1. Georgetown University-Providence Hospital Family Medicine Residency
Focusing on Doctor-Patient Interaction: Peer to Peer Feedback Through Blog Reflections
Elise Morris, MD
Georgetown University-Providence Hospital Family Medicine Residency
Jeanine Turner, PhD
Georgetown University Graduate School in Communication, Culture and Technology

2. No disclosures/conflicts of interests

3. Goals and Objectives
Identify the potential benefits of peer feedback on patient communication through an asynchronous blog
Define concrete steps to facilitate setting up a blog discussion for peer review
Review major Family Medicine resident-peer identified themes in doctor-patient communication that recur

4. Communication Connects to Patient Outcomes
Effective communication is linked to improved patient outcomes (Bensing, JM et al (2006), compliance, adherence to recommendations (Roter & Hall, 1989), and trust (Beck, Daughtridge & Sloane, 2002)

5. Peer Reflection and Commenting
Research on peer commenting in blogs outside of medical contexts support the value of reflection and peer interaction (Sim & Hew, 2010; Sharma & Xie, 2008; Zeng & Harris, 2005)
One study using blogs for self reflection in a residency program found support for the tool but found the implementation and use time consuming (Shaugnessy & Duggan, 2013)

6. Challenges
What are your challenges in fully assessing doctor-patient communication?
Do you have peer feedback on resident communication and how do you incorporate that (group feedback? one other peer?)

7. Group challenges and peer feedback

8. Our challenges were:
Small residency core faculty (3 in addition to PD)
No Behavioral Health professional (to help provide expertise as well as participate in evaluation)
Increasing paperwork and documentation requirements for faculty and residents
Difficulty scheduling times for viewing
Unable to incorporate peer feedback in our current lecture/block rotation scheduling
Never had peer feedback before

9. Addressing challenges
Included this in our HRSA grant in 2011 and again in 2016
Partnered with Georgetown Graduate School, Communication, Culture and Technology Program
Knew we wanted to explore the outcomes

10. Setting up our blog Initiated IRB process
Written and vetted consent forms for patients and residents
Contact IT at Georgetown to set up the blog, initially on ShareStream (had been only HIPAA compliant platform in 2011)
Many Universities have blog sites for other courses
Now, upload videolinks on to box.georgetown.edu, then on to our blog

11. Focusing on Health Literacy
Each July, orient the interns to the blog and hold a 2 hour session on health literacy and feedback to peers on communication
Residents are taped 1/year, all 3 years of a class’s videos and comments remain on the same blog
Also have 1:1 meeting with a faculty member

12. Evolution of Blog Project
34 residents, 5 years, 80 videos, 260 blog posts
Blog start
7 residents
Blog start
21 residents
Blog start
21 residents
**changed numbers
Blog start
21 residents
Blog start
14 residents

13. Setting up our blog

15. Family Medicine Residency Blog

16. iPad for Filming: 256 GB

17. Box: HIPAA compliant
Screen Shot at PM

18. Georgetown University Wordpress Site
Gtown is password protected twice
Wordpress--- need to go to box to view and then blog on word press

19. Wordpress: Go to Privacy Settings and Click Private

20. Outside of Georgetown System

21. Research Projects Associated with Blog
Outlet
Title
Method
Findings
Health Communication
(2016) 31, 11,
What Residents Say about Communicating with Patients
Content analysis of 1,628 message units
7 types of messages
Journal of Communication in Healthcare
Revise and Resubmit
Creating a New Context for Dialogue and Reflection within a Residency Program: The Development of a Blog
Qualitative analysis of 63 posts of 7 residents and 13 doctor and patient interactions
Themes concerning resident concerns, blog topics, and discussion of patients
National Communication Association Presentation:
Dallas, TX, 2017
Creating a Middle Stage: Finding a New Space for Reflection within a Residency Program
Qualitative analysis of 95 responses
Themes identified five categories

22. Review of blog responses
95 blog responses, avg 296 words/response
446 excerpts, 101 codes, 5 sections:
1. visit narrative
2. issues to consider during the visit
3. communication
4. support
5. reflections on the experience.

23. Balance giving information 65
Visit Narrative
Code
Times appeared in Excerpts
Example
Balance giving information 65
This visit for me represents a typical day. I have one thing I am supposed to discuss with the patient bur for the sake of completeness, I end up covering a few other things to try to tie up loose ends
Negotiating the visit 40
Watching this now, I see yet again that I need to be more active in steering the conversation. In someone with low health literacy, maybe the best use of time is to restate the plan, instead of allowing a conversation exploring what he does and does not know about his current medications
Building Rapport with Patients 16
I do get it that sometimes you have to have a social appointment like this and ignore your desire to focus only on medical interventions in order to gain the patient’s trust/rapport. Of course these social visits can assist you in collecting more info about the patient’s social hx, understanding of their health, barriers (real and perceived) to care, etc.
Issues to Consider in the Visit
Computer Use 39
Using the computer to reconcile the med list was a very effective use of EMR
Interpreter Phone
No one can ever find the translator phone so we all end up using our cell phones…it would probably be best to use an official looking phone rather than pulling out a beaded + studded cell phone like I do

25. Communication
Listening to the patient 43
It’s exhausting listening to his disorganized agenda and it doesn’t leave a lot of time to address the interventions which are important to his health
Communication Style 32
I agree with the general theme above that you were very direct during this encounter, more so than I remember you being when we were taped as first years. Since this guy responds well to it, that’s a great thing – it made me think how we need to tailor our communication style to different patients
Body Language 30
Great eye contact and warm close at the end when you shook his hand
Patient Feels Comfortable 26
You were able to get the patient to laugh and feel at ease
Education and Literacy 24
You mentioned the number but reinforced that it was well controlled to help him know what the numbers mean
Calling Patient Out on Bad Behavior 14
It was not good that the patient “broke” her insulin bottle and then didn’t immediately get more. Is there a role for being disapproving or stern anymore? Has anyone had success calling a patient out for “bad behavior”?
Patient Not Talking 9
I felt the other challenge with this patient is that he is quiet and doesn’t offer a lot of in- depth answers

26. Patient Support System 7
I had to write a lot of questions for his daughter (who may kick him out soon) to follow. Each visit is followed by a call to a family member.
Missed Cues from Patient 6
We all miss nonverbal cues…like when she was rubbing her belly when you were looking at the computer. It could have been a clue that she’s having continued post-op pain
Support
Great job 53
You did a great job!
That Happens to Me All the Time 9
I have this exact problem
Reflections
What I Learned from Watching 14
I’ve never described the Quad screen like that before, I think it was straightforward and effective. I’ll have to steal some of your lines
Reflection on Own Video
As I watched the video, I kept thinking, “is that what I actually sound like?”
Agree with Other Comment
I want to dovetail on a few comments that others have started

27. Focus Groups Directly Compared Feedback Experiences
Face to Face
Blog
Communication Channel Differences
Say what you wouldn’t write out
Manage nonverbal critique
More time to think about feedback
More time to reflect
Peer Modeling
No opportunity to observe during traditional face-to-face rounds
Observe peers
Feel closer because of vulnerability
Logistical Concerns
No time to observe during traditional face-to-face rounds
Limited time; need concentrated asynchronous protected time

28. Resident Responses to the Program
Themes Identified
Example
Self Assessment
I noticed I was fidgety.
I did not make much eye contact when using the EMR.
I tried to cover too much with the patient
Comparative Assessments
I learned that we are different but that I am not outside the range of normal
Useful for us to see ourselves and our colleagues to confirm we’re all struggling with the same things, to learn tips from each other
Reflective Comments
I learned how to have more efficient time management as I have a tendency to have lengthier visits with lots of communication with the patient
Time Constraints
It would be more efficient to have the resident pick out a few minutes of the interview. Watching the whole visit is a huge waste of time

29. Ongoing challenges after blog set up
Initially, asked residents to comment on specific items/themes/questions---they didn’t like that
Desired time for 1:1 with faculty
Without protected time, residents didn’t always complete in full
Finding protected time for residents to view peers
Residents have asked for ‘alerts’ when someone comments
Recording early in year and having residents comment throughout the year seems better

30. Future Directions
Consider ways to alert residents on comments or send a summary
Incorporate patient reviews—currently a paper form (could consider a follow-up phone call with questions about communication)
?Assign residents to each other, instead of all classmates, pick half class

31. Thoughts and Challenges to Peer-blog in doctor-patient communication
(break into groups to discuss thoughts and challenges in including peer feedback and/or reflection blog)

32. What would your challenges be to having a reflection blog on doctor-patient communication?

33. Question and Answer
Thank-you!