Selection of data

We decided to go through a random sample from all of the video consultations that lasted less than 20 minutes. The reason for this was that many of the encounters that lasted longer than 20 minutes contained long periods of examination that were not visible on the tape. This was because the video recorder was placed in one location in the examination room, usually before the patient entered, with the intended focus being on the communication between doctor and patient. Accordingly, if the patients were examined on an examination table, they often moved out of the frame of the video recorder and were not visible on screen. This was done partly for practical purposes and partly as a way of protecting patient privacy as much as possible in the setting. Another problem with the longer recordings was the poor sound quality during the examinations that took place out of sight of the video equipment. Since most of the taped consultations lasted less than 20 minutes we decided to eliminate

the longest encounters to avoid spending a lot of time on those that were difficult to study. We were aware that this choice might introduce a selection bias, because it is possible that patients were better cared for in the consultations that took the longest time. However, we have reason to believe that this did not in fact have any major impact on our analysis. Firstly, as already explained, the extra time was often spent on examinations rather than on communicating with patients. Secondly, we observed that even when the doctors had plenty of time (and explicitly stated this to be the case) they did not use this on the patients’ personal issues. Finally, since we had already conducted an observation study in which consultations of all lengths were included, we did also have experience with longer encounters and the impact of time on patient care. What we did, however, notice was a difference in the very shortest consultations, where there were generally poorer levels of communication and the patients were more objectified. We also restricted ourselves to the encounters that were taped before the participating doctors had undertaken the course in clinical communication, since this intervention might have affected how they cared for their patients.

We applied for and were granted ethical approval for the study on the basis of the patients’ broad consent. The recordings were stored as an enciphered file in an external database at the Akershus University Hospital Research Centre and we had to be physically present there to watch them.

2.3.6. Method

Since we planned to elaborate on the findings from the first study, and because we had had positive experiences with the method we used therein, we wanted to use Grounded Theory on this new material. Moreover, changing the mode of data collection would not pose any difficulties to the Grounded Theory approach, since one of its main doctrines is “all is data”. What might, however, have been problematic was the fact that we were now approaching the field with a more concrete research question relating to how doctors cared for their patients, instead of having an open approach as the method explicitly requires. Yet, this new work was really an extension of the initial study and an attempt to develop and tease out the nuances of concepts that were already established. Accordingly, we decided that it was legitimate to proceed with the Grounded Theory approach. Moreover, the new

research question was not a preconceived, theoretical query, but had emerged after thorough work with data from the field. Although renowned philosophers have written about caring and empathy in medical ethics, we did not use these theories to explore the material, but instead we made an effort to stay grounded in the empirical data and open to new possibilities and unexpected answers to our questions.

We conducted the study in much the same way as we had with the first. I travelled to Akershus University Hospital Research Centre and looked through the taped consultations while taking notes. I watched most consultations only once, trying not to get caught up in the possibility of reproducing every incident, but to remain focused on the core question: what is happening in this setting? More specifically, I had listed some elements that might get us closer to providing an answer to our research question:

• Do the doctors care for or touch upon existential values in their conversations with their patients? Are the patients’ personal experiences and values taken into account?

• Are existential values given any value beyond their medical significance, for instance as symptoms of depression?

• Do the patients’ personal values affect his or her treatment, especially in consultations with those who are chronically ill, seriously ill or dying?

• How do the doctors display signs that they are treating the patients as individual human beings?

• To what extent are the patients treated only as objects? How does this transformation from person to medical object take place?

• After objectifying a patient, thus in a sense ruining the human relationship, do the doctors do anything to restore this relationship with the patient?

• How do the patients react to being objectified, especially in vulnerable situations?

The plan was to watch a large number of consultations instead of discussing only a few of them in detail. Initially, I watched each encounter once, repeating parts only if the setting was unclear. I took notes of situations which were particularly interesting, illustrative or incomprehensible in light of the research questions, and I also noted

seemingly deviating events or incidents that suggested a novel explanation. I likewise recorded the specific points in the consultations where existential dimensions or caring for patients as human beings were apparent.

Even though we intended to collect data in much the same way as for the first study, the setting was now quite different; I did not have to sit in the corner of a doctor’s office, trying to be invisible and not disturb the consultation in any way. Instead, I sat in an ordinary office, drinking coffee, taking notes openly, reacting to extraordinary events and stopping the tape whenever I needed to. This had both a positive and a negative influence on the data collection. The advantages are obvious: I could relax, take breaks and write openly. I could also rewind and watch interesting parts over and over again, and could even get the precise wording correct and return later to re-watch a consultation after having reflected upon it. I could not, however, see beyond the frame of the video recorder, which meant that I could not see the entire room and I could not follow the action when the patient or doctor moved, for instance, to the examination table. The doctors’ work between encounters was also missing, and so I was unable to put the consultations in their proper context. Each scenario began with a doctor meeting a patient in a set location, and this setting had the capacity to accentuate the feeling of repetition and routine work. Watching consultations on a screen also meant that I felt more distanced from the encounters. This may have contributed to a more objective analysis, but it also meant missing out on the atmosphere and feelings that these meetings evoked in me personally, which is also a source of data to be analysed.

I arranged three visits to the research centre, watching 30-40 video encounters each time. In between visits I worked with my field notes, analysing them in relation to the first study and in line with the Grounded Theory approach. In this way, I was able to switch between data collection and theoretical analysis in a favourable manner, although we did not use theoretical sampling in this study due to the fixed nature of the material. After I had sat through 101 video encounters, I felt that the emerging theory was quite saturated, and new consultations were not suggesting any novel, significant aspects. After my initial examination of the tapes, I paid four more visits to the research centre to review certain consultations and write down precise passages of conversation for illustration purposes. Two of the other authors of this work, Pål

Gulbrandsen and Reidun Førde, watched a sample of the data independently, and the former also watched some of the tapes with me while we discussed our analysis of the encounters. The emerging theory was developed with my supervisor, Åge Wifstad. During the analysis, I singled out specific consultations that were good illustrations of the emerging concepts of the developing theory. All of the four authors of this work watched these consultations together and discussed their interpretation. Despite differences in background and clinical experience, we were united in our analysis, a sign of high inter-rater agreement.