Lights, Camera, Action… In Healthcare

About eight years ago I was desperate to improve my golf game. I just couldn’t straighten out my drives or hit my irons crisply. (Yes, I’m fully aware that this is a First World problem). I decided to try golf camp in Palm Springs for a few days.

My sensei, a crusty ex-touring pro named Artie McNickle, watched me hit several dozen balls on the driving range, video recorder running. “So, did you figure it out?” I asked with hint of sarcasm after my last shot. I thought I was a hard case.

“Sure.”

“How long did it take you?” I asked.

“One or two swings. But you looked like you were having a good time, so I didn’t have the heart to stop you.”

Artie patiently told me what I was doing wrong. Though it made sense in theory, when I tried to follow his directions, I didn’t get very far.

“Let’s look at the video,” he offered. “Whose swing do you really admire?”

I named Ernie Els and Tiger Woods, two pros with silky smooth yet powerful swings.

“Fine,” he said. On a video screen, I appeared on the left side. As if by magic, Ernie Els was on the right.

Screen Shot 2013-10-18 at 9.48.30 PM

Els, not me

“OK, let’s see where your club is about 18 inches into your backswing.” My hands were low, and the club formed a straight line with my arms; my wrists hadn’t begun to cock. He then showed Els at the exact same point in his swing. His club was facing skyward, forming an acute angle with his wrists. This wasn’t a subtle difference in technique; it was an enormous one.

We then reviewed my follow-through. Once again, about two feet after I’d struck the ball, my club extended straight out from my arms. Conversely, Els had his wrists swiveled about 45 degrees counterclockwise, his right hand rotated powerfully over his left.

Tiger’s swing was slightly different, but similar in all the ways that mattered.

My trek to Palm Springs shaved 2-3 shots off my score (and they haven’t come back). I’m convinced it was the video that did it.

This kind of video coaching has become standard procedure in major league sports. My son Doug, who works in baseball operations, tells me that every major and Triple A minor league game is video recorded. Not only do players watch themselves to see what they’re doing right and wrong, they watch how other teams play pitchers or hitters who resemble them in style and build.

Yet we hardly ever use this extraordinarily powerful tool in healthcare. Thankfully, that’s beginning to change.

Earlier this year, Johns Hopkins surgeon Marty Makary published a JAMA article entitled “The Power of Video Recording.” It’s a thoughtful and eye-opening piece, well worth a read.

Makary reviews several ways video can be used for peer review, quality improvement, and coaching. I’ve previously described the use of video monitoring for hand hygiene: a study performed at Long Island’s North Shore Hospital found a staggering uptick – from 7 to 82 Screen Shot 2013-10-18 at 9.52.15 PM percent – in hand hygiene performance in ICUs that were monitored with cameras pointed to the sinks and gel dispensers. The key was that there was someone in Bangalore, India reviewing the video feed every hour and sending back compliance data, which was posted on an electronic tote board – real-time feedback, either positive or negative. Makary also cites a study in which gastroenterologists whose colonoscopies were video recorded improved their performance by one-third. As Makary observes, the obstacle to doing this is not a technical one: there’s plenty of video equipment in the operating room. “Procedures ranging from cardiac stent placement to arthroscopic surgery are performed using sophisticated video equipment; however, the record button is turned off.”

Adding to this literature, one of the most impressive health services research studies in recent memory was published last week in the New England Journal of Medicine. In it, Screen Shot 2013-10-18 at 9.53.07 PMJohn Birkmeyer, a surgeon and researcher at the University of Michigan, described the results of a study in which 20 bariatric surgeons submitted videos that demonstrated their surgical technique. The recordings were rated by several peers on a 1-5 scale, where 1 was the skill expected of a general surgery chief resident who hadn’t yet performed this complex operation, 5 was that of a master bariatric surgeon, and 3 was that of the average bariatric surgeon. I’m not sure why, but I would have naively guessed that – though the recordings might reveal a quirk or two – everybody’s technique would be pretty good, and not terribly dissimilar.

I would have been dead wrong. The reviewers, who were blinded to both surgeon and institution, used a lot of the terrain on the grading scale. Surgeons in the top quartile averaged a 4.4 (on 5 domains, including exposure, flow, and gentleness), while the lowest quartile surgeons had a mean rating of 2.9. The ratings did not correlate with years in practice, fellowship training, or teaching vs. nonteaching hospital. Instead, they correlated strongly with surgical volume: lowest quartile surgeons averaged 106 bariatric procedures in the prior year, while highest quartile performers averaged 241. (Of course, this doesn’t answer the age-old chicken vs. egg question of whether better performers get more cases, or more cases make better performers. But it does support the use of volume as a proxy for quality, at least until video is more readily available.)

Here’s the amazing thing: after adjustment for any patient differences that might have influenced outcomes, surgeons who were rated in the top quartile technically had far better outcomes than those in lowest quartile. The better technicians got through their cases more quickly (98 vs. 137 minutes) and had lower infection rates and lower overall complication rates. Their patients required readmission, return to ER, or reoperation less than half as often as the patients of their less skilled colleagues. Finally, their mortality rate was one-fifth as high (0.05% vs. 0.26%), all significant differences.

Importantly, all of the participating surgeons were volunteers, and the videos were selected by the surgeons themselves. This makes it likely that the variations observed in the study might understate the real world differences. Scary stuff.

In 2011, Atul Gawande, in one of his wonderful New Yorker pieces, wrote about coaching. Gawande described how he invited a senior colleague, a retired Brigham surgeon named Robert Osteen, to observe him performing a thyroidectomy, a procedure that he had done roughly a thousand times. One piece of Osteen’s advice bore a remarkable resemblance to what I heard from Artie McNickle on the driving range:

Osteen also asked me to pay more attention to my elbows. At various points during the operation, he observed, my right elbow rose to the level of my shoulder, on occasion higher. ‘You cannot achieve precision with your elbow in the air,’ he said.

Yet as helpful as Gawande found the coaching, it was awkward to have the observer in the room – seen by peers, other staff, and especially patients. One patient, seeing Osteen in the corner, asked, “Who’s that?” Gawande called Osteen “a colleague,” adding, “I asked him along to observe and see if he saw things I could improve.” After seeing a look on the patient’s face “somewhere between puzzlement and alarm,” Gawande added, “He’s like a coach.” The patient did not seem reassured.

Just think how much easier it would have been if Osteen had been watching a video feed. (In fact, Gawande’s Brigham group has been experimenting with just that.) Similarly, in the famous Northern New England Cardiovascular Study, cardiovascular surgeons traveled to each other’s hospitals to watch their peers perform surgery, providing honest feedback about matters ranging from surgical technique to teamwork. The result: a 24% decrease in surgical mortality. As fabulous as these results were, the study – performed more than 20 years ago – has not been replicated, undoubtedly because of the hassle and expense of the intervention. Here too, video could make such observation and feedback far more routine.

I had the chance to try Google Glass a few weeks ago, through a company that Google is working with to identify “use cases” in healthcare. Well, here’s one: how about if novice surgeons – or all surgeons – periodically did operations that were observed, in real time, by certified experts, who then provided them rapid, perhaps even real time, feedback.

While the primary use of such information should be for coaching and improvement, after watching the videos (examples that illustrate good and poor technique accompany the Birkmeyer article), I would not want a lowest quartile surgeon rummaging around my abdomen. (Even I, a complete novice when it comes to surgical technique, could easily distinguish between the assured, polished motions of the experts and the hesitant, clumsy moves of the lower performers.) Putting on my ABIM hat, this study suggests that we need to move briskly into measuring the technical proficiency of proceduralists… and perhaps everyone else. One could easily imagine differences like these in the quality of history taking, physical examination, and end-of-life discussions.

As with all quality measures, the primary use should be for improvement. But the surgeon whose technical performance remains poor even after feedback and practice should not be certified, at least for that procedure. In a recent interview, Birkmeyer endorsed this stance, while pointing out the many knotty issues it raises, such as where to set the threshold.

The instinct to go to the video is an area in which the young ‘uns have a big advantage over geezers like me. My wife did a story in the New York Times last year about the digital revolution in doctoring. The Times brought along a videographer to follow one of our VA-based teams on rounds. When the team was visiting one of its first patients, the 78-year-old man had a grand mal seizure. Several of the team members gathered around the patient to attend to his airway and circulation. An intern stood at the foot of the bed and promptly pulled out his cell phone.

Did he go on Epocrates to check the dose of Lorazepam? On UptoDate to find the management algorithm for new onset seizures? No, he began video recording the seizure. A Times reporter asked him why. “I wanted to record his activity…. So rather than describe to [the neurologist] what took place, I can just show them a video of what took place, and they’ll be able to assess better and treat the patient.”

With tools like smart phones and Google Glass, the technical obstacles to the widespread use of video are beginning to melt away. Of course, other barriers – patient privacy, clinician pride, archiving, cost, the “eewww” factor – will remain. Let’s work through these quickly, so that we can take full advantage of this remarkable tool to improve our patient care.

15 Responses to “Lights, Camera, Action… In Healthcare”

  1. Abhay Padgaonkar October 19, 2013 at 10:07 pm #

    Great post, Bob!

    Even high school football games are recorded and game film is used for coaching now. Do you think the record button is turned off” so as not to leave any evidence behind?

    Although 20 bariatric surgeons is a fairly small sample to truly speak of quartiles, the dispersion and correlation in data is fascinating. Don’t you think that the relationship between quality vs. volume is probably shaped like an inverted U?

    I m not sure I agree with your recording intern story though. There should be a difference between a camera operator and a doctor.

    For the most part, CME is a joke. Maybe it needs to change to Coaching & Medical Education whereby the required hours are spent in coaching rather than in cruising the Mediterranean. I just hope that the medical profession is not too arrogant to accept that change.

  2. Sandra October 20, 2013 at 8:38 am #

    Although the study focuses on the use of video monitoring of the operations and such, i can not stop worrying about the other aspect of the study, namely that there are surgeons around there who are not competent to do their job and are still at work!
    Who will guarantee me that i wont get operated on by a clumsy surgeon? And these are apparently surgeons who think that they do a good job, otherwise they wouldn’t volunteer in this project if they knew they sucked!

  3. Pink Ribbon October 20, 2013 at 10:46 pm #

    How inappropriate on a widespread basis. Who are the master surgeons, exactly, and who annoints them, under the scenario described? Did the patient give the intern permission to video the seizure? I would volunteer for video, but I can imagine that there could be inappropriate use by competitors and faux peers.

    Before videoing everything, video the important stuff (such as alarmed exit hospital exit doors) and address the mundane: There is an increasing incidence of egregious dysfunctions in the US hospitals, from conflicts of interest, patient neglect, inappropriate treatments, dangerous robot surgery, EHR crashes worse than healthcare.gov, cut and paste notes, bedside acting (long white coats sans attending intellect) by paraprofessionals, flawed decision support, awful deaths in stairwells, awful deaths on rooftops, and HIT doing more harm than good.

  4. Menoalittle October 21, 2013 at 12:52 am #

    Bob,

    Ernie Els’ swing is different than that of Tiger Woods and both are different than yours and your swing will never come close to that of the tour golfers. Go dream. Did your handicap improve by a few strokes after your video sessions?

    Video may be useful in specific settings to improve skills, notably in residency and fellowship training. But who should be the judge? And who will grade the judge’s surgical technique?

    What I would like to do is to video the EHR CPOE device in action, and compare my efficiency and outcomes as a clinician using EHR CPOE devices for orders with my efficiency when using paper handwritten orders.

    Best regards,

    Menoalittle

    • Bob Wachter October 21, 2013 at 1:05 am #

      Yes, Menoalittle, the answer is yes: my handicap improved by about 3 shots – which is more than I can say for anything else I’ve done, including intense practice and new equipment. There is something about seeing your technique next to that of an expert that makes a lesson come alive. It will be interesting to see whether the surgeons with the low scores can be improved with similar coaching. Birkmeyer’s research group is beginning to study that question.

      That said, golf is (a bit) easier than surgery, and it is far more straightforward to define an expert, since the outcome variable (your score) is unambiguous. Moreover, it doesn’t need case-mix adjustment and isn’t partly dependent on a team and an organization. So, as usual, while we can learn things from other industries, we have to pay attention to healthcare’s fundamental differences.

      All the best.

      — Bob

  5. Michael Millenson October 24, 2013 at 3:02 am #

    In the early 1990s, I visited the OR of Dr. Lanny Johnson, a Michigan orthopedic surgeon who had pioneered arthroscopic surgery. He was good enough to have private pay patients coming to him from Palm Springs, FL in cold weather, and good enough that he had his own dedicated OR with a glassed-in observation deck above and video recording equipment below. Here’s what I wrote about him in my book, “Demanding Medical Excellence” in 1997:

    “Lanny Johnson, a North Lansing, Michigan, surgeon, videotaped each of his surgeries until he left the active practice of medicine. Johnson studied his tapes constantly to find ways to improve. (At one point he even offered his local HMO a “no complications” guarantee.) Johnson’s review of the videos is something college football coaches do all the time. Are athletes less “artists” than surgeons, or does the difference in our expectations come from the mind-set we bring to that question?”

    Money-back guarantee=value-based payment. Video=”best practice” and transparency.

    Did I mention that the other surgeons hated him? Hey, they probably hated Semmelweiss, too, for noodging them to wash their hands. None of this is a matter of technology. All of it is a matter of doctor culture — and blogs like yours, Bob, and articles like those in the NEJM and The New Yorker are an immense help. Oh — and reimbursement changes, too.

    • Dawn Wang October 29, 2013 at 3:01 pm #

      This is such an interesting article. I believe video can be a very important tool in lieu of other better options. I believe that we have to find a way to critique ourselves and each other. Unfortunately this cannot be done effectively in the OR. Not only is it a large expense, but a problem for the patient and the rest of the OR team as well. It reminds me of art school where we all saw each others work. The instructor would constantly go around giving advice. At the end of the project, they were all displayed prominently and we ALL critiqued them. Unlike M & M, it wasn’t about public humiliation but improvement.

      I will certainly put this forward as an option at our QIC conference. We will see if it generates a positive discussion. I am however in a surgical field with a large amount of personality pathology, and we tend to “eat our young.”

  6. Canera Shy October 27, 2013 at 6:16 pm #

    Where was the camera when it was needed? Bob, I think you are going overboard with this camera stuff, just as you did with MOC. How about managing basic infrastructure problems before spying when it is not wanted?

    http://www.sfgate.com/default/article/S-F-General-made-4-search-requests-attorney-says-4928023.php

    Homeless in stairwell
    Critchfield emphasized there is no proof that even if there was someone in the stairwell that day, it was Spalding, the family’s attorney said.

  7. T Little October 31, 2013 at 3:15 pm #

    As someone who has been on the film crew of surgeries, it is not a super easy task or very DIY. Do you want your surgeon adding to their busy thought process mid-surgery “did we get that shot?” While google goggles sounds like a great idea, they do not have any of the technology or lenses & light of a current head-cam which in itself needs frequent monitoring and head mount readjustments. The overhead camera in the OR is useful maybe 40% of the time due to surgeons’ heads constantly getting in the way. To overcome that, we used a minicam on an articulating boom pole (monopod) over the cavity as well as the head cam and combined the two in the edit for proper coverage. While I understand the overall idea of accountability, I am curious how many of these OR shoots were DIY and still contained enough usable footage to be worth a watch. So the cost of filming could also be an obstacle.

  8. Michael McCann January 10, 2014 at 9:34 pm #

    During my time with the DoD as a Patient Safety Manager, we were implementing TEAM STEPPs as a method to improve our PS culture and staff communication and teamwork. We conducted team training in a hi-fidelity simulation center which included video recordings of the training. The video did not lie and team leaders and team members could not hide. This was a great learning tool for team leaders who were very authoritarian to see the impact of their actions on a team as well as on team members who witnessed (through simulation) when they did not speak up when they had concerns. We were able to improve our PS culture as well as adverse incidents related to poor communication.

  9. Kate Burke,MD February 13, 2014 at 2:32 pm #

    Thanks for the great post Dr Watcher! Video is a PERFECT way for patients to ‘re-visit’ the critical part of an encounter with a clinician. I discovered using video initially for my own physical therapy after a skiing accident in 2008 and promote the concept with my patients, medical students and attendings. Video instruction and playback is used in sports ALL the time!!! I desperately wanted to get back on my feet and was frustrated with the xerox copies and stick figure drawings. Now the HIPAA compliant application PostwireHealth makes using video a snap in the clinical environment. The rapid rise of mobile and using video as a communication tool is finally making headway in medicine. A few years ago this notion seemed very techie/difficult and now my medical students want to know why this is not standard practice!! In the best of circumstances patients only retain 50% of our instructions so why not give them a chance to retain the info and share with family members in a simple video format. Therapists, care coordinators and clinicians integrate the practice right into the patient encounter with tremendous patient(and family) engagement. Replaying the visit adds value to the encounter especially in the era of value based purchasing! Utilizing patient specific video exemplifies the true spirit of ‘meaningful’ use in healthcare!

  10. Ryan Kurstin April 1, 2014 at 3:04 pm #

    Whether people agree that the experiment/study was good or not, I have to say that I believe that the use of technology in any way in the medical industry is a great idea. I am open to trying out new ways that can potentially benefit the industry, which in turn makes treatment for patients better.

    In this case, I think that using the footage from surgeries etc as a ‘coaching’ aid, could be useful to interns, and trainees. A combination of being in the room and watching a surgery, then being able to -watch it on video can be very helpful as it will reinforce what they saw whilst watching in real time.

  11. Dennis October 1, 2014 at 1:49 pm #

    Even Residents now watch procedures that they have never done on YouTube to learn the techniques and sequences.

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  1. Lights, Camera, Action… In Healthcare | Wachter’s World | Deesilo | - October 21, 2013

    […] Fantastic. “Clinical Video can be used for peer review, quality improvement, and coaching…. Barriers = Privacy, clinician pride, archiving, cost…” Something tells me we’ll find a way to use video more often to improve clinical procedures + environment. http://community.the-hospitalist.org/2013/10/19/lights-camera-action-in-healthcare/ […]

  2. Lights, Camera, Action… In Healthcare - October 21, 2013

    […] http://community.the-hospitalist.org/2013/10/19/lights-camera-action-in-healthcare/ […]

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