A quiet revolution is underway in the way teachers and students interact using recorded lectures, YouTube, and the internet. In 2004, financial analyst turned online educator Sal Khan began tutoring his niece in math using an online drawing program. As he uploaded these lectures to YouTube, their popularity grew into a social phenomenon.
Today, Khan Academy has provided over 240 million online lessons around the world in over 4000 topics. Stanford, MIT, and other universities now offer massive open online courses (MOOCs) by top professors to all comers. In fact, Harvard Business School no longer offers an introductory accounting class due to the availability of an exceptional online course from Brigham Young University. With high-quality content readily available online, the student-teacher dynamic is changing. Students are expecting excellent instruction and teachers are expecting students to be increasingly knowledgeable about subjects from online viewing. These reciprocal heightened expectations have the potential to create a more dynamic and interactive classroom experience.
These innovations can also transform patient education by bringing patients into the circle of learning. Patients already leverage YouTube and other online sources for health purposes. For example, PatientsLikeMe was started in 2004 by the family and friends of Stephen Heywood who had been diagnosed with amyotrophic lateral sclerosis. This online community helps connect patients with other similarly affected patients and aims to educate patients about the illness experience and potential treatment options. This encourages patients to think synergistically about complex problems such as outcomes, decision-making and ethics. Today, PatientsLikeMe covers more than 1200 health conditions with over 100,000 members.
Given these broad ranging developments, we need to rethink the patient–doctor encounter. The typical encounter follows the traditional pedagogic paradigm of “banking” – in which the teacher, who has the power and the knowledge, seeks to deposit knowledge assets into the learner’s bank (1). Unfortunately, though this approach induces passivity and disempowerment it is the dominant mode of patient education. Instead, imagine encounters where patients are prepared to engage in shared decision-making, allowing the office visit to center on activities that promote patient-centeredness and engagement such as confirming patient comprehension, ascertaining values, and establishing goals.
Video education in medicine: advance care planning
Consider the topic of advance care planning. All patients should discuss their goals of care with their doctors – certainly patients with advanced illnesses deserve such discussions. Yet few patients have these conversations. It seems that physicians find it difficult to broach this topic, are pressured for time, or do not acknowledge the importance of the issue. Decades of advocacy have had little impact. Yet, we have shown that videos can help promote meaningful discussions between patients and physicians (3–5).
Imagine a typical advance care planning discussion occurring today. The physician provides the details of the potential treatment options and reviews the risks and benefits involved – possibly using language that the patient does not understand. What if the patient viewed a short, simplified and standardized video prior to or during the encounter that empowered the patient by presenting possible treatment goals and illustrating the medical procedures most consistent with those goals, reviewing common risks and benefits of each? Next, the physician has a discussion with the patient reviewing the video’s content, emphasizing patient specific considerations and discussing the patient’s questions. This process can improve the patient–doctor encounter, leading to greater interaction, satisfaction and understanding.
Additionally, videos provide a crucial quality control element, widely utilized in intensive care and surgical settings to promote quality and safety, but currently lacking in patient–doctor communication. At present, what information is offered to patients isentirely dependent on which provider the patient has and whether that provider chooses to inform the patient. Standardization is critical to assuring that patients obtain the information needed for informed decision-making.
Many clinical scenarios are suitable for video assistance. Our research consortium has tackled some of them, including providing options to patients about their choices at the end of life, and imagining future disease states such as advanced dementia and the likely medical problems complicating those conditions (3–5). Our studies suggest three important findings: (1) patients often lack essential information regarding their options; (2) the lack of patient information and empowerment leads to unnecessary – and frequently unwanted medical procedures; and, (3) videos can help surmount many of the information gaps and improve out- comes by helping patients avoid unwanted medical treatments (3–6). Receiving medical care that is discordant with patients’ wishes is a medical error no different from administering the wrong medica- tion or amputating the wrong body part. Videos can help empower patients to obtain the knowledge needed to avoid such medical errors. The shifting educational paradigm using online videos and MOOCs may help bring this to fruition.
Opportunities for videos in healthcare and quality control
Consider other ripe opportunities: videos helping caregivers to navigate the health care system or MOOCs reviewing medical illnesses such as dementia and heart failure from the early to late stages. Videos can potentially inform patients and caregivers at almost every point of contact with the health care system. Clinical research validates this perspective: short, well-made and easy to understand videos are associated with a wide range of benefits including improved compre- hension, decision-making, and satisfaction (3–5).
As with all new technologies, issues regarding quality control will arise. Below, we list some of the salient issues for the new video paradigm:
- How can we adequately evaluate all the new videos regarding content, objectivity, point of view and authenticity? Do we have to? How rigorous should these evaluations be without becoming burdensome?
- What criteria should exist regarding creating the videos in regards to the use of special effects and animation versus videos that show clinicians in real clinical settings? Is one more effective than the other or a combination of the two? Do patients prefer real images of doctors and patients rather than actors, avatars, or cartoons?
- Should such videos primarily exist within the non-profit sector where market forces are not as paramount as in for-profit entities? Should one be preferred over the other?The ongoing debate regarding the development of decision support technologies, especially when highly subjective content and media such as video are used, is instructive: when important questions regarding quality control, standardization and objectivity are raised early and transparently then consensus can be obtained (7). The important first step is to acknowledge the questions and to create guidelines for best practices.
Transforming the healthcare landscape with video education
If necessity drives innovation, health care is certainly at such a moment. We face a “silver tsunami” of an aging population, lack of advance care planning, funding cuts, and a growing shortage in primary and palliative care. Given the complexity of the issues involved, the best solutions will address foundational aspects of care. We believe straight-forward ideas – like videos to facilitate understanding – can address these problems if implemented correctly and applied in conjunction with improved communication strategies. The profession of medicine should harness the power of video technology to reinforce the patient–doctor interaction.
Medical progress will undoubtedly add further complexity to patient encounters. New treatments may lead to important benefits but also frequently yield added conceptual complexity for patients (and clinicians). In addition, patients are increasingly bringing their own information from internet searches and online communities to the patient–doctor encounter, the content of which is often unchecked. Using standardized and critically reviewed videos are a potent tool to help clarify complexity and appropriately weigh medical evidence.
While the ideal of activated patients and clinicians has been around for decades, it has not yet been actualized. In our view, a 21st century education paradigm that leverages videos and MOOCs will move us towards this goal. It is time to learn from the rapid evolution of online video learning techniques to empower patients and clinicians with short, simple videos. The physician then becomes a guide to help patients clarify their values and goals built on a solid foundation of information and understanding. Videos are a powerful tool for the patient and physician, and have the potential to significantly improve the delivery of care in an increasingly complex health care system.
This editorial originally appeared in Volume 1, Issues 3-4 of Healthcare: The Journal of Delivery Science and Innovation (HJDSI), released today, December 11, 2013.
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3. The Video Images of Disease for Ethical Outcomes (VIDEO) Consortium.
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