

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3. VIDEO ELICITATION

3.1. History

VE entails the use of a video-recording to stimulate recall, reliving, and reflection on

the recorded interaction by those involved (Henry & Fetters, 2012). The use of VE in

research studies was inspired by the work of Norman Kagan and colleagues on a skill

development programme for therapists, known as the Interpersonal Process Recall Method

(Kagan & Kagan, 1990; Kagan, Schauble, Resnikof, Danish, & Krathwohl, 1969). This

programme makes use of a video-recording of a recent therapy session to aid recall and

stimulate discussion. The therapist, with the help of a supervisor, views the recording and

tries to recall covert thoughts experienced at the time of the interaction. In addition, cues

expressed by the client that indicate they may have unvoiced thoughts are also identified

from the video. This is intended to aid communication and the development of better

therapeutic relationships (Larsen, Flesaker, & Stege, 2008). However, VE procedures have

been adapted by researchers to enable the exploration of participants’ views on the

interaction and other data that is not explicitly captured within the video-recording.

3.2. Principles

Henry and Fetters (2012) highlight that VE studies have traditionally taken a

qualitative approach and adhered to five basic principles (Green and Britten, 1998). Firstly,

data is collected from naturalistic settings (i.e. everyday contexts, such as a doctor’s surgery)

rather than experimental, laboratory based contexts. Secondly, data should be interpreted

with reference to the meaning that participants bring to and take away from the interaction.

Thirdly, studies should focus on the social processes within communication, for example,

how the meaning of symptoms is created by the doctor and patients (Puustinen, 1999).

Fourthly, there is acknowledgement of the reciprocal influence between participants, which

is fundamental in face-to-face interactions. Lastly, researchers take a relativist stance, which

respects the perspectives of all participants involved. Within the context of medical

communication this means that the view of the doctor is not regarded as superior to that of

that patient. The philosophy underlying VE is, therefore, beneficial for the study of DPI as it

is congruent with current formulations of the nature of DPI (see section 2.1).

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3.3. Methodology and Recommendations for Those Conducting VE Studies

Although aspects of VE methodology are flexible, it necessarily involves video-

recording of participants involved in an interaction, followed by VE-interviews with one or

all of the participants. These interviews are then analysed based on qualitative principles

(explained in section 3.2.). Allowing participants to view the video-recorded interaction

throughout the interview is believed to facilitate recall, producing a more detailed report

than using a standard/ non-stimulated interview (Larsen et al., 2008). However, further

extensions to the basic methodology, including etic analysis of video-recordings, mean that

VE is an appropriate method to explore what makes an effective DPI. These adaptations will

be discussed within the four step VE-methodology-framework proposed by Henry & Fetters

(2012), an adapted version of which is shown in Table 2.

Table 2. Methodology for video elicitation studies. Adapted from Henry & Fetters (2012)

Step Key concepts

1 Conceptualising a video elicitation study Choose a research question Decide on the scope of data collection

2 Participants and sampling Determine the unit of analysis and sampling frame

3 Data collection and management Protocol for recording Elicitation interview structure Protocol for data storage

4 Data analysis Integrate data from video-records and interview data

Method for analysing data

At step one, the researcher should chose a research question and decide on the

scope of data collection. As VE interviewing and subsequent data analysis is a lengthy

process, Henry and Fetters (2012) stress that researchers should only use this method when

suitable data cannot be collected by a different method. It has already been identified that

VE would be appropriate to answer questions regarding what makes an effective DPI, such

as “how the communication behaviour of SDM is related to patients’ and physicians’

subjective experience of partnership” (Saba et al., 2006, p. 55). Although not demanded by

VE methodology, researchers should seek to interview both the doctor and patient to

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enable subsequent data triangulation. This may be important to highlight instances in which

the doctors’ and patients’ views on the effectiveness of the DPI are discordant.

Step two requires researchers to consider the participants and sampling frame. A

representative sample of participants is desirable to increase external validity (i.e. the

extent to which the results are generalisable beyond the participants in the study).

However, this would require a large sample size, which is often unachievable due to the cost

and time involved in VE studies (Henry & Fetters, 2012). Therefore, selective sampling of

participants based on characteristics of interest (e.g. women in the early stages of breast

cancer [O’Brien et al., 2008]), may be more appropriate. In addition, researchers are

required to specify the unit of analysis in step two. It has already been recommended above

that VE interviews with the doctor and patient should form two units of analysis. A further

unit is the video-recording itself. Etic classification of the video-recording is beneficial as it

enables the comparison of the objective behaviour and subjective feelings of participants

regarding the effectiveness of the interaction (Kasper, Heesen, Köpke, Fulcher & Geiger,

2011; Melbourne et al., 2011). Moreover, since it has been identified that within DPI

individuals show multidimensional behaviour (see section 2.1), the capture of participants’

verbal and non-verbal behaviour within the interaction, as well as their impressions of these

behaviours is particularly important.

The third step involves data collection. This begins with the recording of the DPI in

video format. In order to stimulate recall and discussion within the VE interview the

recording should be of a good quality and capture the behaviour of both the doctor and

patient. As a result researchers should give consideration to the video-recording equipment

used and how this is positioned within the room (Haw & Hadfield, 2011). How the videos

will be used within the VE interview is also worthy of consideration because interview

structure, interviewer skills, and question formats have the ability to shape the resulting

data (Larsen et al., 2008). For example, interviews may be conducted on the whole video-

recording or on pre-selected segments of interest. These interviews may also take a range of

formats. The most popular is semi-structured, in which the researcher is free to select

questions to elicit information on the unexpressed thoughts and beliefs of the participant

(see Figure 1 for example questions). Usually the interviewer and participant can choose to

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Can you tell me more about how you felt at this point?

Were there any other thoughts going through your mind?

What were your impressions of the physician’s/patient’s actions at this point?

What do you notice about your actions at this point?

How much pressure did you feel under making this decision?

Figure 1. Questions that could be used in a video elicitation-interview. Adapted from Henry

& Fetters 2012

stop the video and comment on important elements (Larsen et al., 2008). However, in some

cases researchers may feel it is necessary to conduct multiple interviews with the same

participant to allow for spontaneous comments and more narrow and focused questioning

(Arborelius & Timpka, 1990; Cromarty, 1996). It is recommended that variation in VE

interview procedure should be tailored to the research question and expertise of the

researchers (Marks et al., 2011). Consequently, the current paper has highlighted multiple

strategies for data collection, but does not a make a judgement about their objective value.

The final step is data analysis. If researchers have followed the recommendations

within this paper they will be required to analyse and integrate three sources of data; video-

recordings, doctor-interviews and patient-interviews. Nowak (2011) recognised that there

is no ‘gold-standard’, or even standardised procedure for the integration of data from

multiple sources. This means that researchers will need to consider a range of strategies.

Within the research literature there are three main approaches to integration of video and

interview data. Approach one involves editing the interview over the video-recording prior

to analysis (e.g. Frankel & Beckman, 1982), which may be beneficial when timing of

comments is regarded as important. However, generation of a single data source in this way

would not be possible when both the doctor and patient have been interviewed. In this case

researchers may choose from the remaining approaches. A second approach uses a single

group of researchers working concurrently with all sources to build a comprehensive picture

of the interaction (e.g. Young et al., 2011). This is an iterative process, which involves

repeated viewing and switching of sources. A caveat of this approach, however, is the

tendency to prioritise data from a single source, which may bias the results. The final

approach is analysis of individual data sources by different sub-groups of researchers

followed by integration of the findings (e.g. Saba et al., 2006). In practice, researchers may

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adapt these approaches or generate a novel integration strategy (Neumann et al., 2011).

Therefore, comprehensive reporting of methodology is of vital importance.

3.4. Further Considerations for Those Using VE to Study DPI

Two further questions are raised as a result of the extensions to VE studies proposed

in section 3.3 and the application of VE to investigate what makes DPI effective. How should

the DPI video-recording be analysed? And is it necessary to measure clinical outcomes?

The analysis of video-recordings has been approached from both a qualitative and

quantitative perspective. Although VE studies have traditionally taken a qualitative

approach to the analysis of interviews there is no reason that this should restrict the

methods used to analyse the video-recording of the DPI. Qualitative approaches, such as

conversation analysis or thematic analysis (see Howitt & Cramer, 2008) provide a detailed

account of the nature of the DPI, including micro-analytic structure and social construction

of meaning (Peräkylä, 2004). In contrast, quantitative approaches commonly use a coding

scheme to classify units of behaviour into pre-selected categories (e.g. Bales, 1950; Ford,

Hall, Ratcliffe & Fallowfield, 2000; Roter & Larson, 2002). The frequency of each code may

then be extracted. Behaviours of interest can be investigated by combining codes that

measure the construct. For example patient-centeredness has been indexed by features

such as discussion of family medical history, patient question asking and physician enquiry

about the results of ongoing treatment (Bertakis & Azari, 2011). This approach assumes that

meaning is inherent to actions. The relative advantages of these systems and the philosophy

on which they are based have been widely debated, with no method the outright winner

(e.g. Heritage & Maynard, 2006; Peräkylä, 2004; Sandvik et al., 2002). Therefore,

researchers are free to make an informed decision as to which method of video-analysis to

use.

It is also important to consider the inclusion of clinical outcome measures in VE

studies, for example, treatment adherence, improvement in symptoms or quality of life.

This will allow researchers to assess the effectiveness of DPI on improving patients’ health,

which is arguably one of the main objectives of the medical consultation (Hugman, 2009).

For example, Saba et al. (2006) used VE to explore SDM. In keeping with the

recommendations above, the researchers developed a quantitative coding scheme to

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identify SDM within the video-recorded DPI interaction and analysed doctor and patient VE-

interviews for main themes and experiences of partnership. The data from etic and emic

perspectives was integrated in a 2x2 matrix (see Table 3). This revealed that in 59% of cases

there was incongruence between the observer perspective and at least one participants’

perspective i.e. it looked good when it did not feel good (simulated engagement), or vice

versa (assumed engagement). However, Saba et al. did not examine clinical outcomes,

which meant that no conclusions could be drawn as to whether SDM behaviour or the

feeling of SDM was differentially linked to health outcomes. Such a conclusion would be

desirable if research findings are to inform health care policies and medical training

programmes (Neumann et al., 2011).

Table 3. Engagement in shared decision making. Adapted from Saba et al. (2006)

Subjective experience of SDM and partnership

Positive/collaborative Negative/non-collaborative

SDM as

measured by

video coding

Present Full engagement

(22%)

Simulated engagement

(38%)

Absent Assumed engagement

(21%)

Nonengagement

(19%)

3.4. Limitations of the Suggested Approach

3.4.1. context is disregarded.

VE studies do not take into account the wider context in which the video-recorded

DPI interaction occurs. The use of videos enables the capture of the diachronic interaction

processes in real time (Haw & Hadfield, 2011). However, the bounds of the video are narrow

then compared to the ongoing process in which the DPI is situated. As such, the DPI is

influenced by individual, societal and organisational factors, which are not explicitly

captured in the video (Kreps, 2011). Researchers are likely to explore individual factors

during VE interviews, for example what the illness means to the patient and how it

influences their life (Adams, Pill & Jones, 1997). However, wider contextual issues are less

likely to be presented or investigated in a systematic manner. For example, the impact of

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limited consultation length on patient-centred care (Mead & Bowers, 2000; Ogden et al.,

2004) or the influence of gender norms on patients’ presentation of concerns (Kaba &

Sooriakumaran, 2007). Puustein (1999) argues that the variability between DPI cannot be

explained without reference to the context in which it occurs. Therefore, despite the use of

multiple data sources and formats of data analysis, VE studies may still not fully capture the

nature of DPI.

3.4.2. data quality.

The use of a video-recording to stimulate recall of a recent DPI may lead to a more

detailed and accurate description than achieved by a standard interview because cues

displayed in the video can help to trigger memories (Elliot, 1986; Henry & Fetters, 2012).

This is particularly important as individuals may have poor memory and meta-cognitive

skills, meaning they are likely to forget or misremember events under free recall conditions

(Nisbett & Wilson, 1977). However, despite this advantage of VE, researchers should be

cautious that interview reports consist of reconstructed memories and may contain

inaccuracies and deliberate or unconscious biases (Hertwig, Fanselow & Hoffrage, 2003). For

example, patients may not be comfortable expressing negative views about their doctor in

VE interviews (i.e. social desirability bias; Kazdin, 2003) or hindsight bias (Fischoff, 2007)

may mean that the patients’ knowledge of the results of their decision may influence how

they recall their involvement in decision making.

Also worthy of consideration is Henry and Fetters’ (2012) warning that the self-

selected sample of participants may introduce a systematic bias into the results. It has been

suggested that doctors and patients who volunteer to let researchers record their medical

consultation may differ from those who do not. For example, patients with mental health

problems or ‘embarrassing’ conditions may be less likely to consent to video-recording

(Coleman & Manku-Scott, 1998). As informed consent is necessary before video-recording

DPI (see section 3.4.4.) researchers cannot avoid this potential bias. However, they should

acknowledge this and interpret their results accordingly.

In addition, questions have been raised as to whether knowledge that the

interaction is being recorded influences the behaviour of the participants. This is a problem

because it would reduce the internal validity of the data collected (Coleman, 2000). Through

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analysis of video-taped consultations between 14 oncologists and 45 patients, Penner et al.

(2007) discovered few camera-related behaviours (e.g. looking at the camera or speaking

about the camera). Consistent with previous research (Hargreaves & Peppiatt, 2001; Martin

& Martin, 1984), participants in Penner et al.’s study reported that they forgot they were

being recorded. In further support, evidence shows that the clinical routine of doctors are

not significantly different when the participants are aware that they are being filmed and

when they were unaware; participants spent the same amount of time on 26/27 tasks

(Pringle and Stewart-Evans, 1990). This can be taken as evidence that doctor and patient

behaviour is not greatly affected by video-recording of the medical interaction.

Nevertheless, these studies only measured camera related behaviour and time on task, thus

limiting the conclusions that can be drawn about the influence of video-recording on the

content and social processes within DPI overall.

3.4.3. practical issues.

Despite the rich data generated from VE studies, practical issues relating to time,

data handling, equipment, and cost may prevent such research from being conducted. VE

interviews should be carried out as soon as possible after the DPI has taken place (Lyle,

2003). However, doctors’ busy schedules often prevent this. Moreover, VE interviews are

time consuming to conduct. For example, Larsen et al. (2008) report that it is common for a

50 minute long interaction to result in VE-interviews lasting for two-to-three hours. Analysis

of videos and interview is likely to take at least twice as long. With three data sources to

analyse, the study will require a substantial time commitment from researchers and

participants. Moreover, a single case generates huge amounts of data, which must be

systematically stored and analysed. This problem is exacerbated as there is no standardised

procedure.

Equipment is also important in VE studies. As has been noted in section 3. 3, the

video-recording should be high-quality and capture the behaviour of both participants to

provide participants with many cues to stimulate recall. But this is not always achieved in

practice (Haw & Hadfield, 2011). Researchers should also make provisions for the possibility

of equipment failure, such as noise within the video-recording or digital analysis software

crashing. Overall, these practical issues mean that the VE studies would be financially

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costly. Nevertheless, the potential of such studies to gain an insight into the nature of an

effective DPI is a good incentive for researchers to overcome these practical limitations.

3.4.4. ethical issues.

Any research study will need to gain ethical approval before it commences.

However, those conducting VE studies may need to pay special attention to three issues

highlighted within the British Psychological Society, Code of Ethics and Conduct (Ethics

Committee of the British Psychological Society, 2009). Firstly, informed consent. This means

that researchers should ensure that individuals understand the purpose and possible

consequences of their participation. All participants must then agree to take part in the

research. It is also desirable for researchers to request permission to use DPI-videos and VE

interviews in secondary analyses, medical training, and conferences (Roberts, 2010). This

will extend the utility of the data and can enable researchers to answer new questions using

existing data sources. Secondly, video-recordings are hard to de-identify, causing the

potential for issues regarding privacy. This may be addressed to some extent by storing

videos in a secure location, separate from the participant’s details (Henry & Fetters, 2012).

Lastly, the content of medical consultations may be upsetting or embarrassing for

participants to discuss in VE interviews, for example, those involving treatment for a

terminal illness. Thus, interviewers should approach these topics sensitively and honour

their responsibility not to cause participants distress.

4. Conclusion

VE studies offer the opportunity to study multiple perspectives on the DPI, which

may be integrated to form a rich data source. Given the complex nature of dyadic, face-to-

face interactions in medical settings, integrative research is often required (Neumann et al.,

2011). Nevertheless, the benefits of VE must be weighed against the practical issues

surrounding such research, resulting from the wealth of data to be collected and analysed.

When interpreting the data researchers should also consider the impact of contextual

factors and the quality of the information obtained from VE interviews.

Furthermore, the ideas presented in this paper raise the question of what is an

effective DPI? It has been explored that this question may be answered from the

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perspective of an observer, the doctor, the patient, or based on clinical outcomes. In

addition, this paper has proposed a research methodology to be conducted in pursuit of

discovering the ‘perfect’ DPI, which satisfies on all accounts. However, research using VE

methodology suggests that disparity is more common than convergence of these

perspectives (Saba et al., 2006). Moreover, there does not appear to be a systematic link

from objective or subjective features of the DPI to consequences of the interaction

(Silverman, 1987; Young et al., 2011). This may be because contextual factors not identified

through application of the VE methodology can influence how participants approach the DPI

and respond to their partner, and thus the outcomes. As a result, it would be a philosophical

question as to which perspective should be regarded as the most important. However,

adoption of this idea would negate the need for multiple approaches since only one would

be of value.

Irrespective of the difficulties in exploring the nature of DPI, VE can make a valuable

contribution to research, psychological theory and medical practice. VE provides an

opportunity for the development of integrative approaches in research, which has been

recognised as important for the progression of science (Neumann et al., 2011). The findings

of research may also be used to inform existing theoretical approaches to the study of

health care communication and DPI (e.g. Rao et al., 2010). Importantly, it can be used to

support the move from the uni-dimensional, ‘authoritarian doctor’ perspective to one in

which the behaviour of both the patient and doctor are seen as integral to the medical

consultation and its outcomes (Marks et al., 2011). Research findings may also be translated

into recommendations for medical training and policies.

It is doubtful that application of VE methodology will reveal the screenplay for the

‘perfect’ DPI. However, VE studies have highlighted the complex, multi-dimensional and

inter-subjective nature of DPI interactions. This finding is important in itself, but has also

influenced health care research and practice, with changes implemented to increase the

effectiveness of DPI.

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