Niall Cameron MBChB MPhil FRCGP DRCOG
NHS Education for Scotland, Glasgow, Scotland, UK
Received 23 February 2006 Accepted 24 March 2006
Effective communication can both enhance patient satisfaction and lead to improved clinical outcomes.Peer review of consultations in general practice using video has been identified as an effective means of communication skills training. A postal survey of general practitioners in the west of Scotland was undertaken to identify motivating factors to submit a videotape of consultations for peer review and to identify barriers to engaging in this process. Analysis of the results demonstrated a number of motivating factors and perceived obstacles and also identified issues regarding the relevance of the feedback received by participants. These findings are examined, highlighting the benefits of this activity, and the paper discusses how these can be enhanced and how any difficulties may be minimised. The paper considers how the quality of feedback provided could be improved and delivered more effectively, ultimately aiming to improve the quality of patient care. Although the results may be considered predictable,the authors are unaware of any previous analysis of these factors.
appraisal, communication skills, feed-back, general practitioners, peer review, videotaped consultations
It has been clearly established that the delivery of effective doctor–patient communication can not only enhance patient satisfaction, but can also lead to improved clinical outcomes. Equally, poor communi-cation can adversely affect clinical outcomes, patient satisfaction and levels of litigation. The pivotal role of communication skills in the delivery of quality patient care has been recognised by the General Medical Council (GMC), and by its inclusion as a core category in general practitioner (GP) appraisal in Scotland.[2,3] The introduction of appraisal and the debate over what evidence will be necessary to satisfy the require-ments of revalidation has raised the question of how doctors can provide evidence of their ability to com-municate effectively. In the Fifth Report of the Shipman Inquiry, Dame Janet Smith addressed this problem and suggested that the evidence submitted for revalid-ation could& include ‘a video recording of the doctor in consultation with patients’.
GPs in the west of Scotland (WOS) have been able to submit a video of consultations with patients to the Department of Postgraduate Medical Education, (DPGME) for external peer review and written feed-back since July 1999. This process required the doctor to submit a tape of nine consultations with a log book which was viewed by two external peer reviewers, who then provided written feedback on these consult-ations. This group was formed in 1999 with six original members, in response to requests for feedback on videotaped consultations from doctors undertaking fellowship of the Royal College of General Practitioners (RCGP) by assessment of performance (FBA). The members are all practising GPs in the WOS. At the time of this study the group met biannually for feed-back calibration and to develop the feedback tool. Doctors submitting a tape received feedback on their consultations, focusing on communication skills, part-nership with patients, health enablement and manage-ment plan.
However, out of a population of over 1800 GP principals only a very small number have accessed this activity, and the majority of those who have were from an educational background. With the introduc-tion of appraisal, the publication of the Shipman Inquiry report and the inevitable impact of revalid-ation, interest in this type of activity may increase. This study set out to look at the reasons why GPs had been motivated to submit a video of their consul-tations with patients, and also to explore the barriers perceived by a sample of those GPs who have not sub-mitted a video of their consultations for peer review.
Both authors are associate advisors in continuing professional development, with a particular interest in the development of communication skills and peer review. Peer review of video recordings of consult-ations has been identified as an effective method to aid the development of communication skills. There is also evidence that these skills will wither if not main-tained by practise. The authors aimed to increase the number of doctors participating in this process and to make it accessible, realistic and inclusive for the general population of GPs. It was, therefore, import-ant to identify, and if possible reduce, any barriers to participation in this activity. Anecdotal evidence sug-gested that there was dissatisfaction with the quality of the feedback provided, and that in particular it had failed to address the participants’ learning needs. The authors wished to explore these issues, and if possible identify how the feedback provided could be more relevant and effective. In turn it is hoped to increase the number of GPs taking part in the video consul-tation peer review process, and to encourage GPs to submit a further tape, allowing them to reflect on any resultant changes in their consulting behaviour and communication skills.
In August 2003, the DPGME WOS database was searched for those doctors who had submitted a video for external peer review since the service had been established in 1999. This group was matched for both age and sex, with doctors who had not submitted a video for peer review. A total of 132 doctors were selected and approached to complete a postal ques-tionnaire. The questionnaire was developed to exam-ine areas of concern that had been highlighted by the peer review group and those doctors who had pre-viously submitted a tape. The questionnaires were piloted with eight GPs, four of whom had previously submitted a tape.
The doctors who had submitted a video for peer review were invited to answer specific questions about their motivations to take part in this activity and the feedback that they had received.
The doctors who had not taken part in this activity were asked to complete a short questionnaire, which examined their reasons for not participating in this activity.
Forty-four doctors had submitted a video for peer review between 1999 and 2003; 39 (89%) returned completed questionnaires. Analysis revealed that the impetus to participate in this process was multi-factorial:
• 34 (87%) identified a desire for feedback about their communication skills as an influencing factor
• 24 (62%) had been motivated to participate to obtain postgraduate education allowance (PGEA) points, which satisfied the requirements of the PGEA
• 15 (38%) had submitted a tape as they considered this was a requirement for established trainers in general practice
• 10 (26%) because they were involved in under-graduate teaching
• 10 (26%) because they were aware that other GPs were using this method
• 3 (7%) because they were considering becoming a trainer.
In addition, 16 (41%) had other motivating factors. Examples of these other factors identified included:
• ‘[It] has been a few years since the MRCGP, [I] wanted to make sure techniques had not slipped’
• ‘considering FBA’
• ‘[to] be able to help [the] registrar practically with setting up and organising a video’
• ‘I really had no true idea of how I appear as a doctor and wished (with a lot of trepidation) to see myself at work.’
Eighty-eight questionnaires focusing on six potential barriers were distributed, 64 were returned (73%). Of these:
• 29 (45%) felt they had no incentive to hand in a video for peer review
• 25 (39%) were uncertain about the practicalities of video recording a consultation
• 15 (23%) felt it was too challenging an activity
• 14 (22%) were not aware that they could submit a video for peer review
• 12 (19%) were concerned about critical feedback
• 2 (3%) identified problems with previous video feedback, e.g. as registrar.
These doctors also identified other factors that had inhibited their participation in this process:
• technical barriers: 8 (12.5%)
• not worthwhile, as it is artificial: 8 (12.5%)
• too much hassle to get consent: 8 (12.5%)
• apprehension: 5 (8%)
• no time/other priorities: 3 (4.7%).
The doctors who had submitted a tape were asked to consider the impact of the written feedback they had received and how this could have been more effective (see Figure 1). The findings indicate that the reaction to the feedback was mixed. A significant number of respondents felt that it did not focus on things that they could change and had little influence in altering their consulting behaviour.
The majority of respondents (66%) considered that it could be improved, and examples of their comments include:
• ‘written feedback had obvious limitations, not least that my perceived learning needs were not acknowledged’
• ‘[there was] little about how to change’• ‘face to face, would be better, but I realise that this is time consuming’
• ‘I was looking for more criticisms and suggestions’
• ‘[it needed] more concentration on the actual process of consulting’.
Positive comments included:
• ‘probably too positive, [the] main achievement was in completing it and submitting it’
• ‘the feedback was very constructive. The more negative comments did not feel attacking at all, which was great since I was nervous about what they may say, and they said a lot of very positive things which felt fabulous’
• ‘whilst I wouldn’t say I changed my practice a huge amount, it gave me a lot of confidence that I was basically doing OK, which was great since it is rare that you are in a situation where your peers see you at work, and even more rare that they are in a position to comment’.
The WOS database revealed that only 44 doctors had submitted a tape of their consultations for peer review. This compares with 322 who had submitted an audit for peer review, and 567 who had submitted a significant event analysis for peer review over the same period.Analysis of the factors that motivated doctors to utilise this activity identified an involvement in train-ing, both at undergraduate and postgraduate level as a significant factor. There was also a very clear desire to receive feedback on their consulting and communi-cation skills. A further incentive was to obtain the PGEA.
This study identified a number of perceived barriers to participation in this particular educational activity. These included lack of incentive, concerns about the practicalities of using video and a significant level of apprehension that the process was too challenging and that they may receive critical feedback. As submitting a tape for review is a voluntary activity, it is likely that those who participated in this process had a substan-tial level of self-awareness regarding their consulting skills. Conversely it can be argued that those most likely to benefit from taking part in this activity were those least likely to submit a tape.
The results demonstrate that a significant number of doctors who had submitted a tape had concerns about the feedback they had received, and identified a number of areas that could be improved. This is particularly likely to affect resubmission rates and the perception and intentions of their colleagues who were considering submitting a tape for review. If this activity is to result in behaviour change it must be valued, and not merely seen as an exercise. However, there was also evidence that a number of those doctors who had submitted a tape had found this activity to be a positive learning experience that would influence their consultations.
It has previously been acknowledged that profes-sionals have reservations when submitting their work for external review. In addition, other sources have suggested that the process of video recording consul-tations, while desirable, may not be practical and feasible for the majority of doctors. Difficulty using the equipment has been identified previously as a barrier. The difficulty in ensuring the delivery of effective feedback when reviewing doctors’ communi-cation skills is well recognised, and the validity of currently available peer assessment tools has been questioned.[9–11]
This was a retrospective survey of doctors’ re-sponses to factors that had motivated them to submit a tape and to explore why others had not chosen this method. A high percentage response rate was achieved, and although the questionnaires used were not fully validated, the existing complete WOS database was used to ensure a matched random sample was targeted.
This survey has demonstrated that if activity in this area is to increase, a need exists to enable participation for all GPs to be feasible and realistic. When compared with the ability to carry out significant event analysis and audit, preparing a video of consultations is likely to require more time and effort on the part of the doctor and also requires additional resources and the support of practice staff. Although this is a pivotal area of our work, there has been little provision of ongoing training in this area, and as a result it is likely to represent a considerable challenge and threat. Con-sideration has to be given not only to practical and technological barriers but also to the purpose and benefits of peer review which have to be clear to potential participants. It is inadequate, of little benefit and potentially harmful to provide feedback, which may correctly identify areas to develop, without the provision of a method of addressing these issues and developing their skills. It demonstrates a need to ensure that the feedback is developmental and learner centred. Given the dissatisfaction with some of the feedback provided, it also identified a requirement to ensure that the peer reviewers had adequate training, were clear about their role, and that the validity and reliability of the feedback and any tools used are stringently assessed.
The desire to receive useful feedback on their consulting skills is likely to remain a consistent incen-tive for many. However, with the introduction of the new GP contract in 2004, the incentive of the PGEA system no longer exists. The new general medical services (GMS) contract encourages the use of patient satisfaction surveys, however, such surveys have sig-nificant limitations as a means of reviewing and developing communication skills. Other more infor-mal methods of peer review, such as a colleague sitting in on a surgery, are also available to doctors who wish to review their communication skills for the purposes of appraisal. However, these methods, which may appear less time-consuming and more practical, could result in collusion with less chance of achieving behaviour change.
To answer these questions, a number of initiatives are being developed. A course designed to provide training in consultation skills for those GPs who are not from an educational background has been estab-lished. This allows the participants to review and develop their communication skills in a small group setting and to submit a videotape for external peer review. Approaches have been made to the local primary care trust to support the provision of the necessary tech-nological support, and this has been agreed. The accom-panying logbook has been substantially rewritten, and now requires the doctor to document their learning objectives with the aim of promoting self-reflection prior to submission. The development of the group of peer reviewers has focused on ensuring that the feed-back provided is descriptive, addresses the learners’ identified objectives, is balanced, highlights strengths and areas to develop, and offers suggestions for change.
Work has begun to develop the feedback tool to ensure that it is valid and reliable. A monitoring process of the perceived value of the feedback pro-vided is also planned. The authors hope that these innovations will result in the provision of relevant and effective feedback which will encourage greater num-bers of our colleagues to participate in an ongoing process of peer review to develop their consulting skills.