Video Elicitation Interviews: A Qualitative Research Method for Investigating Physician-Patient Interactions

We appreciate the researchers who took the time and effort to respond and add to our article on video elicitation interviews. We agree with professor Carney that methods related to video elicitation interviews have long been used in medical education. However we know of only a few efforts to publish evaluations of these methods.(1, 2) An important challenge for medical educators using video elicitation techniques will be to develop standardized methods that can be implemented and evaluated across multiple training programs in ways that will allow researchers to investigate whether these techniques lead to better educational or patient -centered outcomes.

Professor Step alludes to the value of video elicitation as an educational or "coaching" technique and also highlights the theoretical differences between self-report measures and data from direct observation. Both types of approaches provide useful information that can be valid for different kinds of research questions. We agree with professor Step that video elicitation interviews are one method with the potential to bridge the gap between these two different perspectives. We did not discuss analysis of nonverbal communication in our article and certainly agree with Professor Step that analyzing nonverbal communication requires a special set of skills. However, we do think that the basic method of video elicitation interviews could be adapted to investigate not only verbal but also nonverbal patient-physician communication.

Finally, we appreciate Professor Saba's detailed and quite thoughtful commentary on video elicitation interviews, which benefits from his first- hand experience with the method. We second his call for additional studies to better understand the strengths and limitations of this method and to develop more nuanced methodological standards. We hope our article will inspire communication researchers to work out how video elicitation interviews can be used to measure and promote patient- and relationship- centered outcomes. In addition, all three commentators have alluded to two mundane but universal challenges that researchers face when using this method: First, how can researchers use modern technology to conduct video elicitation interviews efficiently, reliably, and in ways that respect patient confidentiality? Second, how can researchers navigate the significant regulatory barriers inherent in collecting video-recorded data while maintaining ability to share data (which is often publicly funded) and collaborate across institutions?

1. Markakis KM, Beckman HB, Suchman AL, Frankel RM. The path to professionalism: Cultivating humanistic values and attitudes in residency training. Acad Med. 2000;75:141-50.

2. Edwards A, Tzelepis A, Klingbeil C, et al. Fifteen years of a videotape review program for internal medicine and medicine-pediatrics residents. Acad Med. 1996;71:744-8.

Competing interests:   None declared

Henry and Fetters have written a comprehensive paper on the use of video elicitation interviews.1 We have used this type of interview to investigate treatment decision making in early stage breast cancer and found this research method to be feasible and useful.2,3

In our study, we videotaped the initial consultations of women with early stage breast cancer and their medical oncologist or surgeon. One to two weeks later, we interviewed patients and physicians (separately) while they watched their own consultation on a digital video disk (DVD). We found that this method provided information that would not have been obtained by relying on a researcher's view of a videotaped consultation. During the video-elicited interviews, patients sometimes expressed views that they did not share with the physician during the consultation, highlighting the importance of obtaining the patients' perspectives. For example, while watching the video recording of an oncology consultation, the patient expressed concerns about treatment and the oncologist appeared to address them. However, when asked for her views about that segment of the consultation, the patient told the interviewer that she did not want further treatment and did not think that the oncologist had taken her concerns seriously.

As Henry and Fetters point out, the video-elicited interview method is not without its limitations. We agree that it is important for researchers to choose the most appropriate method to answer the research question. In our study we had presumed that treatment decision making would occur during the surgical or medical oncology consultation.2 However, during pilot testing, we found that patients described one or more stages of treatment decision making as taking place at home prior to or following the consultation with the physician. We adapted our interview guide to capture these decision making experiences and to contextualize decision making that did take place during the medical encounter.

We agree with Henry and Fetters' assertion that it may be difficult to distinguish among comments made by participants that are recollections, reliving, or reflection. In our study, participants were interviewed one to two weeks after the consultation. It is possible that participants could have included comments pertaining to post consultation decision making processes during the interview.4 Future studies of video-elicited interviews should consider the nature of the participant's comments during the interview and whether it is possible to disentangle comments that recall, relive or reflect upon events that occurred during the encounter.

References 1. Henry SG, Fetters MD. Video elicitation interviews: a qualitative research method for investigating physician-patient interactions. Ann Fam Med 2012;10:118-125.

2. O'Brien MA, Ellis PM, Whelan TJ, Charles C, Gafni A, Lovrics P, Mukherjee SD, Hodgson N. Physician-related facilitators and barriers to patient involvement in treatment decision making in women with early stage breast cancer: perspectives from physicians and patients. Health Expect 2011 Sep 16. doi:10.1111/j.1369-7625.2011.00712.x.

3. O'Brien MA, Whelan TJ, Charles C, Ellis PM, Gafni A, Lovrics P, Hasler A, Dimitry S. Women's perceptions of their treatment decision- making about breast cancer treatment. Patient Educ Couns. 2008 Dec;73(3):431-6. Epub 2008 Aug 28.

4. Feldman-Stewart D, Brundage MD, Van Manen L, Svenson O. Patient- focused decision-making in early-stage prostate cancer: insights from a cognitively based decision aid. Health Expect 2004;7:126-41

Competing interests:   None declared

Anyone who has ever taken a public speaking course in the video age has experienced the cringe that accompanies viewing a recorded version of one's own speech. As public speaking teachers know, reliving a communication act can provide strong motivation to improve performance, as well as reveal the speaker's motives, decisions, and emotions during the speech. This issue of AFM offers an article by Henry and Fetters documenting a similar methodological procedure for studying the inner-life of communicators in healthcare interactions.

During my undergraduate and graduate training in social science communication, self reported data via self-administered surveys and questionnaires (usually from students!) was the standard mode of data collection. It was indeed quick, and enabled large sample sizes efficiently. However, upon taking up postdoctoral studies in a medical research institution I encountered a very different approach to studying communication. Here the standard observational methods were more akin to linguistics and rhetorical discourse than the social psychological perspective I was steeped in. It struck me that each mode of study lacked the information (provided by the other) necessary to construct the most valid depiction of human communication process. So I learned how to observe communication via the multitude of coding schemes that dice and slice interaction whichever way you like it, though not necessarily the way the interactants thought of it. Currently available observational coding schemes offer rich descriptions of communication process as well as the ability to model it, or link to outcomes. Video elicitation interviews provide a way to link those same observable communication behaviors with real time, person-centered, social cognition.

As the authors continually remind, the video elicitation is not without its challenges. It should be reiterated that this method, as presented, does not necessarily lend itself as a means of studying nonverbal behavior. Though video elicitation interviews can be valuable in addressing questions regarding nonverbal behavior, the intricacies and assumptions inherent to that field require more tailored methods. Additionally, the challenge to de-identifying data in a healthcare setting is significant. As the authors point out, some IRBs are not prepared to accommodate these methods and may need additional orientation and assurances before signing off. In which case, this article will be an invaluable tool for offering a well conceptualized plan.

If communication is about sharing meaning, then new methods are needed to access meaning held and constructed in interaction. Meta- perceptions of another's behavior drive communication just as much (if not more) than the concrete reasons or tasks that define encounters. It is a great step forward to invite the interactants into the observer's space to compare notes. This article provides an incredibly detailed template for how to do just that.

Competing interests:   None declared

When video-recording was introduced into family medicine in the 1970's, few of us had seen ourselves projected onto a screen except perhaps during the requisite viewings of home movies at family gatherings. What a different world we live in now. Any of us with a smartphone can casually videotape ourselves and moments later post it to a social networking site for viewing by others who can then comment and engage us in dialogue.

Initially, explaining to clinicians and patients the value of recording their interaction took a leap of faith. The value of the new technology had to outweigh the costs of intrusion, loss of privacy, and the installation of expensive microphones, video cameras, and televisions.

Yet a confluence of forces has made the timing of Henry and Fetters (1) excellent article on video elicitation interviews absolutely perfect. More people are comfortable being videotaped, physicians and patients increasingly recognize the value in exploring the real interactions that occur in medical encounters, qualitative research has gained respect as a valid method of scientific inquiry, and the technology of recording in clinic has become easier and more affordable.

Henry and Fetters argue persuasively for the value of video elicitation interviewing as a legitimate clinical research methodology. Revealing the nascent state of the art, their review of the baker's dozen of extant studies using video elicitation highlights both the potential areas for application and the problems that emerge from the current inconsistency in the field. The interweaving of their own and others' experiences yields very helpful, specific guidelines for study design, the crafting of questions, and the limitations of the methodology. They have mapped an uncharted territory, capturing both its potential riches and risks.

What emerges from their work is that the power of a video elicitation interview comes, in large part, from its fundamental relationship-centered approach. First, it allows us to peek inside the relationship among a participant's thoughts, emotions and behaviors and how they work together in our decision-making. This methodology is particularly well-equipped in accessing what Polanyi identifies as tacit knowledge--an individual's guiding beliefs, assumptions and values that often remain in one's periphery, unknown to others and often unknown to themselves unless prompted (2). As participants watch themselves acting in a real situation captured on the video, the verbal and nonverbal stimuli helps ground them and seems to allow a qualitatively richer set of responses than are often obtained in surveys or more general interviews.

Second, this particular elicitation method also requires the very quick, but meaningful, formation of a face-to face human relationship, in part because the sharing of tacit knowledge requires a level of trust between people. Ensuring the confidentiality of the elicitation interview remains key so that both physicians and patients can feel comfortable to discuss aspects of their experience they may not otherwise disclose. As with any relationship, certain rules, roles and boundaries must be clarified in order to function effectively. Since during the interviews, unplanned disclosures of thoughts and emotions may emerge, interviewers should be prepared for how best to handle the intensity and intimacy of the elicitation experience.

Finally, the method requires interviewers to be mindful of the relationship among their own thoughts, feelings and behaviors that operate during the inquiry. Anchoring, or the cognitive tendency to focus on one point of information, can occur during video elicitation not only for the participants, but also for interviewers. An early comment can become the lens that through which both interviewer and participant begin to see all the following stimuli that emerges from the video. As Henry and Fetters rightly note, the training of the interviewer is essential.

Because of its grounding in this web of intra- and interpersonal relationships, video elicitation provides important and qualitatively different information from many other more established sources (e.g., survey questionnaires, direct observation). However, while it is often rich and engaging, we should be careful not to conclude that it represents a more accurate view of reality than the data gained from these other methods; it simply provides a different perspective.

Although understudied and therefore underutilized, video elicitation interviewing clearly needs to face the rigorous methodological inquiry that will help establish its validity and reliability. Henry and Fetters not only identify many potential research issues, but their comprehensive treatment of the methodology will no doubt naturally trigger many more, such as: * How does the timing of the elicitation interview following the clinical encounter affect the data one obtains (e.g., immediately after, one week)? * What could we learn from sequential elicitation interviews following the same patient-physician dyad over several clinical encounters? * Is there any research value in having the physician and patient participate together in a video elicitation interview?

Participants' first reaction to watching themselves on videotape often is "Do I really sound and look like that?" In that moment, the participant confronts themselves and what they have done. The video elicitation interview takes provides a vehicle of this powerful awareness by crafting a context of multiple relationships that can be safely explored--within the participant, within the interviewer and between the two. In that nexus, rich and multilayered information emerges. For this reason, the video elicitation interview is well-suited for the scientific inquiry into the physician-patient interaction. Henry and Fetters have given us an operation manual and an invitation to take a methodology that is relationship-centered and uses technology we have been familiar with for over forty years. It is up to us to push play and begin the inquiry.

References 1. Henry SG, Fetters MD. Video elicitation interviews: a qualitative research method for investigating physician-patient interactions. Ann of Fam Med 2012:10; 118-125. 2. Polanyi, M. The tacit dimension. New York: Doubleday & Co, 1967.

Competing interests:   None declared