and a specialist at another to identify pat- terns of talk that could affect quality of care. Although the teleconsultation may allow the specialist and primary care provider to exchange information and ideas, such a teleconsultation may restrict patient involvement in the encounter, he says. "While patients usually account for about 40 percent of the talk occurring in traditional consultations, they account for only 23 percent in teleconsultations," he notes. Patients rarely asked questions or asserted a perspective or an opinion- something less than ideal considering how much a patient interacts with his or her doctor can have profound effects on diagnosis, treatment, and even health improvement, Street says. Patients who actively participate in consul- tations with their physicians, he explains, receive a greater amount of infor- mation, understand the issues better and are more satisfied with their care-all of which make for an overall improved quality of care. Not only can patient participation affect the quality of a visit to the doctor, but a growing body of research indicates that it can contribute to improved health and healthier behavior, Street adds. Limited patient participation may be due to several factors, he notes. The presence of an additional medical expert may unintentionally limit patient involvement as the two physicians converse with one another about the case, he says. Street also points to cultural and demographic variables, noting that patients who are more involved in their consultations tend to have more formal education and be in the middle to upper income bracket. However, people in remote, rural areas who are likely to have telemedicine encounters tend to be poorer and have less formal education compared with their urban and suburban counterparts. Street also notes that very little group discussion takes place in these encounters, possibly due to the actual construct of the encounter, which places the patient and primary care giver side by side, facing a monitor with the spe- cialist