Can video recording revolutionise medical quality?
BMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h5169 (Published 21 October 2015) Cite this as: BMJ 2015;351:h5169All rapid responses
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Makary et al discuss the possibility of using video recordings to improve health professionals' practice, giving the example of reviewing a recording of an operation if they were going to reoperate on a patient.
Many specialties already store vast amounts of data about patient procedures. For example, during cardiology electrophysiological procedures, information from haemodynamic monitoring, monitoring of electrical waves from the cardiac catheters are recorded and stored. During ablation procedures, for example for atrial fibrillation, a 3D model of the heart is constructed and used to guide the ablation. This model is then stored and may be referred to if the patient requires further ablation procedures.
Will the NHS and any private or third sector providers have the capacity to store, and make retrievable, the increasingly large data files that we hold about patients? In the example of cardiac electrophysiological studies, the data are often stored in local or specialised systems. This has the advantage of involving a smaller database from which data can more quickly be retrieved. The disadvantage is that the information system is less joined up, and an anaesthetist in a surgical theatre, for example, may not be able to access information from the patient's peri-ablation haemodynamic monitoring. The elderly care consultant may only be able to access the summary report from an 24 hour Holter monitor, and may not be able to review the rhythm strip.
As well as considering what the implications are for doctors, we also need to consider the implications for patients of recording and storing their images and sounds. We already store images from modalities such as xray, CT and MRI routinely and photographs play a key part in recording for specialties like dermatology, but patients may perceive video images as more sensitive than numerical data or still images. Investigation of the views of individual patients and of patient representatives regarding the use of video images and sounds for managing an individual's case, for service evaluation and improvement and for teaching and training may help to guide future developments of our services.
Competing interests: No competing interests
The ubiquitous smart phone that has millions of users starting from toddlers who have joined the race has bounced vibrantly with its applications in all possible fields; however, echoes of its misuse can be felt reverberating in our ears. Smart phones can be a boon or a bane but most often they are misused in the wrong hands. There is a lot of hard work put in to start something innovative and useful but its usefulness slowly diffuses, leading to misuse/abuse that reaches its peak. A gadget that was once useful, a lifeline, can turn out to be a burden. The in vivo greed in humans has taken a toll on our mother nature in all possible ways that it can.
Video recording can be a fundamental right for patients to record their conversations, go back home listen to it, get a gross idea of the pathophysiology of the disease that was explained to them by browsing the net for the disease, correlating it with their symptoms and for some it would be reconfirming the right dose, the right drug and right time. Doctors are known for their incompressible prescription and limited talks which can further culminate into a feeble doctor-patient relationship.
Dr Barbara Korsch, professor of pediatrics who practises at USC-affiliated Children’s Hospital Los Angeles, has been studying the nuances of communication. In her carrier spanning up to 4 decades she had witnessed a few patients who had received marvelous medical care but they wouldn’t turn back, or follow orders due to faulty communication.
Paramedical staff members violating the practice policies by posting rare cases or recordings online, bystanders of patients capturing another patient's recording, jeopardizing one’s personal life are some of the hazards associated with these ubiquitous smart phones.
Video recording would revolutionalise medical care and is indeed a boon for patients who seem to have lost faith in doctors but patients need to embrace this change as a safe guard rather than considering it as a lethal weapon and bombarding it on doctors according to their whims and fancies. Lastly physicians need to redress their ideologies towards patient care and no more consider patients as passive and helpless sufferers; they need to be cautious enough in how they communicate and examine their patients as they are constantly scanned by their patients who are well equipped with powerful gadgets.
Competing interests: No competing interests
What a clear, positive and sensible analysis from Prof. Makary et al. It turns an incident which was (very) embarrassing for the medical profession into an occasion for considering the advantages to both patients and doctors in clinicians taking the initiative and introducing 'recorded daylight' into procedures otherwise usually only fully reviewed (if at all) by those actually carrying them out.
Those with whom I have been discussing this article also warm to Prof. Maheed's response. Yes, patients have the right to take an audio recording of how they are treated by doctors in many circumstances. Rather than, as some, reacting with self-defeating hostility to this increasingly easy, and increasingly deployed, option in the hands of patients, it is far better to embrace the change and make sure one understands its origins, implications, and usefulness. This is a patient initiative which, in the UK and most of USA, is entirely legal, and it's here to stay.
Dr Kumar's response we find alarming. The argument that there isn't 'time' for doctors to adhere to all relevant 'health and safety guidelines' (at least in some circumstances where an anaesthetist is involved, it is to be presumed), but that it would be 'insulting' for there to be recorded evidence of such non-adherence, deserves no respect from patients, their families, or any part of the medical profession, I suggest. It is, perhaps, at least as courageous as fair for the BMJ to publish Dr Kumar's views; but one has to wonder what his employers would think when reading them – or a tribunal or court would think, if such views were introduced into evidence after, say, a surgical fatality involving their author.
Competing interests: No competing interests
It could be a double edged sword. Most health professionals are well behaved but recording is an insult. We will be wasting more time in trying to look the best. There are procedures which look ghastly for the common man. Sometimes to save time, staff resort to procedures which are against health and safety guidelines. To be on best behaviour we need to wait for the most appropriate time and instruments which may be lacking at times but we get on and get the job done.
We can't afford this new insult.
Competing interests: No competing interests
In England, patients have the right to record their consultations with doctors. They can even record a consultation without a doctor’s consent, because the information they are recording is personal to them and is thus exempt from the data protection principles in the Data Protection Act. Hence, doctors cannot decline a patient’s request to record their consultation. Doctors can though ask patients to explain why they wish to make a recording. There may an innocent explanation – for example, the patient may find it difficult to understand and retain the information they receive during a consultation and wants to be able to listen again to the consultation later. If a doctor thinks that being recorded could affect their performance during the consultation, they can ask the patient not to make a recording. But ultimately doctors cannot decline a patient’s request if they insist on going ahead with a recording. With the ubiquity of smartphones, many patients now have the ability to make an audio or video recording of their consultations. Recording of consultations may therefore become more common and something that doctors will have to accept.
References
Majeed A, Birch R, Swinyard P. Can I stop a patient recording our consultation? Pulse 21 October 2015.
http://www.pulsetoday.co.uk/your-practice/dilemmas/can-i-stop-a-patient-...
Footnote: This rapid response is based on an article I wrote for the Professional GP magazine Pulse.
Competing interests: No competing interests
Video: an under-used source of data for research on the quality and safety of health care
In their editorial Martin Makary and colleagues make a case for routinely video recording clinical events. Their arguments, and those made by respondents so far, focus on two questions: What is the effect of video on the behaviour of health professionals? and: Who might use video and for what purposes?
Makary et al.’s response to the first question is grounded in the notion, theorised by Michel Foucault, Erving Goffman and other sociologists, that people behave differently when they know that they are being watched. Yet we also know that awareness of eyes and cameras around us can fade; and they do not always stop people from behaving in ways they know might be considered inappropriate. Indeed those being watched and those watching frequently do not have a shared understanding of what counts as appropriate or acceptable behaviour. The comments by Rick Sykes and Nithin Kumar are a point in case: what is seen as an in-excusable breach of protocol by the former is seen as an entirely understandable ‘workaround’ by the latter.
The responses to the second question are twofold. On the one hand, commentators have given examples of how health professionals, both inexperienced and experienced, might use video to learn by reviewing recorded past events, e.g. to prepare for performing a clinical procedure. On the other hand -and this may well be the more controversial issue- they suggest that video could be used by external parties with the authority to monitor compliance with protocol, or to investigate adverse events.
I wish to highlight a third possibility, namely to use video as a source of data for social science research. Using specialist methodologies social scientists have already been able to render visible, measure and explain the day-to-day delivery of health care. For instance, video data of surgical operations, produced with the laparoscopic camera, wide angle cameras and microphones worn by the surgical team have been used to identify intra-operative decision making strategies (1); measure the frequency of occurrence of problems of communication between surgeons and scrub nurses (2); and detect barriers to the successful completion of the WHO Surgical Safety Checklist (3).
Much of this research takes advantage of distinct properties of video. For instance, the possibility of replaying the audio and visual record in slow motion makes it possible to attend to critical details that are extremely difficult to register and record, let alone remember, in real time. Much like the microscope made it possible to analyse a blood sample at the level of blood cells, so can video recordings make it possible to render visible and analyse human behaviour at the level of a pointing gesture, a rising intonation, or momentary shift in the direction of gaze. It is at this micro-level that evidence about the delivery of health care can be gathered and interpreted.
At the moment, video is still relatively under-used in social science research on the quality and safety of health care; much research still relies on recollections gathered through interviews, or on notes taken on-the-spot as researchers observe practice. Regardless of whether a policy of routine video recording will be adopted on the grounds stated by Makary et al., increasing the use of video in studying clinical practice could revolutionise the evidence base for developing health care policies, guidelines and protocols.
References
(1) Bezemer J, Murtagh G, Cope A, Kneebone R. Surgical decision making in a teaching hospital: A linguistic analysis. ANZ J Surg 2014 (Epub ahead of print).
(2) Weldon S-M, Korkiakangas T, Bezemer J, Kneebone R. Music and communication in the operating theatre. J Adv Nurs 2015;71(12):2763-2774.
(3) Korkiakangas T. Mobilising a team for the WHO Surgical Safety Checklist: a qualitative video study. BMJ Qual Saf 2016 (Epub ahead of print).
Competing interests: I have used video as a source of data in my research and published on video based methodologies..