Residency programs often observe their residents in training to gauge their performance, with some even videotaping residents as they examine patients.
Studies in recent years in primary care and emergency medicine show that videotaping residents during patient visits can help improve trainees’ communication skills. But it can make some residents uneasy.
Austin Barry, MD, a second-year internal medicine resident at University of Nebraska Medical Center (UNMC), recalls feeling a sense of dread in the lead-up to being recorded last year.
“You’ve got to fit it into your schedule and find a good candidate, perhaps someone you’ve seen in clinic before but also not someone who’s coming in for a sensitive subject, and then have the consent discussion,” he says. Those conversations can be tricky, but Barry says once the encounter begins, both he and the patient tend to forget they’re being filmed.
Still, as awkward as it is to see yourself on tape, he says the feedback early in training is invaluable. “It captured moments where I could see how I came across to patients vs how I thought I was, like if I used a statement that sounded like I blamed the patient or spewed a bunch of medical jargon.”
However, residents recently expressed concerns about videotaping practices on Reddit’s residency forum. “They got cameras in the exam rooms where patients get their consult & physical exam,” user ToughBuy1483 posted. “Apparently, patients sign a waiver in advance? Madness.”
Another user, posting with the moniker DrFranken-furter, described three Midwest-based residencies that use this practice in family and internal medicine outpatient clinics. “One of them films and reviews with residents. The other two have the preceptors essentially turn on the camera randomly during their exams to spot check them for thoroughness,” the user noted.
Last year, the Joint Commission loosened its accreditation guidelines for hospitals filming and recording patients. Previous guidelines required organizations to obtain informed consent from patients before using images, video, or audio recordings of them for internal training and education purposes. The new standard states that a “hospital considers patients’ privacy and complies with law and regulation when making and using recordings, films, or other images of patients.”
Videotaping is more common in teaching hospitals, according to Lori Bruce, MA, MBE, HEC-C, associate director of Yale University’s Interdisciplinary Center for Bioethics. While videotaping can improve patient outcomes, ethical and legal troubles can arise when hospitals aren’t up front with patients about their rights and don’t have strict rules to protect patient privacy.
Despite changes in accreditation standards, Bruce told Medscape that clinicians should continue notifying patients about recordings.
“Videotaping patients should only be done with the patient’s explicit consent after ensuring their [mental] capacity,” said Bruce. “Are they an adult with full decision-making capacity? Or are they a minor? Do they have a disorder of consciousness, dementia, or are under anesthesia or heavily medicated?”
Residency programs should also consider what identifying information might be within view of the camera and if trainees and others in the room know they are being recorded, she says. Securing the images should be another top concern, since health facilities are increasingly vulnerable to data breaches. Bruce says residency programs must determine where video files will be stored and for how long.
Recording as a Teaching Tool
Recording exams and office visits during graduate medical training can offer a greater sense of a resident’s capabilities and the chance to self-reflect and build emotional intelligence, according to Mark Knudson, MD, family and community medicine professor at Wake Forest University School of Medicine in Winston-Salem, North Carolina.
He says that during orientation, videotaped observations are used to evaluate residents’ communication skills. Then, in the program’s human behavior rotation, residents choose additional patient encounters to record. In all situations, patients have to give their consent for videotaping, he says.
“We make clear to the patient each time that the purpose of this is not to look at them but at what the doctor does.” The camera is aimed at the resident to assess their interpersonal skills and patient engagement, with the exam table typically on the other side of the room, says Knudson, who outlined the process in a recent Frontiers in Psychology article.
Soon after, the resident joins Knudson, a behaviorist, and a peer to watch the recording and to identify ways to improve future interactions. Knudson says the videos are only used for teaching purposes and are deleted from the school’s server following the group review. “We’re very strict about that, even back when we used VCRs and had to physically destroy videotapes with a magnet,” he says.
University of Nebraska Medical Center residents in Omaha usually record a few encounters with patients who have more complex complaints, said Rae Witt, MD, associate program director of the school’s internal medicine residency program.
She told Medscape that staff will ask patients for permission to record the visit and obtain written consent, but that residents also further discuss it with them. The exam room has a third-party platform to record and secure the observation files, which are reserved solely for resident education.
Later, Witt meets with the resident to review sections of the recording, highlighting what the trainee did well and areas for improvement, such as balancing computer and patient time. The Accreditation Council for Graduate Medical Education wants residents to seek feedback from as many evaluators as possible, and video recording helps, Witt says.
“If faculty are in a room directly observing a resident, especially in the clinic where they are the primary care provider, it changes the dynamic of the visit,” she said. Video recording can create a more natural exchange that allows residents to see themselves in action, she said.
Knudson and Witt say that most patients are happy to participate and appreciate being part of the learning process, but they acknowledge that it can initially be uncomfortable for residents.
Rules of Consent
Ioan Lina, MD, a head and neck surgery resident at Johns Hopkins University, told Medscape that residents in his program are not recorded while conducting patient exams. But with technological advances making interoperative recordings possible, he says there are ethical and legal challenges to be sorted if the tech should ever become part of surgical training and skills assessment.
The school’s institutional review board has already begun evaluating how residency programs might navigate ethical and privacy concerns. “It will be interesting to see how that will be interpreted medically and legally, if it’s discoverable, and how patients respond,” said Lina.
To avoid legal trouble, hospitals or clinics that record patients should document their cases of informed consent. They should also regularly update policies to comply with confidentiality regulations and privacy laws, such as the Health Insurance Portability and Accountability Act (HIPAA) and the Health Information Technology for Economic and Clinical Health Act (HITECH), says Richard F. Cahill, vice president and associate general counsel for The Doctors Company, a medical malpractice insurer in California.
The American Medical Association provides guidelines for recording patients for public education as well.
“The documents should contain a history of editorial updates so that, in the event of an unexpected complication, the appropriate [information] can be reviewed and enforced with greater certainty,” he told Medscape.
Residency programs should establish clear guidelines for how the recorded material will be used, labeled, maintained, and purged. Even if the video was designed for training purposes, he says, recordings may become evidence in legal proceedings if an adverse event occurs during filming.
Steph Weber is a Midwest-based freelance journalist specializing in healthcare and law.
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