1. Just Act Natural: Viable options and best practices for resident video review Erin G. Sheppard, PhD Central Michigan University College of Medicine Central Michigan University, Family Medicine Residency Kristine M. Diaz, PsyD Oakland University William Beaumont School of Medicine Department of Biomedical Sciences Aaron J. Grace, PsyD Medical College of Wisconsin Waukesha Family Medicine Residency The 34 th Forum for Behavioral Science in Family Medicine

2. Disclosure of Commercial Interest We have no commercial interests to disclose.

3. Objectives Describe a variety of video recording and reviewing methods Outline strategies for integrating video recording and review into a residency program (e.g. informed consent requirements, faculty/staff training, evaluation and feedback methods). Identify potential challenges a residency may face, and how to most effectively navigate these challenges

4. Intended Audience Faculty interested in initiating, enhancing, or expanding their video review program.

5. Background and Relevance to ACGME Milestones

6. Background Video review has been used since the 1960s (Allen DW, McDonald FJ, Orme ME, 1966) Many medical schools & residencies use this format including FM, IM, Pediatrics, and EM (Coleman, 2000; Edwards et al, 1996; Rosenzweig et al, 1999) Other higher education programs: education, psychology, social work, nursing. Benefits- Formative versus summative feedback (promotes improvement) Beyond content (tone, nonverbals) Self-evaluation Integration of behavioral and medical (interviewing/communication and physical exam) “the gold standard of communication teaching” (Kurtz, Silverman, Draper, 2005)

7. ACGME Requirements Human Behavior and Mental Health “There must be instruction and development of skills in the diagnosis and management of psychiatric disorders,…patient interviewing skills, and counseling skills. This should include videotaping of resident/patient encounters or direct faculty observation for assessment of each resident’s competency in interpersonal skills.”

8. ACGME Core Competencies and Milestones Communication ‒ Develops meaningful, therapeutic relationships with patients and families 1.Creates a non-judgmental, safe environment to actively engage the patient and families to share information and their perspective 2.Effectively builds rapport with a growing continuity panel of patients and families; Respects patients’ autonomy in their health care decisions and clarifies patients’ goals to provide care consistent with their values ‒ Communicates effectively with patients, families, and the public 1.Identifies physical, cultural, psychological, and social barriers to communication; Uses the medical interview to establish rapport and facilitate patient-centered information exchange 2.Negotiates a visit agenda with the patient, and uses active and reflective listening to guide the visit; Engages patient’s perspective in shared decision making; Recognizes non-verbal cues and uses non-verbal communication skills in patient encounters 3.Effectively communicates difficult information such as end- of- life discussions, delivery of bad news, acknowledgement of errors, and during episodes of crisis ‒ Utilizes technology to optimize communication 1.Uses technology in a manner which enhances communication and does not interfere with the appropriate interaction with the patient

9. ACGME Core Competencies and Milestones Professionalism ‒ Demonstrates humanism and cultural proficiency 1.Consistently demonstrates compassion, respect, and empathy 2.Elicits cultural factors from patients and families that impact health and health behaviors in the context of the biopsychosocialspiritual model 3.Incorporates patients’ beliefs, values, and cultural practices in patient care plans Practice Based Learning and Improvement ‒ Demonstrates self-directed learning 1.Consistently evaluates self and practice, using appropriate evidence- based standards, to implement changes in practice to improve patient care and its delivery

10. Benefits and Challenges of Various Precepting Methods

11. Shadowing Benefits Better able to see nuances of facial expression, etc. Less question about who is watching Fewer security concerns as there is no permanent record (video) of the encounter Challenges More obtrusive Tendency of patient to talk to faculty Patient and resident more aware when faculty is making a note of something More physically demanding (standing constantly)

12. Closed-circuit Benefits Less obtrusive Able to take notes without resident knowing Less physically demanding Challenges Sometimes miss nuances The unseen Observer can be intimidating More risk for security concerns (fixed if never record)

13. Live Benefits Possibly conducive to immediate feedback (but not guaranteed) Can observe precepting as well Opportunity to not record Able to intervene if necessary Challenges More demanding on faculty’s schedule (less flexible)

14. Feedback After Clinic Benefits More flexible for faculty Can review follow-up / documentation in chart Challenges Impossible to provide immediate feedback Must record (security risk)

15. Individual review Benefits Creates less defensiveness More efficient use of resident time Easier to get consent (less intrusive to patient) Challenges Only 1 perspective (plus faculty)

16. Group review Benefits Can get multiple perspectives Multiple residents can be scheduled for video review at once Residents able to learn from others’ successes and struggles Challenges Resident might not be able to see their own patient / most of time is spent viewing someone else’s patient May end up being significantly later

17. Watch with faculty Benefits Able to get faculty perspective (normalizing, congratulating, problem- solving) Challenges May lead to defensiveness Can be inefficient

18. Watch alone Benefits Lowest risk for defensiveness More thorough review Adherence? Challenges No direct faculty perspective More time consuming

19. Just discussion with faculty Benefits Most efficient Able to cover much more content (5 patients in half an hour) Challenges Not able to see full nuances / dialog / nonverbals

20. Benefits of Video Review Designated time for resident with attending faculty physician and behavioral scientist to provide feedback on clinical interviewing. Resident obtains feedback from two different healthcare professionals on interpersonal and communication skills. Residents prefer to learn from real patients versus simulated patients.

21. Implementation of Video Review

22. Costs of video equipment Informed Consent Collaboration with Institution, Faculty, and Staff Assessment and Evaluation of Residents

23. High cost Benefits Less security risk better image / sound quality can have multiple monitors allows for live observation Challenges High cost can be prohibitive, resulting in NO program Source: Muench J, Sanchez D (2012). A review of video review: New processes for the 21 st century. Presentation at the 33 rd Forum for Behavioral Science in Family Medicine, Chicago, IL.

24. Low cost Benefits If have poor program buy- in, can at least trial a program Challenges Security risk Can only have multiple monitors Unable to do live observation Miss beginning of encounter Source: Muench J, Sanchez D (2012). A review of video review: New processes for the 21 st century. Presentation at the 33 rd Forum for Behavioral Science in Family Medicine, Chicago, IL.

25. Informed consent

26. What is informed consent? Conversation/discussion Not the form Not the signature The form and signature are ways of documenting that the discussion took place

27. What is informed consent? Form helps prove informed consent, form is not informed consent Tension between informative and defensive/legal purposes

28. Important Distinctions Recording not “made as part of the patient’s care” or “to assist with treatment” X-ray Laproscopic images Ultrasound Picture of wound/injury/rash to send for 2 nd opinion / observe progression Different informed consent - usually already included - becomes part of medical record

29. Important Distinctions Recording not “for commercial use” Testimonials, advertisements (video/print) Different set of AMA guidelines / legal ramifications Probably should involve a distinct informed consent process (conversation / form)

30. Impaired Capacity/Children Temporary Surrogate or guardian can consent, as soon as patient regains capacity, must re- obtain from patient Sustained (minor/permanently incapacitated) Obtain from surrogate or guardian Seek assent Right to refuse Capacity is not binary

31. Essential Elements Voluntary may be stopped at any time may be limited at any time Viable alternative (declining will not affect care in any way) Purpose (only purpose is for education) Who will see / have access (resident? Faculty? Other residents? Public? Commercial?) Risks (security, when erased) Only for today’s visit Signature needed Source: AMA 5.046, Butler et al.

32. Institutional elements Consider if it is not in the patient’s best interest (Ebbe, 2013) Patient explicitly withholding information because they are being recorded Genital / pelvic / breast exam

33. Informed Consent Form Should have essential elements described above Readability of form is paramount Readability not equal to understanding (Hochhauser, 2004) Importance of conversation Simple concepts in addition to simple language

34. Patient Suggested Improvements for Consent Forms Simpler and shorter consent Summarize highlights and keep details separate Include a glossary and define terms Use lay language Give general information about clinical trials Add space to write questions Use larger fonts Emphasize important information Use graphics and videos Jimison et al., 1998.

35. Consider Language Use “…furthermore, you hereby grant to [institution] exclusive rights in perpetuity to use and to authorize others to use in any print and electronic media (present and future formats) its choice of interviews and images, voice and likeness and to use the individual’s name in connection therewith.”

36. Consider Language Use “This recording will only be viewed by qualified professionals (i.e., [institution] residents, medical students and teaching faculty affiliated with the Department of Family and Community Medicine of the University) and will be used exclusively for the following educational purposes:” Better: “This recording will only be seen by my doctor and faculty members of this program to help my doctor improve interviewing skills.”

37. Consider Language Use “I transfer the rights for the recording to the [Healthsystem] Family Medicine Center for educational purposes, and release the clinic from liability which might arise from making such recordings.”

38. Informed Consent I understand that my visit today will be recorded for educational purposes. _____________________ Signature Date

39. Patient Revoking Consent “I understand that I may revoke this consent in writing without penalty or consequence at any time. I agree that [institution] may retain and use any recordings made before I revoke my consent, but only for the purposes described in this consent document. ” Correction: If patient revokes consent, s/he has the option for all prior recordings to be erased “within reasonable time frame.” Source: AMA 5.046

40. Suggested Consent Form

41. Collaboration with Institution, Faculty, and Staff

42. Suggested Approach for Organization/Institution Emphasize that benefits outweigh the risks Video review is a valid tool for resident learning and evaluation Policies/procedures will be in place to reduce risk- informed consent Security of video/patient information will be maintained

43. Collaborate with Institutional Departments/Committees Collaboration with Risk Management to ensure compliance with other corporate policies, procedures, values. Work with Forms Committee to gain approval of Consent forms.

44. Addressing Concerns HIPAA anxiety: Access to recordings will be limited to essential staff only (Director of Behavioral Science, Faculty physician, Resident) Recordings will be stored in a secure location and erased after clinical precepting with attending physician Collaboration with IT, Simulation lab, etc. Point person- Behavioral Science Faculty responsible for all coordination

45. Faculty Getting buy-in: rationale behind video recording and review important in GME Compliance with ACGME Standard amongst other residency programs Benefits for residents Learning communication and interviewing skills Improvements in physical exam skills Promotes integration of behavioral/mental and physical health Making it a requirement

46. Faculty Participation Scheduling (FM and BM faculty plus resident in same place same time) Teaching priorities (commitment to teaching residents self-evaluation, providing immediate feedback, setting educational goals) Address questions/concerns.

47. Resident Educating on the purpose and goals of video recording and review Setting expectations Number of patients recorded; active participation during review This is a requirement of residency curriculum Appropriate patient selection Minimizing anxiety; maximizing openness, curiosity and flexibility

48. Staff/MA Level In-training Communication with Resident (selecting patient) Checking in and Rooming the patient Explaining the video recording process Obtaining Informed Consent (ensure staff understanding) Starting and stopping the recording Responding to resident issues (refusals, etc.) Verbal and nonverbal communications throughout this process

49. Sample Script for Staff/MAs “Hello ______( pt name) _________.” “It looks like you will be seeing Dr. ___________ today. As you know, Dr. __________ is a resident physician. A few times each year our supervising doctors watch Dr. ___________’s work in the clinic to make sure he/she’s doing a good job. They’d like to watch your visit with Dr. __________________ today, if that’s okay with you.” (If “Yes”) “Great, they’d like to record Dr. _____________’s performance through cameras ( point to camera & microphone) and watch it later with him/her to give feedback on his/her strengths and weaknesses. How would you feel about having your visit video-recorded?” (If “Yes”) “This is completely voluntary, and we have a consent form that explains all of the details. Let’s go through it together, and please let me know if I can answer any questions as we go.” (Go through consent form with patient) “As long as you agree, we just need your signature on this form saying that it is okay to video-record your visit today.” “Please let us know if there is any point throughout the visit that you would like us to stop the recording.” “Do you have any other questions or concerns before we start?” “Thank you very much for your participation.” Originally created by Deb Bonitz, PhD; Modified by Erin Sheppard, PhD

50. Additional Information for Staff/MAs Hesitation: If patient is hesitant to video, address any questions or concerns they have. If they are still not comfortable/unsure, discontinue the process. Reassure them that this is a voluntary process, and we do not need to record their encounter today. It is completely unacceptable for a patient to feel forced into this. Minors: Get patient’s assent (verbal agreement). Guardians MUST provide written consent (sign consent form). Both must be obtained in order to move forward. Video Security: Videos are saved on the video server, secured by password, that is only accessible to Simulation/technology staff and supervising Faculty. The video system is locked each night. Videos will be deleted immediately after the video has been reviewed (approximately 1 week after recording). Originally created by Deb Bonitz, PhD; Modified by Erin Sheppard, PhD

51. Additional Information for Staff/MAs Cameras: Cameras may be turned on or off at any point throughout the visit. Patient maintains control of this, and may choose to discontinue the recording at any time. Resident training: If needed, remind patient that doctor is a resident in training and has to be supervised with every patient during residency. The benefit is patients get two doctors taking care of them. Video date: Video consent form is only good for the date on the paper. Does not mean that every encounter from here on will be on video. Consent must be obtained each time. Nudity: If patient has rashes, is here for genital/breast exam, or needs to expose private areas, this is not an appropriate patient to request that we record the encounter. Inform resident they must choose a different patient they are scheduled to see that day. Privacy: If patient refuses video and seems very concerned about privacy, you can offer to move them to a room with no cameras. Originally created by Deb Bonitz, PhD; Modified by Erin Sheppard, PhD

52. Scheduling Videotaping CMU Waukesha McLaren Genesys

53. Evaluation and Feedback Methods

54. Evaluation of Resident Start with Resident’s goals and self-evaluation “What are you hoping to gain from today’s review? What are your goals?” “How do you think you did? What were your strengths and weaknesses?” General evaluation forms Patient Centered Observation Form * (University of Washington Department of Family Medicine. Contact- Larry Mauksch M.Ed) Medical Interview Skills Competency Evaluation (Created by Florida Hospital East Orlando Family Medicine Residency Program. Contact- Timothy Spruill Ed.D) Video Precepting Record (Created by Columbia St. Mary’s Family Medicine Residency, The Medical College of Wisconsin; Adapted from the FM program at Hennepin County, Minneapolis. Contact- Dennis Butler, PhD)

55. Created by University of Washington Department of Family Medicine. Author: Larry Mauksch

56. Created by University of Washington Department of Family Medicine. Author: Larry Mauksch

57. Evaluation of Resident Competencies Checklists Well Child Acute Care Adult Preventative Services Chronic Illness Psychiatric Disorder Prenatal Delivering Bad News Cultural Competency

58. Created by faculty and residents at Columbia St. Mary’s Family Medicine Residency, The Medical College of Wisconsin. Author: William Geiger, MD

59. Created by faculty and residents at Columbia St. Mary’s Family Medicine Residency, The Medical College of Wisconsin. Author: Dennis Butler, PhD

60. Evaluation of Resident Validity and reliability of assessment increases when: (Rosenzweig, et al, 1999) A single observer reviews a recorded encounter multiple times Multiple reviewers are utilized for one encounter DBS, FM Faculty, Peers Multiple encounters are used (same resident, multiple patients) Same day; over the course of the year; over the course of residency Evaluation tool is simple/user-friendly Well-defined items (behavioral anchors) Raters undergo training How to use evaluation tool Identifying key behaviors Understanding the scale

61. Giving Feedback Establish an open and constructive environment (reduce resident anxiety= this is a learning experience, we don’t expect you to be perfect) Let the video play and provide feedback at the end Versus Stopping the video throughout to discuss/provide feedback. Both? Should be given immediately (go through evaluation form together) Needs to be concrete and specific “Good job” = bad feedback “By using patient’s name, maintaining appropriate eye contact, sitting down, and using empathic statements, you did a nice job of establishing rapport.” = better feedback Should be focused on identifying resident strengths and weaknesses Utilize feedback to assist in goal-setting: What should the resident work on for next video review?

62. Summary

63. Best Practices Start at the Organizational level to ensure necessary supports are in place and you are in compliance. Decide on a procedural model: real versus simulated patients; individual versus group review Discuss rationale and benefits for the residency in faculty meeting. Faculty buy-in = Resident buy-in Provide formal lecture to residents as a group to provide rationale, educate on process, address issues. Provide in-training for support staff. Develop a comprehensive but user-friendly informed consent form Identify your evaluation form and train users (don’t forget residents’ self-evaluation) Make feedback an open and constructive discussion- including goal-setting Welcome feedback from all

64. Anticipating and Evaluating Challenges CMU Waukesha McLaren Genesys Your Program?

65. Discussion

66. Contact Us! Erin G. Sheppard, PhD shepp1eg@cmich.edu Kristine M. Diaz, PsyD kmdiaz2@oakland.edu Aaron J. Grace, PsyD aaron.grace@phci.org

67. References 1.Allen DW, McDonald FJ, Orme ME. (1966) Effects of feedback and Practice Conditions on the Acquisition of a Teaching Strategy. California, CA: Stanford University. 2.Butler D.J. (2002). Informed Consent and Patient Videotaping, Acad. Med., 77, 181–184. 3.Coleman T. (2000). Using video-recorded consultations for research in primary care: advantages and limitations. Family Practice, 17, 422-427. 4.Ebbe, B. (July 16, 2013). Personal communication. 5.Edwards A, Tzelepis A, Klingbeil C, et al. (1996). Fifteen years of a videotape review program for internal medicine and medicine-pediatrics residents. Academic Medicine, 71, 744-748. 6.Hochhauser, M. (2004). Informed consent: Reading and understanding are not the same. Applied Clinical Trials Online. 7.Jimison, H., Sher, P.P., Appleyard, R., & LeVernois, Y. (1998). The use of multimedia in the informed consent process," Journal of the American Information Association, 5 (3) 245-256. 8.Kurtz S, Silverman J, Draper J. (2005). Choosing and using appropriate teaching methods. In: Kurtz S, Silverman J, Draper J, editors. Teaching and Learning Communication Skills in Medicine. 2 nd ed. Oxford, UK: Radcliffe Publishing; 77-103. 9.Muench J, Sanchez D (2012). A review of video review: New processes for the 21 st century. Presentation at the 33 rd Forum for Behavioral Science in Family Medicine, Chicago, IL. 10. Opinion 5.045: Filming Patients in Health Care Settings. (2006). American Medical Association Code of Medical Ethics. 11. Opinion 5.046: Filming Patients for the Education of Health Professionals. (2003). American Medical Association Code of Medical Ethics. 12.Rosenzweig, Bringham, Snyder, Xu, McDonald. (1999). Assessing Emergency Medicine Resident Communication Skills Using Videotaped Patient Encounters: Gaps in Inter-Rater Reliability, The Journal of Emergency Medicine, 17(2), 355-361.

68. Thank You!