Paired Observation and Video Editing (POVE) Blending Continuous Peer Feedback and Reflection to Strengthen Communication Training Larry Mauksch, M.Ed, University of Washington

Acknowledgments Angel Platus, MD Angel Platus, MD Kim O’Conner, MD Kim O’Conner, MD Stu Farber, MD Stu Farber, MD Tom Greer, MD, MPH Tom Greer, MD, MPH Many in this room Many in this room

A challenge in teaching and assessing communication in medicine… Without protected time, it is difficult for learners to intentionally …. Practice Define Reflect upon Refine the use of Refine the use of Assess Assess Integrate Integrate …communication skills

Goals: Paired Observation and Video Editing To help students develop a lasting, articulate “observer self”--the ability to reflect on and refine (communication) skill use to optimize interactions with patients. To help students develop a lasting, articulate “observer self”--the ability to reflect on and refine (communication) skill use to optimize interactions with patients. To demonstrate “growing competence” in using core communication skills. To demonstrate “growing competence” in using core communication skills. To create a learning laboratory for faculty To create a learning laboratory for faculty

Course Philosophy Clinicians have a strong, but often undisclosed desire to become more effective communicators. Clinicians have a strong, but often undisclosed desire to become more effective communicators. They experience ineffable inadequacy They experience ineffable inadequacy If given the language, time, and responsibility, trainees will help one another increase competence. If given the language, time, and responsibility, trainees will help one another increase competence. Assessment and learning should be part of one integrated, ongoing process. Assessment and learning should be part of one integrated, ongoing process.

Differentiation Precedes Integration Observing and categorizing behavior enhances articulation Observing and categorizing behavior enhances articulation One’s precision (differentiation) in describing skills is proportional to one’s ability to be creative in skill application (integration). One’s precision (differentiation) in describing skills is proportional to one’s ability to be creative in skill application (integration). With a distant reference to Michael Polyani’s book, Personal Knowledge

Course Design: 4 weeks Paired Observation Phase Paired Observation Phase 3 weeks 3 weeks Video Editing and Presentation Phase Video Editing and Presentation Phase 1 week 1 week

Paired Observation: First 3 weeks Students see patients on preceptors’ schedule Students see patients on preceptors’ schedule They always see patients together alternating roles as observer and “physician” They always see patients together alternating roles as observer and “physician” Tracking forms are used to: Tracking forms are used to: structure observation and feedback structure observation and feedback catalog interviews for video editing catalog interviews for video editing Instructor(s) give mini didactics, review videos and discuss encounters with students Instructor(s) give mini didactics, review videos and discuss encounters with students Interviews are videotaped, with patient consent Interviews are videotaped, with patient consent

Mini Talk Topics 4 week course (12-14 hours of presentation) Orientation to course Orientation to course Giving and receiving feedback Giving and receiving feedback Video recording, editing and patient consent Video recording, editing and patient consent Overview: relationship, communication and efficiency Overview: relationship, communication and efficiency Mindful practice Mindful practice Upfront, collaborative agenda setting Eliciting the patient perspective Reaching common ground Family assessment Behavior change / primary care counseling Requested topics

Schedule: Paired Observation MonTuesWedThursFri Orient, Giving Feedback Clinic Agenda setting ClinicClinicClinicDebriefClinic Shared Decision ClinicOverviewClinicDebrief Cues and PPI ClinicClinic Video review Clinic Tape catalog

Video Editing-4th week Students create a video essay examining their growth Students create a video essay examining their growth Students design, film and edit a role-played teaching tape Students design, film and edit a role-played teaching tape Students present their work in one or more interactive seminars to fellow students, residents and faculty Students present their work in one or more interactive seminars to fellow students, residents and faculty

Videotape Editing: Instructions for Students For video essay, “study your growth by including..”: For video essay, “study your growth by including..”: Baseline skills Baseline skills Struggles Struggles Best performances Best performances Use protected time to review, catalog and edit Use protected time to review, catalog and edit Create a teaching tape Create a teaching tape Be creative and have fun! Be creative and have fun!

Schedule: Video Editing MonTuesWedThursFri Video review and editing Clinic Teaching tape creation Eval Video review and editing Present Teaching tape creation Present

Summary of a 4 Week Course Student pairs see patients in 3 weeks Student pairs see patients in 3 weeks 75% of patients consent to be videotaped 75% of patients consent to be videotaped Video essay is minutes. Video essay is minutes. Video essay presentations easily take 90 minutes because discussion is expansive. Video essay presentations easily take 90 minutes because discussion is expansive. Teaching tapes have been used to train hundreds of students and faculty Teaching tapes have been used to train hundreds of students and faculty

All students demonstrate growth in: Upfront collaborative agenda setting Upfront collaborative agenda setting Picking up on patient cues and exploring patient, family and cultural perspective Picking up on patient cues and exploring patient, family and cultural perspective Expression of empathy Expression of empathy Reaching mutual agreement on a plan Reaching mutual agreement on a plan Efficiency Efficiency

Student Evaluations ( 11 pairs of 4th year students) “Peak experience” “Peak experience” “Best course in medical school” “Best course in medical school” Students feel: Students feel: More organized More organized More able attend to the patients More able attend to the patients More able to learn about disease, because they are… More able to learn about disease, because they are… Less anxious about time management Less anxious about time management Interviewing is less mysterious Interviewing is less mysterious

POVE - secondary outcomes Faculty learning Faculty learning Students learn teamwork skills Students learn teamwork skills Student pairs are efficient Student pairs are efficient Contribution to the educational community Contribution to the educational community

Other Applications Use only Paired Observation (no video): Use only Paired Observation (no video): Medical student / Residency training on a larger scale Medical student / Residency training on a larger scale Faculty development Faculty development CME CME Conceptual preparation can be done without faculty time: videos, reading, Powerpoint Conceptual preparation can be done without faculty time: videos, reading, Powerpoint Videotapes(or CDs or DVDs) become portfolios Videotapes(or CDs or DVDs) become portfolios

Limitations Not all rotations would work Not all rotations would work Decreased patient volume? Decreased patient volume? Start-up cost for AV and computer equipment Start-up cost for AV and computer equipment Some people may have difficulty learning to accept and give feedback Some people may have difficulty learning to accept and give feedback Paired observation may feel burdensome to preceptors (…but it takes no more time) Paired observation may feel burdensome to preceptors (…but it takes no more time) POVE design deserves research… POVE design deserves research…

Video Editing Tips Orientation takes < 40 minutes (iMovie 2) Orientation takes < 40 minutes (iMovie 2) Introduce students to editing by using three, one minute clips of themselves in role plays Introduce students to editing by using three, one minute clips of themselves in role plays Use software tutorial programs Use software tutorial programs Tapes should be no longer than 30 minutes Tapes should be no longer than 30 minutes Use short clips, 15 seconds to 3 minutes Use short clips, 15 seconds to 3 minutes Clips should include enough lead to create context for the viewer seconds Clips should include enough lead to create context for the viewer seconds

Video Editing- Costs and Equipment Current prices of PCs and Macs between $1100 and $2500 and beyond Current prices of PCs and Macs between $1100 and $2500 and beyond Get lots of RAM - at least 512; 1gig better Get lots of RAM - at least 512; 1gig better Consider buying extra hard drive for storage and faster editing Consider buying extra hard drive for storage and faster editing Using analog cameras requires purchase of analog to digital converter, about $300 Using analog cameras requires purchase of analog to digital converter, about $300 Cost of VCR, monitor and tapes Cost of VCR, monitor and tapes

Logistical Considerations Preceptors must be oriented, trained if possible Preceptors must be oriented, trained if possible Great way to reinforce resident learning and educate faculty Great way to reinforce resident learning and educate faculty Distribute precepting across several senior residents and faculty Distribute precepting across several senior residents and faculty Nursing staff need to be included to make sure patient flow is not adversely affected Nursing staff need to be included to make sure patient flow is not adversely affected Protect time in the preceptor’s schedule Protect time in the preceptor’s schedule Distribute schedules ahead of time to all involved Distribute schedules ahead of time to all involved

Logistical Instructions for Students Meet nursing staff and preceptors in advance of each clinic Meet nursing staff and preceptors in advance of each clinic Protect time for video review and logging Protect time for video review and logging Never see two patients at the same time, especially with the same preceptor Never see two patients at the same time, especially with the same preceptor Protect time in advance for student video presentation Protect time in advance for student video presentation

POVE DISSEMINATION PROJECT Funded by Arthur Vining Davis Foundations Funded by Arthur Vining Davis Foundations Three year program to create a learning community with 9 medical schools Three year program to create a learning community with 9 medical schools

Goals To disseminate the POVE model To disseminate the POVE model To stimulate faculty exploration of how to teach and how students learn To stimulate faculty exploration of how to teach and how students learn To provide an in-house resource for the creation of training tapes To provide an in-house resource for the creation of training tapes To study the learning process of medical students and their teachers To study the learning process of medical students and their teachers

Participants Receive Three day training in Seattle (winter, 07’) Three day training in Seattle (winter, 07’) Computer with video editing software Computer with video editing software Curriculum and site visit Curriculum and site visit Three day learning & evaluation conference in Seattle for one faculty and two students (fall, 08’) Three day learning & evaluation conference in Seattle for one faculty and two students (fall, 08’)

POVE Research Web surveys of faculty and students Web surveys of faculty and students Qualitative and Quantitative Qualitative and Quantitative Learning and Evaluation conference Learning and Evaluation conference Focus groups Focus groups Faculty Faculty Students Students Video essay reviews Video essay reviews Teaching tape reviews Teaching tape reviews Pre-post tape comparison Pre-post tape comparison