This systematic review focused on the rationales, methodology and outcomes of medical video-vignette studies with APs. Scripted studies provided more specific rationales for using video-vignette designs with APs than clinical studies and directed more efforts at increasing/testing internal and external validity. APs’ perceptions of communication overlapped generally with CPs’ perceptions. Meanwhile, their evaluations overcame ceiling effects. These results have interesting methodological, theoretical and practical relevance.
Scripted studies paid the most attention to increasing the designs’ methodological soundness. Specific methodological rationales for conducting video-vignette studies with APs were provided, such as the opportunity to study communication systematically. This fills a gap in clinical care studies, in which only correlations, but no causality between communication and outcomes can be determined.58,59
Unfortunately, some scripted studies included container-concepts of communication (e.g., patient-centeredness). When positive effects are found, it remains unclear which specific element(s) of communication influenced outcomes.15,58
Additionally, as argued, when videos are watched by multiple APs, the reliability of assessments increases.60,61
Another argument for including APs was that their evaluations can overcome ceiling effects. APs’ evaluations were indeed not high; averagely 54.28 on a 0–100 scale. By comparison, a meta-analysis of CPs’ satisfaction ratings showed an average score of 80.00 (0–100 scale).20
Moreover, a recent study compared CPs’ satisfaction scores with those of APs viewing these videotaped consultations. Mean score (1–6 scale) for CPs was 5.8, while for APs it was 4.0 (p
APs’ ratings thus seem to overcome this limitation of CPs’ evaluations.4,5
Accordingly, these and other methodological rationales provide strong foundations for conducting video-vignette studies with APs.
To achieve internal validity, APs reflected on manipulations in scripted consultations. Unexpectedly, ‘experts’ (doctors/researchers) were not often asked to comment on manipulations, although they may have insight into the manipulations’ (theoretical) success. Moreover, little information was provided on how exactly scripts were created, i.e. it often remained unclear what input researchers used to develop scripts and at what point(s) the scripts were validated.
Focusing on external validity, some studies argued that APs’ perceptions overlap with CPs’ perceptions. However, none of these studies determined whether APs watching videotaped consultations and CPs in these consultations overlapped on outcome measures. As stated earlier, such a study has recently been performed.62
In this study—taking into account CPs’ skewed satisfaction scores—APs’ and CPs’ evaluations were correlated. Additionally, a meta-analysis in psychology63
showed that lay people can make reliable judgments for (non)verbal communication based on brief (clinical and scripted) videotaped interactions.
Theoretical evidence supporting the external validity of APs can be found in simulation theory and is supported by neuro-cognitive studies on empathy. According to simulation theory, we infer other persons’ mental states by matching their states with resonant states of one’s own mental state.64
Neuro-cognitive studies show that the brain’s mirror neurons fire when a particular action is carried out or observed.65
They form the basis for empathy,66–69
as they are involved in experiencing and observing emotions in others70
and allow people to adopt another person’s perspective.71
Indeed, some oncological scripted studies included survivors alongside healthy participants. Their perceptions overlapped, indicating that healthy people can put themselves in the shoes of (cancer) patients.72
However, the methodological and theoretical rationales and advantages of using APs as proxies for CPs are relevant only when APs’ perceptions of communication are applicable in clinical practice, which is mainly supported by our results. APs’ perceptions of communication overlap mostly with those of CPs. A few—seemingly—contradictory findings were found. APs disliked information-exchange during bad news conversations, while CPs mostly valued this behavior. However, CPs often report receiving too much information during these conversations.73–78
Besides, while most studies point to the positive effects of patient-centeredness, a study with APs51
and review on CPs12
found that for purely physical complaints, a patient-centered style may be suboptimal.
Despite these promising results, various aspects should be taken into account when interpreting APs’ perceptions for clinical practice. First, in one study APs’ perceptions were unrelated to CPs’ satisfaction scores. The considerable age difference (students versus seniors) may be responsible for this finding, as age influences communication preferences.79–81
Future studies should take background characteristics influencing preferences—e.g. gender,81,82
—into account. Consequently, students should not be included as APs merely for convenience. Second, the diversity in APs’ evaluations should be kept in mind. The long-term doctor–patient relationship possibly influencing CPs’ evaluations cannot be captured by studies using APs. Thus, as video-vignette studies make it possible to disentangle the effect of various communication elements, these elements should afterwards be tested in clinical care.
This review has its limitations. First, the literature is inconsistent in the terms used for “analogue patients”. To include all relevant articles, both forward and backward reference searches on possible relevant articles were performed and included studies’ references were hand-searched. Future studies should use the term “analogue patients” consistently. Second, we excluded trained observers, but included lay people trained for this specific study. As studies may have used inconsistent labels, we screened for detailed information on observers. Despite these precautions taken, inadequately indexed and little cited relevant studies may have been missed, as we used a top-down search strategy.