Patient and public involvement (PPI) in research continues to be embraced with ever-increasing commitment and enthusiasm by patients and researchers alike. However, along with the excitement comes discomfort and disagreement about issues such as representativeness, tokenism, definitions of partnership and expertise, and the terms by which PPI is conducted. To better understand these tensions, Jennifer considers the utility of concepts such as ideology, virtue signalling, competing knowledge regimes, and contested legitimacy. Exploring PPI through these different analytic frames will lead us to fresh insights as to why these tensions exist and how they might be addressed.