Family Practice Vol. 17, No. 5, 422-427
© Oxford University Press 2000
Using video-recorded consultations for research in primary care: advantages and limitations
Department of General Practice and Primary Health Care, University of Leicester, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW, UK.
Coleman T. Using video-recorded consultations for research in primary care: advantages and limitations. Family Practice 2000; 17: 422–427.
Received 15 October 1999; Revised 29 March 2000; Accepted 16 May 2000.
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Abstract |
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 Top Abstract IntroductionHow have video-recorded...Effect on internal validityEffect on external validityInterpreting the evidenceRecommendations for researchersConclusionReferences |
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Background. Video-recording primary care consultations is an established technique for primary care research. Despite the widespread use of video-recording to help answer a variety of research questions, little is known about how this recording technique influences the findings of studies in which it is employed.
Objective. This article investigates how video-recorded consultations have been used in research and discusses how this technique may influence both the internal and external validity of studies.
Conclusion. Using video-recorded consultations for research purposes may cause bias in the characteristics of doctors and patients who agree to participate in research. There is little evidence, however, that video-recording influences the behaviour of either GPs or patients. Recommendations are made for researchers who are considering using video-recorded consultations in their research.
Keywords. Primary care, research methodology, review, videotape recordings..
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Introduction |
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TopAbstractIntroductionHow have video-recorded...Effect on internal validityEffect on external validityInterpreting the evidenceRecommendations for researchersConclusionReferences |
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Filming consultations is now an established method of recording general practice consultations, and video-recorded consultations have been used for a variety of primary care research purposes. Of all observing and recording techniques, video-recording has been recommended as the best method for researching doctor–patient communication because it captures all modalities of the interaction between participants in a consultation.1 This ability to obtain a complete record of both clinicians' and patients' consulting behaviour has enabled researchers to investigate a variety of research questions, for example how GPs detect depression and psychological distress.2–5 Being able to video-record consultations has enabled researchers to tackle research questions which were unanswerable before this technology became available. This article investigates how video-recorded consultations have been used in completed research and discusses the advantages and limitations of using this observation technique.
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How have video-recorded consultations been used? |
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TopAbstractIntroductionHow have video-recorded...Effect on internal validityEffect on external validityInterpreting the evidenceRecommendations for researchersConclusionReferences |
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A Medline search from 1966 to the present day used combinations of the MeSH terms FAMILY PRACTICE, PHYSICIAN PATIENT RELATIONS and VIDEOTAPE RECORDING to identify papers describing studies which have used video-recorded consultations. A search for these terms as text words in abstracts and additional searches of the CINANL and EMBASE databases were also conducted. Additionally, the Cochrane Database of Systematic Reviews was inspected but found to contain no data of interest. Abstracts retrieved by these strategies were scanned and those describing the use of video-recorded consultations for teaching or training in consulting skills were discarded. Papers retained for this discussion paper utilized video-recordings of ‘real’ (i.e. not simulated) patients' consultations with primary health care professionals to answer research questions. Where ‘real’ consultations were video-recorded to evaluate educational interventions or clinical competence, these papers were included. The bibliographies of papers retained for this review were inspected and, from these, any papers which appeared relevant were also obtained and considered for use. Other relevant papers known to the author but not found by the search strategy are included. The keywords describing this latter group of papers make no reference to video-recording, indicating that all papers using video-recorded consultations may be difficult to find. It follows that, despite using a systematic approach, some relevant papers may remain unidentified. Consequently, this article is best considered as a discussion paper, rather than a review. Table 1
shows how researchers (in identified papers) have used video-recordings of ‘real’ consultations in their research and suggests why researchers might have chosen to use this technology. Few researchers have attempted to assess the impact that using video-recording could have on their study results, so this is considered below.
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Effect on internal validity |
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TopAbstractIntroductionHow have video-recorded...Effect on internal validityEffect on external validityInterpreting the evidenceRecommendations for researchersConclusionReferences |
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A study with high internal validity is one in which the observed results are true and have not been influenced by bias, confounding or chance.6 Being observed may alter the behaviour of participants in research, and it is possible that doctors and patients who are video-recorded could be influenced by the presence of a video-camera to change their consulting behaviour. This is an important point: although filming consultations provides a complete record of what actually happened, the consultation participants may behave in an ‘atypical’ manner. This issue may be of most importance where researchers aim to record doctors' and patients' ‘normal’ behaviour. Researchers, therefore, need to pose the question "Does awareness of video-recording affect the behaviour of doctors or patients?"
Doctors' behaviour
Only one study has attempted to determine whether GPs' awareness of being video-recorded influences their consulting behaviour.7 Pringle et al. studied the consulting behaviour of four GPs whilst they were either aware or unaware of their consultations being video-recorded. The researchers used an objective coding schedule (called TIMER8) to divide GPs' consulting behaviour into 27 components and found no significant differences in the distribution of these behaviours between consultations where GPs were either aware or unaware of video-recording.
Pringle's study illustrates some of the difficulties involved in answering this important question. His study demonstrated that awareness of video-recording did not significantly influence the consulting behaviour of four GPs as measured by the TIMER coding schedule. However, GPs' consultations are complex doctor–patient interactions and one could devise many different coding schedules for describing the varied facets of communication that take place.9 Although TIMER describes some aspects of doctor–patient communication, there may be other qualities of the doctor–patient interaction which are important, yet remain undefined. Consequently, despite Pringle's findings, there still may be some aspects of GPs' consulting behaviours which are influenced by video-recording, and research on this question is required. This important point is developed further in the recommendations to researchers made at the end of this article. Additionally, Pringle's study investigated the effect of video-recording on only four GPs, which limits the generalizability of his findings.
Patients' behaviour
There currently is no evidence to address the question of whether awareness of video-recording influences patients' consulting behaviour. A study with a similar design to that of Pringle would be unethical as current guidelines make it clear that patients should be able to give informed consent to video-recording.10 Consequently, one cannot be entirely certain whether patients' recorded consulting behaviour is ‘typical’ of their normal consulting behaviour. Patients' views after leaving video-recorded consultations suggest that, where they consent to recording, this process is of little consequence to them11 and they are no less satisfied with their consultations than other patients.12 In one study, ~70% of patients who consented to recording agreed on a post-consultation questionnaire that they ‘forgot’ about the presence of a video-camera during their consultation, and <5% felt that their GP had dealt with them in an ‘unusual’ way.11 Encouragingly, >90% who consented to recording felt that video-recording could be a valuable research tool in general practice studies.11
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Effect on external validity |
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TopAbstractIntroductionHow have video-recorded...Effect on internal validityEffect on external validityInterpreting the evidenceRecommendations for researchersConclusionReferences |
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The degree of external validity6 (generalizability) which a study possesses determines the extent to which research findings can be applied. For example, where a study sample is representative of a larger population, the results obtained in the study sample hold for the larger population. In studies which use video-recorded consultations, external validity could be compromised if participating GPs differed from others. Additionally, if patients who consent to video-recording differ from others, this could limit the generalizability of research findings to all patients.
Effect on GPs' participation
Researchers using video-recordings of consultations generally have given scanty details about participating GPs and even less about those who decline to participate. Some GP researchers have conducted studies in their own practices,7,13,14 suggesting that participating GPs were selected because it was perceived that they were more likely to take part (a ‘convenience sample’). One Australian study15 found that GPs agreeing to video-recording were no older, no more qualified and working in no bigger practices than those who refused. This study15 also examined whether participants' and non-participants' attitudes towards their role (i.e. as a GP) differed, and found that non-participants were more likely to favour a medical system based on free enterprise and ‘fee-for-service’ remuneration. A UK study16 noted that where GPs agreed to be video-recorded for research purposes, they were more likely to work in teaching or training practices, to be members of the Royal College of General Practitioners and to have qualified as a doctor during the last 10 years.
Effect on patients' participation
Studies in which the vast majority of patients consent to video-recording are more likely to have externally valid (i.e. generalizable) study findings than those where many patients withhold consent. Most studies have reported >80% of patients consenting to video-recording. Patients' withheld consent rates, however, seem to vary with the amount of information and the number of opportunities to ‘opt out’ which are given to patients. In studies where GPs or practice staff have sought patients' consent, this has often been done verbally and immediately prior to their consultation and low rates of withheld consent have been reported,12,14,17,18 Where written consent forms have been used or patients' consent has been sought by a researcher who is not a member of practice staff and patients have had more time to consider consenting, withheld consent rates generally have been higher.5,11,19–21 The Southgate guidelines10 now require that researchers obtain written consent and give patients adequate time for consent decisions; therefore, if these guidelines are adopted, the latter range of percentages may be more representative of the withheld consent rates which would occur today.
The proportion of patients who consent to video-recording is important, but if the study sample who consent to filming are representative of the population from which they derive, then study results can still be externally valid with high withheld consent rates. However, if systematic, qualitative differences exist between patients who are video-recorded and those who withhold consent, then the external validity (i.e. generalizability) of study findings will be compromised. Martin and Martin11 suggested that patients presenting with anxiety, depression and gynaecological conditions were more likely to withhold consent than others, but, unfortunately, provided no statistical evidence to support this assertion. Their survey of patients11 who withheld consent to video-recording did, however, note that these patients were worried about confidentiality and having ‘embarrassing’ problems. Two later studies19,20 found that patients presenting with mental health problems and younger patients were more likely to withhold consent to video-recording. Additionally, in consultations where patients withheld their consent, GPs perceived them to be more distressed or embarrassed.20
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Interpreting the evidence |
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TopAbstractIntroductionHow have video-recorded...Effect on internal validityEffect on external validityInterpreting the evidenceRecommendations for researchersConclusionReferences |
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The previous sections suggest that using video-recorded consultations could have an impact on the internal validity of a study by affecting how doctors or patients behave. Also, by video-recording consultations, researchers probably restrict their access to certain groups of doctors and patients, and this can reduce the external validity of study findings. These issues require further consideration.
Internal validity
This is probably most important where researchers want to investigate the everyday behaviour of doctors or patients. Pringle's work suggests that doctors' consulting behaviour may not be affected by their awareness of video-recording,7 but researchers need to assess the relevance of this study to their own field of interest. They need to consider whether TIMER8 adequately measures the aspects of doctor–patient communication in which they are interested. Whether or not patients' behaviours are affected by recording is more difficult to judge. It is possible that patients who feel neutrally or well disposed to being recorded will not alter their behaviour as a consequence of recording, but we have no way of proving this. We are unlikely ever to be able to determine whether patients' awareness of video-recording influences their consulting behaviours because covert recording of patients is unethical.10 By following the Southgate guidelines10 and allowing patients plenty of chances to ‘opt out’ of video-recording, patients with strong negative feelings about being recorded are unlikely to consent, perhaps minimizing effects on recorded patients' consulting behaviour. Internal validity is not threatened where studies use video-recordings to assess the reliability of methods for assessing consultation competence.22,23 Here the research question is focused on the assessment method and the video-recording acts as ‘raw material’ on which multiple assessors make judgements which are compared. Also, where researchers are interested in answering questions about GPs' optimum consulting performance or best clinical behaviour, it is unlikely that awareness of recording will influence the internal validity of study findings.
External validity
Where studies hope to answer research questions which can be widely generalized, the effects of video-recording on study samples become most important. Study findings may not be generalizable to all clinicians and patients unless a research sample is representative. Research described above suggests that extrapolating study results to older GPs who are not members of the Royal College of General Practitioners, teachers, students or trainers could be most problematic.16 GPs who agree to be video-recorded for research purposes may have different attitudes to those who do not consent to recording.15 These different attitudes could be reflected by differences in their clinical practice, so that those who refuse to be video-recorded might have systematic differences in their consulting behaviour. Additionally, as younger patients and those suffering from overt mental health problems appear less likely to consent to video-recording,19,20 research findings may not be applicable to these patients. However, most of the evidence about how video-recording could influence external validity is derived from a small number of studies,15,16,19 so further work is required.
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Recommendations for researchers |
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TopAbstractIntroductionHow have video-recorded...Effect on internal validityEffect on external validityInterpreting the evidenceRecommendations for researchersConclusionReferences |
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When planning to use video-recording, researchers should give careful thought to whether this is the most appropriate data collection technique and, in particular, whether video- recording is likely to influence the behaviour of doctors or patients in a way which will jeopardize the internal validity of research findings. Additionally, thought should be given to how the use of video-recording may bias the research sample and caution should be exercized where research questions are relevant to younger patients, mental health issues or issues which could embarrass patients. Caution should also be employed where GPs' ‘normal’ clinical behaviour is the focus of research and researchers hope to generalize their research findings to all GPs.
In order to assess the advantages and limitations of video-recording consultations adequately, further data are required, and where researchers use video-recorded consultations they should:
- Report their methods of recruiting the clinicians involved and give data to compare those who agree to participate with those that do not.
- Clearly document their method of obtaining patient consent.
- Monitor the characteristics of patients who are asked to consent to video-recording and compare those who agree to recording with those who withhold consent. Researchers should monitor qualities which are important to the results of their research (e.g. pre-consultation measures of psychological distress in studies where the management of psychological illness is the focus for study19).
- Consider monitoring clinicians' behaviour to determine whether or not it is influenced by recording in any way which is relevant to the aims of their study. This could involve comparing covert recordings of clinicians with those where clinicians are aware of video-recording. Researchers could use Pringle's methodology,7 but need to select a method of describing clinicians' behaviour which is appropriate to the focus of their study.
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Conclusion |
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TopAbstractIntroductionHow have video-recorded...Effect on internal validityEffect on external validityInterpreting the evidenceRecommendations for researchersConclusionReferences |
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Video-recording of consultations has been used to help answer a variety of primary care research questions, but the use of this technique may cause bias in the characteristics of doctors and patients who participate in research. More information is required to judge objectively the advantages and limitations of video-recording, and this will become available if researchers follow the recommendations made in this article.
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Acknowledgments |
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I am grateful to Mrs M Whatley for valuable secretarial assistance, to Dr Robert K McKinley for his comments on an earlier draft of this paper, and to a conscientious and thoughtful anonymous reviewer.
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References |
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TopAbstractIntroductionHow have video-recorded...Effect on internal validityEffect on external validityInterpreting the evidenceRecommendations for researchersConclusionReferences |
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