Patients, doctors, and videotape: a prescription for creating optimal healing environments?

Despite repeated calls for greater patient autonomy, shared decision making, and exploration of patient preferences, relatively little is known about how patients actually experience care as a face-to-face interactional process. A selected review of the literature in this area suggests that important asymmetries exist. Key among them is the tendency to report experiences from the point of view of only one member of the doctor-patient dyad. Thus, patients might report on their experiences of the system gone awry or professionals might attempt to understand the root cause(s) of an error by describing the conditions under which it occurred. Either way, information about the experience of care tends to be reported as a "my side" telling. Optimal healing environments are defined as health care contexts that are based upon mutual respect and build positive, resilient relationships among participants, using the qualities and resources of those relationships to enhance health. Understanding optimal healing environments also requires a knowledge of how doctors and patients share time and space together in the consultation (an etic or outsider perspective) and also a knowledge of the participants' experience of their time together (an emic or insider perspective). After reviewing its methodological roots, the IMPACT approach (Interactive Methodology for Preserving and Analyzing Clinical Transactions) using videotaped encounters along with independent commentaries by participants is described and applied in two different types of analyses: one in which the doctor-patient dyad is the unit of measure; the second in which physicians are stratified by having historically high or low satisfaction scores. In the latter approach, doctors' and patients' comments are compared across strata. At the dyadic level, and despite large gaps in income and social status, doctors and patients exhibit a strong tendency to cluster in terms of where they comment, so much so that in a pilot study using the approach, each stopped and commented on the videotapes at the "same" location (within an utterance of one another) 60% of the time. This finding flies in the face of traditional sociological thought, which holds that the greater the social distance between actors (doctors and patients), the more difficult it should be to communicate. With respect to being stratified by historical satisfaction scores, doctors with high historical satisfaction were found to comment more often, make fewer assumptions, take longer with their patients, and be more vigilant than doctors with historically low satisfaction scores. We conclude that videotape review is a parsimonious way of integrating face-to-face communication with the participants' lived experience of the care process, a necessary ingredient in creating optimal healing environments.