Background
High-quality communication is an essential requirement for physicians when conducting medical consultations. It enables physicians, for example, to adequately provide information to, and gather information from, patients [
1]. The growing interest in research investigating how to optimize medical communication is therefore not surprising. However, solid evidence on how physicians’ communication impacts patient outcomes, such as satisfaction or information recall, is still scarce. This may be because causal relationships between specific aspects of communication and outcomes are difficult to prove in actual medical practice, as these relations are influenced by many (confounding) variables. To overcome this barrier and provide solid evidence, an experimental video-vignettes design can be used.
A video-vignettes design requires the development of multiple (brief) videos of a scripted medical consultation [
2]. The key to this design is standardization: the communication, medical content, and appearance of the environment and the characters are kept exactly identical across videos except for the communication elements of interest. By varying, i.e. manipulating, specific verbal or non-verbal communication elements across conditions while keeping the remainder constant, we can study the effectiveness of specific elements in physicians’ communication. The video vignettes are viewed by study participants, who can be either disease-naive (‘healthy’) individuals or patients with a medical history regarding the disease in the video vignette. These so-called analogue patients are instructed to imagine themselves being in the shoes of the patient in the video. Consequently, (analogue) patient outcomes can be easily assessed without needing to manipulate or intrude on actual medical consultations.
Previous research has indicated that analogue patients can be validly used as proxies to actual patients to evaluate physicians’ communication behavior [
3,
4]. However, a prerequisite to the ecological validity of the video-vignettes design, i.e., the extent to which the act of watching a video vignette as an analogue patient resembles a patient’s experience in actual medical practice, is that analogue patients sufficiently engage in the video. Video engagement is a multidimensional construct which can be defined as the degree to which analogue patients view the video attentively, submerse in the video vignette’s story, identify with the video patient, and experience empathy and emotions [
5]. The level of analogue patients’ engagement is likely to depend on how the videos are developed. Many methodological variations are possible, yet little empirical data is available on the potential consequences of such variations on (analogue) patient outcomes [
2,
6].
Two of the most salient methodological issues with regard to the video-vignettes design are how the video vignettes are introduced and which focus is used to show the medical consultation. Because these two issues may crucially influence analogue patients’ engagement when viewing video vignettes, they are the focus of the current study. An introduction to the video vignette can be added to familiarize analogue patients to the setting and the characters, inform analogue patients about the video patient’s situation, instruct, and/or engage analogue patients. Various introduction formats may be used. For example, the researcher could show a written introduction on paper or a (computer) screen or provide an audiovisual introduction, i.e., showing video images with a neutral voice-over or a videotaped scene in which the patient introduces his−/herself [
2]. Likewise, several variations are possible when considering camera focus. Since the physician’s communication is under investigation in most video-vignette studies [
2,
6], it is essential for analogue patients to be able to observe the communication behavior of the physician depicted in the video vignette. The focus on the physician in the video vignette is thus a logical consequence, which can be effectuated by using camera shot types facing the physician, such as (medium) close-ups of the physician, or over-the-shoulder-of-the-patient shots. Alternatively, to enable analogue patients to better observe the (natural course of the) interaction between the physician and the patient, one could decide to incorporate camera shots depicting the patient’s communication behavior (as well) [
2]. Broadly considered, two choices are therefore available with regard to camera focus, i.e., to focus on the physician only, or to alternate camera focus between the physician and the patient. Furthermore, in case of the latter, the amount of time and the specific moments that the patient is shown can be varied and might influence analogue patients’ engagement with the video vignette.
Although no evidence exists regarding the effects of introduction format or camera focus on video-vignette engagement, some hypotheses can be put forward based on literature from other fields. With regard to introduction format, engagement might be highest when stimulating multiple sensory modalities [
7]. An audiovisual introduction is therefore expected to have the strongest engagement-inducing effect when compared to an introduction provided only visually, such as a written introduction. With regard to camera focus, alternating between the physician and the patient might increase attentional engagement as a mere result of analogue patients’ responding to novelty or change, i.e., the so-called orienting response [
8]. Furthermore, research suggests that observing another person’s emotional expressions stimulates feelings of emotional empathy through mirror neuron activity [
9], and it is known that emotional faces attract more attention than neutral faces [
10]. This indicates that focusing on the video patient specifically when expressing emotions can enhance emotional and attentional engagement even more.
The aim of this study was to systematically investigate the effects of introduction format and camera focus on analogue patients’ video engagement. Firstly, analogue patients’ engagement was expected to be the strongest when watching a video vignette with an audiovisual introduction, when compared to a written introduction. Secondly, alternating the camera focus between the physician and the video patient was expected to cause a higher level of engagement, as compared to a physician-only variant. More specifically, alternating the camera focus depicting the video patient’s emotional expressions, was expected to cause higher levels of engagement than an alternating variant that focusses on the patient at relatively neutral moments, and a physician-only variant. Thirdly, combining an audiovisual introduction and alternating camera focus depicting the patient’s emotional expressions, was expected to induce the highest levels of engagement.
Discussion
Video-vignette studies are imperative for the systematic investigation of physician-patient communication. Results of this experimental study indicate that methodological choices with regard to video-vignette development can influence the ecological validity of video vignettes. First, how the video vignettes are introduced mattered: analogue patients showed stronger
emotional engagement in response to an audiovisual introduction, showing the patient in the hospital’s waiting area while the story was introduced by a voice-over, as compared to a written introduction displayed on a computer screen. In particular, the audiovisual introduction caused a stronger cardiovascular response in analogue patients while viewing the video-vignette introduction. This effect was sustained during the subsequent watching of the medical consultation. Second, alternating camera focus between the physician and the patient, specifically depicting the patient’s emotions, caused the strongest
emotional engagement in analogue patients, as reflected by their electrodermal response to the vignette. Alternating camera focus between the physician and the patient, depicting the patient at relatively neutral moments in the consultation, did not enhance engagement compared to showing only the physician, indicating that the effect on emotional engagement was indeed a result of showing the patient’s emotional facial expressions. Third, no effects were found on analogue patients’ self-reported engagement, with only one exception; an interaction effect of introduction format and camera focus was found on analogue patients’ self-reported
emotional engagement. Focusing only on the physician during the consultation resulted in lower levels of emotional engagement when combined with the audiovisual introduction, as compared to the written introduction. This may indicate that analogue patients’ emotional engagement is disrupted by not showing the video patient during the video-vignette consultation if the video patient has been audio-visually introduced first. Fourth, exploratory analyses showed that the perceived realism of the video patient was influenced by the variation in camera focus. Findings suggest that analogue patients need to see, and not only hear, the patient during the video-vignette consultation, in particular at emotional moments, to perceive the patient and his/her behavior as realistic. Summarizing, our findings imply that an audiovisual video-vignette introduction combined with a camera focus on patient’s emotional expressions during the video-vignette consultation results in the highest levels of
emotional engagement in analogue patients. The magnitude of effects found on analogue patients’ emotional engagement, in particular on the psychophysiological measures (which were medium effects), were comparable to the effects of analogue patients’ age [
12], and physician’s trust-conveying [
22] or affective [
23] communication, as shown in previous video-vignette studies. This underscores the significance of current findings. This evidence may inform methodological decisions during the development of video vignettes, thereby enhancing the ecological validity of future video-vignettes studies.
The current findings correspond with previous research showing an increase in electrodermal activity and blood pressure in response to video clips in which the characters express emotions, such as sadness and fearfulness [
24]. This increase in physiological activity is most often interpreted as emotional arousal, but other psychological processes, such as attention can also lead to changes in physiological activity [
11,
14]. To establish whether these effects signify emotional arousal or attention, results for self-reported engagement can be examined. However, in this study no direct effects of introduction format and camera focus were found on self-reported engagement. Nevertheless, the interaction effect on self-reported emotional, and not attentional, engagement implies that the increase in physiological activity may be best interpreted as reflecting analogue patients’ emotional engagement. Moreover, these results indicate that neither analogue patients’ identification with the video patient, nor their attention to, and immersion in the video vignette, are influenced by introduction format or camera focus. Other methodological considerations, such as video duration, age of analogue patients [
12] or the casting of actors, might be more relevant to these dimensions of engagement, and should be investigated in future research.
Patient emotions are an inherent part of most medical consultations and therefore inducing emotional engagement, including emotions, in analogue patients is desirable. Based on the current findings, we would thus advise to enhance analogue patients’ emotional engagement by introducing the video vignette audio-visually and by alternating camera focus, depicting the video patient’s emotions. Nevertheless, this rationale requires some qualification. First, inducing particularly strong emotions may be less desirable for research in which emotions might distract analogue patients from the task at hand, e.g., the evaluation of the physicians’ information provision [
2]. The current results indicate that limiting emotional engagement is feasible if necessary for specific study purposes, without heavily impacting other dimensions of engagement. Second, analogue patients may be steered or biased towards experiencing particular emotions as a consequence of observing the emotional response of the video patient. Focusing on the video patient’s emotional expressions might therefore not
always be the best option. Researchers who do not want to show the patient at all during the video-vignette consultation should consider using a written introduction instead of an audiovisual introduction. Alternating camera focus between physician and patient showing the patient at relatively neutral moments during the medical interaction might be a suitable alternative as well.
A strength of the current study is its combined use of a multidimensional self-reported measure of engagement and physiological measures indicating emotional engagement. Previous research using video vignettes has shown limited overlap between these measures [
12], which underscores their unique value. The current results suggest that the psychophysiological measures may have been more sensitive to the effects of variations in the methodological aspects under investigation. Furthermore, the use of psychophysiological measures enabled disentangling the effects of the methodological variations in specific phases of the video vignette. A limitation of these psychophysiological measures is their lack of specificity in meaning. The effects on electrodermal and cardiovascular measures in this study indicate increased involvement of the sympathetic, and/or the withdrawal of the parasympathetic branches of the autonomic nervous system [
11]. As emotional and attentional processes activate the same bodily systems, this may signify either emotion or attention or both [
8]. At present, psychophysiological measures are most often used to indicate emotional arousal [
25], without differentiating between emotions. However, in a review by Kreibig, it is argued that the emotional arousal response is more differentiated, with specific patterns of peripheral physiological activation in response to different emotions [
14]. The differential effects found in this study, i.e., introduction format affecting cardiovascular but not electrodermal activity, and camera focus influencing electrodermal but not cardiovascular activity, may therefore indicate that introduction format and camera focus may affect different emotions. The current state of evidence is however not sufficient to further speculate on this matter and future research into this area is thus warranted. Another limitation regards our sample of analogue patients. Although our student sample enabled the recruitment of a large number of analogue patients and restricted the (possible) confounding influence of variables such as experience with disease or medical consultations, this sample strategy limits the generalizability of our results. For example, older individuals’ engagement is on average stronger [
12], and therefore a more heterogeneously aged sample might enhance variability in engagement levels and make it more likely to find effects. Furthermore, this study compared the effects of two introduction formats and three camera focus variants, because these variations were often used in video-vignette studies [
2] and/or were expected to affect engagement differently. However, other variations in introduction and camera focus are possible, e.g., a read out loud introduction by the researcher [
26], and should be investigated in future research.