The aim of this workstream, as stated in the original protocol, was to understand better patients’
responses to questions on communication and seeing a doctor of their choice (aim 4).
In our application we set out plans to address this by conducting interviews with 40 patients, with 20 from a white British background and 20 from an Asian background. Interviews with minority ethnic participants
were designed to contribute to our understanding of variations in patients’experience of care in these
groups, complementing our analyses of GP Patient Survey data and our experimental vignette study (seeChapters 5and6, respectively). We envisaged all interviews drawing on psychological approaches to cognitive interviewing, focusing on (1) comprehension of the question, (2) recall and assessment, (3) decision processes and (4) response processes.
We have expanded on our original design in several important ways. First, following our application, literature on the use of video elicitation interviews to stimulate recall and reflection on a medical encounter
was published and to us appeared to be of direct utility for the aims of this study.101Video elicitation
approaches, outlined in the methods section, use a series of detailed and specific prompts to enable
participants to‘relive, recall and reflect’on their recent medical consultation.101We therefore adopted this
approach in preference to that of cognitive interviewing.
Second, following discussions with practices, we were concerned that a‘one size fits all’approach to
recruiting patients to the study from both white British and South Asian backgrounds was unlikely to be sufficiently sensitive and robust. We therefore made the decision to conduct the South Asian interviews as a stand-alone study, recruiting three additional practices with a particularly large proportion of South Asian patients on their lists and using dedicated researchers fluent in South Asian languages, together with appropriate study materials. This resulted in 23 interviews specifically with patients from a Pakistani background, conducted in the language of their choice. Our analyses of these interviews identified broadly similar concerns between our South Asian sample and the sample in the main study and we report these briefly in this chapter.
Finally, we expanded our original sample size of 20 interviews with white British patients to>50, from a
variety of backgrounds (but all were fluent in English). Video elicitation interviews are challenging to conduct well and we felt that it was important to enable the research team to build up sufficient confidence and expertise to generate rich data, as well as to reach a more diverse patient population.
This chapter focuses in the main on interviews with the English-speaking population (n=52).
Methods
This strand of work was conducted alongside the quantitative study outlined inChapter 3. The recruitment
of practices, GPs and patients was, thus, the same for both. The work outlined in this chapter focuses on subsequent interviews with patients who gave consent for their consultation to be video recorded. The IMPROVE study advisory group made important contributions to study design, particularly our approach to
recruiting patients and the use of both a‘brief’and a‘full’study information sheet, and reflected on our
analysis and findings.
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Recruitment of general practices
The study was conducted in general practices in two broad geographical areas (Devon, Cornwall, Bristol and Somerset and Cambridgeshire, Bedford, Luton and North London). Practices were eligible if they (1) had more than one GP working a minimum of four sessions a week in direct clinical contact with patients and (2) had
low scores on GP–patient communication items used in the national GP Patient Survey [defined as practices
below the lower quartile for mean communication score in the 2009/10 survey, adjusted for patient case mix
(age, gender, ethnicity, self-rated health and deprivation)102]. Low-scoring practices were chosen to maximise
the chance of consultations within the practice being given low patient ratings for communication (nationally,
94% of patients score all questions addressing doctor communication during consultations as‘good’or
‘very good’in the GP Patient Survey). Some, but not all, of these practices had previously participated in our
individual GP-level patient experience survey (seeChapter 9for details).
Recruitment of patients and recording of consultations
Video recording of GP–patient consultations took place for one or two GPs at a time within each
participating practice. A member of the research team approached adult patients on their arrival in the practice to introduce the study. The patients were given a summary of the study as part of a brief information sheet, as well as a detailed full information sheet and a consent form. A member of the research team discussed these documents with each patient and sought consent to video record their
consultation. Video cameras, set up in participating GPs’consulting rooms, were controlled by the GP;
physical examinations took place behind a screen and were thus not captured on camera. Data collection ceased when we reached our required number of video-recorded consultations that patients judged to be
less than good for communication, as required for the quantitative analysis described inChapter 3. All
videos were stored on an encrypted secure server accessible only to members of the core research team. The recordings were made available to GPs for the purposes of continuing professional development. Immediately after the consultation, the patients were asked to complete a short questionnaire. This
contained items relating to GP communication that were adapted from the GP Patient Survey (Table 1),
alongside participant information including age, ethnicity and health status. Video elicitation interviews and analysis
The patient questionnaire contained a tick-box question asking patients if they were willing to participate in a face-to-face interview about their experience of the consultation. We subsequently contacted (by telephone or e-mail) those patients who expressed an interest in taking part. We aimed to interview at least one patient per participating GP. When more than one patient expressed an interest, we used a maximum variation sampling approach to reflect a mix of patient characteristics and questionnaire responses. Prior to the commencement of the study, we were particularly interested in interviewing
TABLE 1 General practitioner–patient communication items used in the patient experience survey Thinking about the consultation that took place
today, how good was the doctor at each of the following? Please put a✗in one box foreachrow
Very good Good Neither good nor poor Poor Very poor Doesn’t applya
Giving you enough time □ □ □ □ □ □
Asking about your symptoms □ □ □ □ □ □
Listening to you □ □ □ □ □ □
Explaining tests and treatments □ □ □ □ □ □
Involving you in decisions about your care □ □ □ □ □ □
Treating you with care and concern □ □ □ □ □ □
Taking your problems seriously □ □ □ □ □ □
patients who had given at least one response of‘poor’or‘very poor’in relation to a doctor’s communication skills.
We conducted video elicitation interviews with all participants (n=52). In these interviews, participants
were shown a recording of their consultation with the GP and asked specific questions relating to the
consultation and their questionnaire responses (Box 1). The video elicitation technique is an established
interview method that allows in-depth probing of experience during the interview by enabling participants
to‘relive, recall and reflect’on their recent consultation.101
The interviewers watched each consultation usually on at least two occasions before the interview and identified particular points at which they wanted to stop the recording or when they wanted to use
prompts specific to the consultation content or to the respondent’s answers on the questionnaire. During
the interview, the video recording of the consultation was shown to the participant, usually on two occasions. The participant was encouraged to stop the recording at any point to discuss a particular element of the consultation with the interviewer. The interviewer also stopped the recording as
appropriate in response to a request from the participant, or to something said by the participant, or to her own prepared notes.
The analysis followed the principles outlined by Loflandet al.103These form a series of reflexive steps
through which data are generated, coded and recoded, making particular use of memos to aid analytical thinking. Data analysis took place in two stages. The first stage occurred during data collection. A coding frame was devised from the topic guide, previous literature and early interviews. Each interviewer (JN, NL and AD) coded her own interviews in NVivo 10 software (QSR International, Warrington, UK). A number of analysis meetings were convened in which the interviewers and other members of the project team (JB, NE and JBe) discussed the data and themes. To ensure familiarisation with all of the data, the lead author (JN) listened to all interviews and read all of the transcripts. The coding frame was refined in response to discussions and as analysis progressed.
Ethics considerations
Approval for the study was obtained from the National Research Ethics Service (NRES) Committee East of
England–Hertfordshire on 11 October 2011 (reference number 11/EE/0353).
BOX 1 Video elicitation interview approach
Video elicitation interviews
Data generation focused particularly on participants’recall of and reflection on the consultation and how this was expressed in their choice of responses on the questionnaire immediately post consultation. In each
interview, the video of the consultation was used to encourage more accurate recall of specific events during the interaction. Our approach did not aim to establish the facts of what occurred, but rather explored the meaning to patients of actions that were performed in the consultation. The interview guide used was semistructured; however, we maintained a tight focus on specific moments and events captured in the recording.
Participants were asked some brief introductory questions about whether or not they had previously consulted with this doctor and whether the problem that they were consulting about was new or ongoing. Participants were then shown their consultation on the researcher’s laptop. They were encouraged to reflect as they watched the recording. Participants were also given their questionnaire responses and invited to talk through them. The recorded consultation was used as a prompt, enabling further in-depth discussion of their experiences in the consultation and their responses to the survey questions. Participants were also asked to identify behaviours in the consultation that they considered as contributing to their question responses and which could be changed to improve consulting performance.
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Results
Participant recruitment
Consultations were videoed with 45 participating GPs from 13 general practices. During the period of data collection, a total of 908 patients had face-to-face consultations with participating doctors. Of these, 167 (18.4%) were ineligible (mostly children) and 529 completed a questionnaire (71.4% response rate) (Figure 2).
Video elicitation interviews
A sample of patients whose consultation was video recorded participated in a video-elicitation interview. In total, interviews were conducted with 52 patients (35 women and 17 men) who had consulted with 34 different doctors across 12 GP surgeries in rural, urban and inner-city areas in the South West and East of England.
The interviews took place between August 2012 and July 2014, and were conducted in a location chosen
by the participant within a maximum of 4 weeks of the recorded consultation (Table 2). Researchers
preferred that interviews were not conducted at the GP surgery in case it inhibited patients in their
narrative. However, a few participants specifically requested that their interviews be held at the GP surgery.
Attended face-to-face appointment with GP taking part in study
(n = 908) Ineligible (n = 167) (including 149 children) Eligible (n = 741) Missed (n = 15) Approached (n = 726) Declined (n = 189) Agreed to participate (n = 537) No questionnaire completed (n = 8)
Communication items not answered by patient
(n = 4)
Patient completed questionnaire
(n = 529)
Patient answered communication items
(n = 525)
Patient participated in interview
(n = 52)
All of the interviews were conducted in English and lasted between 26 and 97 minutes (average 58 minutes).
The participants were aged between 19 and 96 years, with 22 (42%) aged>64 years and 30 (58%) aged
between 19 and 64 years. The participants consulted for a range of conditions, some chronic and some
minor. The names used in the following sections are not respondents’real names.
Questionnaire completion
In interviews participants were well disposed towards the process of questionnaire completion and generally keen to contribute their views. Most participants described completing the questionnaire with relative ease and as a simple task. Despite this willingness to contribute, there was little variety in questionnaire responses:
the majority of participants reported care to be‘good’or‘very good’across all seven communication items
on the questionnaire. Indeed, no respondents in our interview sample chose to score‘poor’or‘very poor’,
despite our original aspiration to focus in particular on patients who expressed dissatisfaction with their care.
Twelve respondents did, however, use the‘neither good nor poor’option in at least one domain, although
five of these also scored‘very good’on at least one other domain. As a result, in our small sample we had a
lower proportion of scores in which every domain of GP communication was judged to be‘good’or‘very
good’than in the national GP Patient Survey sample (77% in our sample vs. 94% nationally). Thus, despite
the lack of‘poor’responses, we were able to explore patients’responses in those who had expressed more
dissatisfaction than average.
Disconnect between the‘tick and the talk’
Although scores on the questionnaire were largely positive, some narratives in the interviews were more critical of aspects of GP communication. We outline three types of narrative relating to the relationship between questionnaire responses and further reflection on the consultation experience expressed during the interview.
Rewatching the consultation endorsed positive questionnaire scores
For some participants, their reflection on the consultation during the video-elicitation interview led to a repeated endorsement of the questionnaire responses they had given, and thus their narrative account was consistent with their previous evaluation of care. In all cases these responses were positive. Participants had been pleased with the quality of the consultation at the time of completion of the questionnaire. On rewatching the consultation this view was endorsed and in some cases further strengthened. Some respondents pointed to elements in the videoed consultation that had impressed them:
. . . his [GP’s] movements, his mannerisms . . . I’m asking the question, he didn’t exactly ignore me, he says no, that’s for gout. He actually explained it . . . And he’s still doing some work . . . So he’s not stopped and put all his attention on me, because if you stop doing that you probably forget what you’re doing here, so he’s done both. He’s answered my question and he’s also continued working, and that’s a good thing for me.
Colin (53151034)
High quantitative scores were followed by some criticism in interviews
Some participants scored the consultation highly on the questionnaire, yet the subsequent interview was peppered with tones of criticism about aspects of the consultation.
TABLE 2 Location of video elicitation interviews
Location Number of interviews
Participant’s home 44
GP surgery 6
Other location (chosen by participant) 2
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Criticism in the interview was often subtle, with participants often seemingly unaware of the discrepancy between their narrative and their questionnaire responses. Although they spoke of their consultation in a tone that was not particularly positive, participants remained loyal to the positive scoring they had applied on the questionnaire immediately following the consultation:
I gave it‘good’because . . . well she was listening to me, but I guess most of the time she was the one talking rather than listened to what I was saying . . . Not in a negative way, like completely, but I feel she didn’t really give me proper time to properly explain myself a little more . . . giving me a little bit more time, to explain my symptoms.
Steven (60121017)
Participant reappraises the consultation during the interview
A small group of participants who had scored their GP highly on the questionnaire underwent a process of
reappraisal of the consultation during the video-elicitation interview. They voiced criticism of the doctor’s
behaviour and proceeded to review their original score. Through the process of rewatching, participants spontaneously identified more negative aspects of the consultation that they had not been aware of previously:
Jack (55161002):I suppose you’re proving to me that I marked that wrong [taps questionnaire] [laugh] . . . Yeah, but he [GP] did, he did, he was concentrating on my leg and not worrying about the fact that the tablets were upsetting me.
Interviewer:Mm. And how did you feel?
Jack’s wife:Well, I felt the same thing. He, sort of, ignored the fact that he’d got all these side effects and all that.
Emma had scored elements of her consultation as‘very good’on the questionnaire:
. . . now I’m thinking, well no, he didn’t really sort of ask about symptoms or think, y’know, so perhaps not so good. Listening–yeah he listened but didn’t pick up on things, like you say, like the cough, he didn’t sort of pick up on erm, little things.
Emma (27131004) On occasion there was a dramatic shift in point of view when the consultation was reshown. During the rewatching of the interview, Martha began to critique more aspects of the consultation, such as the
doctor’s lack of explanations and unexpected examination:
I remember him just like, because he, because it’s quite rushed . . . you, er, can’t, you don’t, I don’t know, you’re just, it’s just like, er, er, and then, fine, I don’t know, I suppose I remember thinking why is he taking my temperature, and then just seeing how it must be OK, erm, I, I definitely remember him when he was just doing that with my, feeling my neck [slight pause] wondering what he was doing. [laughs] I just remember thinking, this is a bit weird, like why is this connected to my ear.
Martha (62111010) In a number of the interviews, therefore, there was a mismatch between the subsequent account and previous responses to questions. At times participants were happy to critique an experience during the interview, sometimes at great length, yet they had been reluctant to do so on the questionnaire.
Participants were able to explain in great detail elements of the consultation that they experienced to be negative, yet when asked to complete the questionnaire on that basis they still scored the doctor as
‘good’. The use of the video-elicitation method identified the possibility that other factors fed into the
There was, therefore, on a number of occasions, a disconnect between the‘tick’and the‘talk’: differences between the narrative given in the interview and the responses recorded previously in the questionnaires.