gms | German Medical Science

GMS Zeitschrift für Medizinische Ausbildung

Gesellschaft für Medizinische Ausbildung (GMA)

ISSN 1860-3572

Video-assisted feedback in general practice internships using German general practitioner's guidelines

project medicine

  • corresponding author Regine Bölter - University Hospital Heidelberg, Dept. of General Practice and Health Services Research, Heidelberg, Germany
  • author Tobias Freund - University Hospital Heidelberg, Dept. of General Practice and Health Services Research, Heidelberg, Germany
  • author Thomas Ledig - University Hospital Heidelberg, Dept. of General Practice and Health Services Research, Heidelberg, Germany
  • author Bernhard Boll - Privat General Practice Drs. Boll/Lüken, Heidelberg, Germany
  • author Joachim Szecsenyi - University Hospital Heidelberg, Dept. of General Practice and Health Services Research, Heidelberg, Germany
  • author Marco Roos - University Hospital Heidelberg, Dept. of General Practice and Health Services Research, Heidelberg, Germany

GMS Z Med Ausbild 2012;29(5):Doc68

doi: 10.3205/zma000838, urn:nbn:de:0183-zma0008389

This is the translated version of the article.
The original version can be found at: http://www.egms.de/de/journals/zma/2012-29/zma000838.shtml

Received: February 24, 2011
Revised: April 25, 2012
Accepted: June 16, 2012
Published: November 15, 2012

© 2012 Bölter et al.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by-nc-nd/3.0/deed.en). You are free: to Share – to copy, distribute and transmit the work, provided the original author and source are credited.


Abstract

Introduction: The planned modification of the Medical Licenses Act in Germany will strengthen the specialty of general practice. Therefore, medical students should get to know the daily routine of general practitioners during their academic studies. At least 10% of students should get the possibility to spend one quarter of the internship, in the last year of their academic studies, in a practice of family medicine.

The demonstrated teaching method aims at giving feedback to the student based on video recordings of patient consultations (student-patient) with the help of a checklist.

Video-feedback is already successful used in medical teaching in Germany and abroad.

This feasibility study aims at assessing the practicability of video-assisted feedback as a teaching method during internship in general practice.

Teaching method: First of all, the general practice chooses a guideline as the learning objective. Secondly, a subsequent patient – student – consultation is recorded on video. Afterwards, a video-assisted formative feedback is given by the physician. A checklist with learning objectives (communication, medical examination, a structured case report according to the guideline) is used to structure the feedback content.

Feasibility: The feasibility was assessed by a semi structured interview in order to gain insight into barriers and challenges for future implementation. The teaching method was performed in one general practice. Afterwards the teaching physician and the trainee intern were interviewed.

The following four main categories were identified: feasibility, performance, implementation in daily routine, challenges of the teaching concept.

The results of the feasibility study show general practicability of this approach. Installing a video camera in one examination room may solve technical problems. The trainee intern mentioned theoretical and practical benefits using the guideline. The teaching physician noted the challenge to reflect on his daily routines in the light of evidence-based guidelines.

Conclusion: This teaching method supports quality control and standardizing of learning objectives during the internship in general practice by using general practice guidelines. The use of a checklist enhances this method in general practice. We consider the presented teaching method in the context of the planned modification of the Medical Licenses Act is part of quality control and standardisation of medical teaching during general practice internships. In order to validate these presumptions, further, evaluation of this method concerning the learning objectives using the guidelines of general practice need to be carried out.

Keywords: Video feedback, general practice, guideline, evidence based medicine, internship


Introduction

The current modification to the regulation of the medical license in Germany is intended to strengthen the specialty of family medicine [2]. One core aim is that undergraduate medical students gain a more comprehensive picture of the job profile of a GP during their academic studies. During two weeks continuous experience in a practice and accompanying education, students are familiarized with the approach to and way of working in family medicine. Additionally, during the last year of academic study at least 10% of students should have the opportunity for a clinical placement in general practice.

There is an intensive one-to-one teaching and learning relationship between a trainee intern and the teaching physician in the GP practice [9]. This offers the opportunity to impart complex knowledge and for the trainee intern to experience realistic clinical learning. Video-assisted feedback is one possibility to facilitate feedback in this complex teaching and learning situation. This method has been successfully implemented in other fields of German medical training as well as internationally [1], [5], [10], [11].

The reported teaching method in this article is intended to contribute to quality of medical education as well as to professional political discussions promoting standardization of vocational training during the medical student internship. The method of teaching reported is based on video recording of consultations between the trainee intern and a patient. A guideline and a recorded video are the primary resources for concepts of the physician's checklist – based formative feedback. The daily work of a GP is characterized by a high number of patients a day with short consultation time (on average nine minutes per patient) [8]. Prior to this study, it was unknown if this method of teaching could be implemented in a general medicine practice in a German context.

The feasibility of the discussed method of teaching was simulated and evaluated in a pilot study with a trainee intern and a teaching physician. The main aim was the collection of data relating to opportunities and barriers to the implementation of this teaching method. The results can be used to modify the teaching method according to identified needs of the trainee intern and the teaching physician and to implement this educational initiative on a wider basis.


Teaching method

The basic concept for the video-assisted feedback during the internship comes from the guidelines of the German Society of General Practitioners and Family Medicine, which is typically based on a patient’s reason for encounter [http://www.degam.de/]. The guidelines define the professional and the medical learning objectives for the trainee intern. The guidelines are the foundation for the “Checklists” which are used during the feedback process.

As preparation, the trainee intern chooses a patient’s reason for encounter guideline in a short and long version. The guidelines are freely available on the website of the German Society of General Practitioners and Family Medicine: http://www.degam.de/. The trainee intern receives an introduction to the guideline from the teaching physician. In this preliminary talk, learning objectives (for different fields of competence) for the contact of the trainee intern, as well as treatment goal for the patient, are determined.

The learning objectives relate to the primary fields of clinical competence:

  • communication and physician patient interaction (history taking and therapy planning)
  • medical examination according to patient’s reason for encounter
  • a structured case report based on the guidelines

Recruitment of patients for this clinical teaching model would take place as follows:

A patient with the specified symptom will be requested to participate in the teaching exercise at the consultation. This patient will be informed about the teaching method and a written consent will be gained. When a patient agrees to be treated by a trainee intern (history taking, diagnostic intervention and treatment plan) this will be recorded on video and the consultation will be carried out by the trainee intern.

At the end of the consultation, the trainee intern reports the results of the consultation to the teaching physician while the patient is present. The treatment plan will be discussed with the patient and if necessary modified.

During a separate “debriefing” outside the consultation hours the physician gives a video-assisted formative feedback to the trainee intern. The feedback is supported by a Checklist based on the guideline (see table 1 [Tab. 1]).


Analysis of the pilot study

The pilot study for this teaching method was performed in a GP practice using the guideline for “cough” as the patient’s reason for encounter. Evaluation of the process took place via semi structured interviews with the actors being the trainee intern and the teaching physician. Qualitative interviews gave the opportunity to evaluate weaknesses and difficulties during the implementation of the teaching method and also gain ideas for improvement for the actors themselves in order to enhance this teaching method. After transcription of the interviews, main categories and sub categories were developed [8].

Two physicians from the researcher team coded the categories independently. The main categories were gained deductively from the compendium. The sub categories were developed inductively from the interviews.

The researchers chose a qualitative research method in order to gain more knowledge form the actors about their subjective experience and to identify barriers and opportunities for the implementation of this teaching method [3].

The four main categories were:

  • Feasibility
  • Performance
  • Implementation in routine
  • Challenges of the teaching method

The results of both interviews are described consecutively. Firstly, the main categories are discussed, then the sub categories, which are further emphasized by a quote.

Interview of the teaching physician

Feasibility

Four sub categories were identified in terms of "feasibility".

  • Technique
  • Time
  • Patient involvement
  • Data security

The camera was placed in one examination room (doctor`s office) for one week. At the beginning, there was some scepticism about the new technique (using video camera and debriefing using a computer), however, the implementation worked better than anticipated;

“I remember the introduction of computers into the daily routine at the beginning of the 90s. Back then we had a lot of concerns like the intimacy being disturbed or there being a third “person” in the physician’s office, and now it is just there.” Teaching physician

A change of teaching method is from the teaching physician’s point of view possible. The average amount of time for one guideline is estimated for one to two hours of preparation, including debriefing with the student and formative feedback. An important question concerning feasibility is the possibility to recruit enough patients. In the pilot study recruitment of patients was uncomplicated; they were identified by the main symptom “cough” at the reception desk. Patients did not hesitate to participate because of the video recording. The teaching physician from the pilot study did not see any prospective problems with the motivation of patients to participate. The participating patients did not express concerns related to data privacy protection. The declaration of consent was no barrier.

Performance

Four sub-categories according to „performance“ were identified:

  • Guideline
  • Feedback
  • Learning objects - Checklist
  • Feedback training

Dealing with the guideline was a positive experience for the teaching physician. The teaching physician compared his every day work with the standard from the guideline, by way of study example with the guideline “cough”. This was discussed with the trainee intern. The teaching physician valued this reflection on clinical practice:

“I think the self-assessment and questioning one’s self is important to see how the guideline is implemented in my own practice. I discussed the consultation with the trainee intern according to the guideline “cough” directly afterwards to see how I performed actually and how much did it differ from the guideline, or if we are on the wrong track; and have determined that basically it is the same”. Teaching physician

The feedback was no problem at all. There was already a fixed appointment every Friday with the trainee intern for the reflection over the week. The teaching physician judged the checklist as helpful to structure the different learning objectives. The teaching physician would probably require half a day voctaional training, in order to get familar with the new teaching method.

Implementation of the teaching method in clinical practice

Three sub-categories for “implementation” could be identified:

  • Recruitment of teaching physicians
  • Technical support
  • Supervision

For the implementation of the teaching method into the daily routine, the technique must be straightforward. It must be embedded into the everyday course of events in a practice.

“Initially I thought – this will be additional to my every day work, but this was the normal defence reaction. I got a good impression of the teaching method and would use this method again.” Teaching physician

From the perspective of the physician participating in the pilot study the recruitment of teaching physicians would be no problem. A fixed camera as technical equipment in one office for the time the trainee intern is present is conceivable. The teaching physician would require technical support and a specific contact person. Support from the university staff would also be sensible with supervision of the formative feedback process and the video analysis once during the three month trainee intern placement envisioned.

Challenges

One sub-category according to “challenges” was identified:

  • Self-reflection

The teaching physician identified self-reflection as the primary challenge. From this perspective, the willingness to reflect on everyday work is a basic requirement for the teaching physician and the trainee intern. The teaching physician thinks that being filmed would be a special situation; nevertheless, he can imageine using this technique in his daily routine:

„The video is an important tool for self evaluation. Absolutely clear, because the self-assessment is often inaccurate.” Teaching physician

Interview with the trainee intern

Feasibility

Three sub-categories according under “feasibility” were identified:

  • Technique
  • Time
  • Data security

From the trainee intern’s point of view, the effort required for the technique with camera and computer was significant. She was confident that a little bit of training would make it easier and that familiarisation with the technique would not be a long lasting barrier. The amount of time spent for the guideline review and the patient consultation was no problem at all for her. An important theme was data security. It was very important for the trainee intern that the use of the video for vocational teaching would only be permitted with explicit consent from the student.

Performance

Three sub-categories according to “performance” could be identified:

  • Guideline
  • physician (trainee intern) - patient - relationship
  • Feedback

The trainee intern describes dealing with the guideline as profitable. She compared the symptom orientated guideline with a chapter of a textbook. The amount of time was inconsequential:

“I did not consider it to be any additional effort. It makes sense to deal with cough, for example. First, I read the guideline and afterwards the chapter on cough in a textbook. Finally, I discussed it with Dr. [teaching physician].” Trainee Intern

The consultation of the trainee intern should be as much as possible realistic. The camera was experienced as a “third person”, however, it enabled a better “two-person” relationship between trainee intern and patient than the presence of teaching physician:

“In my opinion, it is better for the trainee intern-patient relationship if there is just one person there, without the GP sitting next to me, who will be spoken to again and again.” Trainee intern

The student gained the first experience with the method of video recording during university course [5]. The main difference was that they dealt with actors playing the patient’s role. This experience made the further use during the clinical placement in general practice easier:

“I saw video recording in Medi_KIT (communication- and interaction training for medical students (RB)) with actors and not with real patients, this was fascinating, […].” Trainee intern

Implementation

Three sub-categories according to “implementation” could be identified:

  • Theory by guidelines
  • Practical Orientation
  • Accompanied vocational training

The student has a positive opinion towards integrating the new teaching method into clinical teaching. Learning the medical theory this way was seen as a practical and relevant way of learning.

“I could imagine learning successfully in becoming familiar with the guideline and discussing it afterwards. Also, to see the patient myself with this particular symptom was very good. Theory and practice focus gives more attention to a topic.” Trainee Intern

Challenges

One sub-category according to “challenges” could be identified:

  • Data security

Particularly the right to use the records later on in vocational training or research must be with the consent of trainee intern and patient. Clear data security procedures are expected.


Discussion

This article describes a teaching method that could be used in the medical trainee intern and discusses the challenges and opportunities for the implementation in a teaching general practice.

The Netherlands advanced training for becoming a general practitioner has already integrated periodical video recordings of a consultation in order to evaluate the communication skills of young physicians. General practitioners or psychologists rate performance according to a standardized check-list of the consultation for structure, subject matter and communication capability [12], [13].

The implementation of video-supported trainee intern–patient consultations level during the internship in the general practice is an approach which is very close to the GP`s every day work and an excellent teaching method.

The trainee intern experiences a real consultation with a patient without the presence of the teaching physician and, nevertheless, later supervision by the teaching physician is available.

The answers to the interviews show that the theoretical and practical aspects of the method using the guidelines are valuable. In our view, this teaching method is a good opportunity to improve practical experience using evidence-based medicine. The expectation is for a better understanding and acceptance of general practitioner guidelines due to the engagement with the guidelines during the clinical placement. Moreover, a better implementation of general practitioners` guidelines is desirable [4], [7].

The improvement of competence in the trainee intern and the critical reflection of daily practice by the teaching physician were significant gains. Teaching physicians can use the opportunity to reflect upon their usual use of guidelines. Additionally, the teaching objectives in the teaching General Practice can be standardized without detailed specifications. This teaching method supports the university institutes of General Practice in their aim of quality improvement.

The potential technical set-up problems may be solved by installing long-term camcorders in the teaching practices. The use of less expensive webcams may be evaluated before implementation in a number of practices. Furthermore, the basic technical equipment or financial support and the technical support must be the duty of the university institutes. Another precondition would be the data privacy conditions for this teaching method. The faculty should provide printed forms for the teaching physician.


Conclusion

The results refer describe first performance of video-assisted formative feedback during clinical placement in general practice. The positive appraisal in the follow-up context of the interviews suggests the possibility for wider implementation. This teaching method supports quality control and standardizing of learning objectives during the internship in general practice by using general practice guidelines. The use of a checklist enhances this method in general practice.

In order to validate these presumptions further evaluation of this method concerning the learning objectives using the guidelines of general practice need to be carried out. We consider the presented teaching method in the context of the planned modification of the medical licensure to act as one part of quality control and standardization of medical teaching during general practice internship.


Competing interests

The authors declare that they have no competing interests.


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