Sampling for qualitative research using quantitative methods. 2. Characteristics of GPs who agree to videotaping

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1 Family Practice Oxford University Press 1996 Vol. 13, No. 6 Printed in Great Britain Sampling for qualitative research using quantitative methods. 2. Characteristics of GPs who agree to videotaping of consultations Tim Coleman Coleman T. Sampling for qualitative research using quantitative methods. 2. Characteristics of GPs who agree to video-taping of consultations. Family Practice 1996; 13: Background and objectives. Studies using video-recordings of GPs' consultations have been important in investigating GPs' clinical behaviour. Unfortunately, the characteristics of participating GPs are rarely described, making it difficult to assess how representative they are or how generalizable the studies' results can be. This paper documents the recruitment of 53 GPs to a research project which involved video-recording their consultations to determine how GPs approach the topic of smoking cessation with patients. Methods. The Attitudes to Smoking Advice Questionnaire was used to select GPs with diverse attitudes towards discussing smoking with patients. Results. Out of 123 GPs who were eligible to take part, 53 (43.1 %) agreed. GPs who agreed to become research subjects were younger, more likely to work in teaching or training practices and more likely to be current members of the RCGP. Conclusions. When planning studies which utilize video-recordings of GPs' consultations, researchers should give consideration to how this apparent self-selection by participating GPs could influence research results. Keywords. GPs, research methodology, videotape recordings. Introduction Video-recording of GPs' consultations is an established technique in general practice research, which has been used in studies exploring a wide variety of areas including doctor-patient communication, 1 GPs' detection of depression," the influence which medical computing has on GPs' behaviour 4 and the adequacy of data held on general practice computing systems. 3 Video-recording has been recommended for use in studies of doctor-patient communication, as it records all modalities of interaction between participants in a consultation. 6 Unfortunately, studies which utilize video-recorded consultations generally give scanty details about the GPs who participated as research subjects and the methods of their selection. 2 -*- 1 - t Some studies have taken place in the researcher's own practice/ 8-9 suggesting that participating GPs were chosen because it was perceived Received 1 April 1996; Accepted 15 July Department of General Practice and Primary Health Care, University of Leicester, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW, UK. that they were likely to agree to take part (a 'sample of convenience'). GPs can hold strongly negative views about the video-recording of consultations 10 and it is not known how acceptable they find the use of this technique for research. The internal and external validity of studies which involve video-recordings of 'real' consultations could be compromised if there are qualitative differences between GPs who allow themselves to be recorded and those who refuse. This paper describes how GPs were recruited to a study which aimed to video-record their consultations in order to describe how GPs use their routine consultations to promote smoking cessation. The project involved video-recording of GPs' surgeries and semistructured interviews with GPs. An ideal sample of GPs would include individuals who exhibited diversity in their behaviour during interactions with smokers and who described a wide variety of reasons for broaching or avoiding the topic of smoking with patients. To facilitate selection of such a sample, the Attitudes to Smoking Advice questionnairewas used to measure GPs' attitudes towards discussing smoking with patients during routine consultations. This questionnaire has been shown to be valid and reliable for this purpose." The final GP sample was chosen to reflect as wide a variety of reported attitudes as possible. It was 531

2 532 Family Practice an international journal hoped that GPs' behaviour with smokers would be as diverse as their reported attitudes. The aims of this paper are: (i) to describe the characteristics of GPs who will agree to be video-recorded for a research project; (ii) to document the reasons GPs advance for refusing to participate; (iii) to illustrate the use of the Attitudes to Smoking Advice Questionnaire to systematically sample GPs for a qualitative interview project. Methods Originally, postal questionnaires were sent to all 468 GPs on the Leicestershire FHSA list. The full details of this survey have already been reported. 12 Thirteen attitude statements exploring GPs' attitudes towards discussing smoking with patients during routine consultations were included on the survey instrument. Another paper explains how the Attitudes to Smoking Advice Questionnaire subscales were derived from these 13 statements. 11 The two subscales of the Attitudes to Smoking Advice Questionnaire are the enthusiasm and perceived efficacy subscales. These subscales measure GPs' enthusiasm towards discussing smoking with patients and GPs' belief in the efficacy of their antismoking advice. Evidence of their construct validity and internal reliability has already been presented. 11 Selection and recruitment of GPs GPs with diverse reported attitudes towards discussing smoking with patients were systematically selected using scores calculated for each GP on the enthusiasm and perceived efficacy subscales. GPs' scores on each subscale were clustered around the median, 11 suggesting that dividing the distributions using tertiles before sampling from the central portion and tails of each distribution was most logical. 11 Figure 1 summarizes the rolling recruitment process. This process of selecting GPs by differences in their reported attitudes continued until the required quota from each of the six thirds agreed to participate. The two scores for each GP were treated as being independent of one another and only one attempt was made to recruit each GP. GPs who could not be contacted after three successful calls to the surgery were classified as refusing to participate. Whilst on the telephone, GPs who refused to take part in the study were asked, 'Could you tell me what in particular it is about the study which makes it difficult to take part?' If they made reference to the use of video they were then specifically asked 'What concerns does the use of video-recording cause you?' GPs' answers were recorded longhand by TC. The main themes which GPs reported were identified by content analysis of these non-verbatim transcriptions. 18 GPs selected randomly each week (3 from etch of the 6 thiids) 5 stage process: CO (ii) (iii) (iv) (v) ' Short "populist" letter to all 18 ftpliming details of tbe Budy. Subject of study U described u "preventive medicine' Follow-up telephone call to the 18 two weeks later Further details (em to GPs who expressed an interest in participating Follow-up telephone call to interested GPs a further two weeks later Face-to-face interview arranged to discuss participation Recruitment ends when 7 or 8 GPs from each third agree FIGURE 1 Recruitment of GPs Information obtained to allow comparison of participants with non-participants To allow comparison of GPs who agreed to participate in the project with those who refused, data about all GPs on the Leicestershire FHSA list was collected from a number of sources. The FHSA gave information about GPs' gender, numbers of partners in GPs' practices and number of hours worked by each GP. Current membership of The Royal College of General Practitioners was obtained from the College and the time that had elapsed since the GP had qualified was found in the Medical Register. The time since qualifying was categorized as greater or less than 10 years ago at 1 January It was hypothesized that GPs who had qualified as doctors later than 1 January 1984 were more likely to have been exposed to video-recording and this could influence whether or not they would agtee to be filmed for a research project. The training status of GPs' practices was supplied by the Leicestershire, Nottingham and Derby Vocational Training Schemes and the undergraduate departments of General Practice of the Universities of Leicester and Nottingham enabled undergraduate teaching practices to be identified. TC categorized GPs into those who were known personally to him and those who were not. Any brief meeting between TC and a GP resulted in the GP being classed as 'known to researcher'. Chi-square tests were used to compare the characteristics of those who agreed to participate in the project with those who refused. Results Of the 468 questionnaires sent in the initial survey 327 (69.9%) were returned after two reminders. Full details of the differences between respondents and nonrespondents have already been reported. 12 Briefly,

3 Lack of time (e.g. too many < menu, too buy, Just appointed a new pinner, already Video-recording viewed as a problem (ice Box 3) Other objections (inadequate i iiiisa of research took, non-eagjish Video-taped consultations: GP characteristics 533 No. ofgpi reporting difficulty Based on the responses of 58 (out of 70 GPs) who could be contacted. FIGURE 2 Responses to question "could you tell me what in particular it is about this study which makes it difficult for you to take part?" Two GPs were no longer practising, reducing the denominator to 123 and making the agreement rate 43.1%. Table 1 compares characteristics of GPs who refused to participate with those who finally agreed to take part. There was no association between the size of GPs' partnerships and agreement to be videorecorded. GPs' reasons for refusal to participate Of the 70 GPs who were eligible to participate but refused, 12 would not talk to TC or could not be contacted. The remaining 58 gave their views in the telephone interview. GPs were allowed to cite more than one reason for refusal. Lack of time was the most common reason, being mentioned by 36 GPs, but 33 refusers specifically mentioned that they were unhappy with the use of video-recording. Again, GPs often raised multiple objections. The main themes which GPs reported as barriers to their participation are summarized in Figures 2 and 3. Only one GP cited the topic of the study as a reason for non-participation. Concern for self (feeling threatened, self-conscious, inhibited) 22 Previous bad experience of video-recording Doubts about validity of video-recording 8 Concern for patients' reactions 6 Not been video-recorded before 5 Other 8 ^pn»hihmg disruption and time taken by video) Question asked to 33 OPt FIGURE 3 Responses to question "what concerns does the use of video recording cause you?" Members of the Royal College of General Practitioners, GPs who had qualified less than 10 years ago and women GPs were more likely to respond. Outcome of GP recruitment In total 125 GPs were approached and asked to take part in the project before the desired quota from each of the thirds agreed. A total of 53 GPs were recruited. Discussion These data show that it is feasible to recruit service GPs who are not already acquainted with researchers for studies involving the video-recording of their consulta-, tions. In this sample, however, nearly 60% of GPs refused, making recruitment an onerous task. Additionally, there are qualitative differences between GPs who agree to be video-taped and those who refuse. The fact that the subject of the project was only cited once as a reason for refusal suggests that these findings are likely to be generalizable to situations where researchers ask to video-record GPs' consultations for other purposes. Table 1 suggests that GPs who are familiar with the use of video-recording are more likely to agree to participate in this type of research. Teaching and training practices are likely to use video-recorded consultations for teaching or the training purposes. Younger GPs are more likely than older GPs to have experienced consultation analysis using video-recording during their training. Also, it is not surprising that GPs who are acquainted with the researcher were more likely to agree to participate. The researcher works in an academic department and most of the GPs known to him are associated with this organization. It is worth noting, however, that the GPs who gave consent to be videorecorded appear happy with their final decision. One year since the first GP was recruited, 44 GPs have been approached for data collection and only two have withdrawn co-operation (unpublished observations). Unfortunately, it appears unlikely that either of the main barriers to GPs' participation in this type of research can easily be overcome. Researchers often pay

4 534 Family Practice an international journal TABLE 1 Comparison of GPs who refused to have consultations video-recorded with those who agreed Characteristic of GP No. (%) of GPs refusing to be video-recorded with characteristic (total = 70) No. (%) of GPs agreeing to be video-recorded with characteristic (total = 53) P-value (on chi-square test of difference between proportions) Works in training practice Works in teaching practice MRCGP Qualified < 10 years ago Known by researcher Male Full time (versus less than full time) 13 (19) 20(29) 17(24) 9(13)- 5(7) 49(70) 64(91) 26 (49) 31 (58) 28 (53) 19 (36) b 11 (21) 44(83) 49(92) Data missing for three GPs. b Data missing for one GP. GPs for their participation in projects, but this does not relieve GPs of their reported time pressures. Figure 3 demonstrates that many GPs have personal and emotive reasons for objecting to video-recording of their consultations. Although the data in Table 1 suggests that familiarity with the use of video-recording may be associated with some GPs' agreement to participate, Figure 3 demonstrates that past experience of videorecording can act as a disincentive for a minority. Research into doctor-patient communication is still in its infancy, making it difficult to predict how the characteristics of a GP sample might affect study findings. GP trainers are more patient-centred than other GPs, 14 so this sample is likely to demonstrate greater patient-centredness than a random sample of GPs. Researchers should note that when recruiting GPs to studies which involve video-recording of consultations, success is more likely amongst younger GPs who hold the MRCGP qualification and work in teaching or training practices. If appropriate to answering the research question(s) posed, asking only GPs with these characteristics to take part is likely to minimize recruitment efforts. Where a more catholic sample is required, however, researchers must give careful consideration to how the characteristics of the sample obtained might influence research findings. This work suggests that a considerable amount of selfselection occurs when GPs are asked to take part in research which involves video-recording their consultations. The characteristics of GPs who participate in this kind of research need to be considered when assessing research findings. Researchers need to be aware that recruiting GPs as subjects for this kind of research can be extremely time-consuming and any attempt at obtaining a sample of GPs which is truly representative of the whole profession is likely to be doomed to failure. Acknowledgements I am indebted to Mrs Margaret Whatley for secretarial help. Dr Andy Wilson, Dr Bob McKinley and Mr Martin Williams made useful comments about earlier drafts. References II Campion PM, Butler NM and Cox AD. Principle agendas of doctors and patients in general practice consultations. Fam Pract 1992; 9: Tylee AT, Freeling P, Kerry S. Why do general practitioners recognise major depression in one woman patient yet miss it in another? Br J Gen Pract 1993; 43: Tylee AT, Freeling P, Kerry S, Burns T. How does the content of consultations affect the recognition by general practitioners of major depression in women? BrJ Gen Proa 1995; 45: Pringle M, Robins S, Brown G Topic analysis: an objective measure of the consultation arid its application to computer assisted consultations. BrMedJ 1985; 290: Pringle M, Ward P, Chilvers C. Assessment of the completeness and accuracy of computer medical records in four practices committed to recording data on computer. BrJ Gen Pract 1995; 45: Inui TS, Carter WB. Problems and prospects for health services research on provider-patient communication. Med Care 1985; 23: Heramark G. Reactions of patients to video recording of consultations in general practice. BrMedJ 1985; 291: Pringle M, Stewart-Evans C. Does awareness of being videorecorded affect doctors' consultation behaviour? BrJ Gen Pract 1990; 40: Pringle M, Robins S, Grown G. Computer assisted screening: effect on the patient and his consultation. Br Med J 1985; 290: Baird AG, Gillies JCM. Assessing GPs' performance: videotape assessment is threatening. BrMedJ 1993; 307:60. Coleman T, Williams M. Sampling for qualitative research using qualitative methods. 1. Measuring GPs' attitudes towards discussing smoking with patients. Fam Pract 1996; 13:

5 Video-taped consultations: GP characteristics 535 ColemanT, Wilson AD. Anti-smoking advice in general prac- ' 3 MaysLN, Pope ^Rigour and qualitative research. Br Med J tice consultations: general practitioners' attitudes, reported 1995 > 311: practice and perceived problems. BrJGenPract 1996; 46: M Law SAT, Bntten N. Factors that influence the patient ceng7_9j tredness of a consultation. BrJ Gen Proa 1993; 45: