Advances in digital technology are allowing for convenient recording and dissemination of operative videos to a wider audience. Originally, many videos were focused on basic sciences and preclinical education, but the number of people recording clinical encounters as a tool for training, research, assessment, and revalidation is increasing.1 Surgical videos provide clear images taken from the operator's point of view, allowing vital intraoperative findings to be clearly illustrated and comprehensively explained.2
The ease at which these videos are being recorded has allowed many scientists and clinicians to share their work with colleagues, but has also given anyone with internet the opportunity to access surgical and procedural videos.3 As the use of these recordings grow within the health care system, it is vital to address the ethical concerns to ensure patient safety. This article discusses the ethical issues that intraoperative recording pose and provide recommendations to surgeons who already use these recording devices.
Current guidelines on the matter are limited. The American Medical Association addresses the issue of recording patients for the education of health care professionals.4 Their opinion articles address many important issues like informed consent, confidentiality, and security, but they fail to clearly establish views on ownership and identification risk reduction.
The American College of Surgeons addresses many ethical issues in their Statements on Principles such as physician fees, publications, discrimination, and informed consent, but does not include video or audio recording anywhere in their guidelines.5 Specifically lacking, is the section on informed consent that outlines only four main topics to address with patients:
- The nature of the illness and the natural consequences of no treatment.
- The goal of the operation and potential risks.
- The more common known complications.
- Alternative forms of treatment, including nonoperative techniques.
The American Surgical Association has an appointed ethical committee. This committee has the responsibility to research potential unethical behavior and submit recommendations regarding disciplinary action. This, while helpful in a case-by-case basis, fails to provide overarching ethical guidelines by which the association feels its members should abide by.
Research institutions have a designated review board to evaluate and approve research protocols to ensure ethical standards are upheld. However, this level of scrutiny is not maintained for educational videos.
TOPICS FOR CONSIDERATION
Medical and surgical procedures involving patients that are recorded for the purposes of assessment or training can be undertaken only when the patient has given informed consent. Before recording is performed, the patient must understand the purpose for the recording, its audience, and how long the recording will be kept, as the recording may only be used for the purposes for which the patient's consent has been obtained.6 The patient must be assured that refusal to consent to a recording will not affect their quality of care.
Many institutions have generalized consent forms, which cover multiple topics all in one sheet. Although these consents may broadly give permission to allow recordings, many fail to address the purpose for the recording, who will see it, and how long the recording will be kept. Without such guidelines, the interpretation of what is to be done with this data is left to the physician and may not concur with the patient's wishes.
Increased access to photographic, video, or audio recording potentially weakens privacy for the patient and may cause the patient distress if it were to become public. It is vital that these conversations remain confidential according to the patient's wishes. Poor handling of recordings and increased availability reduce privacy for the patient and increase the risk of breaching confidentiality, especially if a patient's face or identifiable marks are included.
It is common for surgical procedures to take hours to complete and surgeons will discuss the care of other patients throughout the operation. Audio recording may capture identifying or compromising information about the other patient. If these recordings are placed in the record of the patient undergoing the operation, they will be out of the control of the patient who was the subject of the discussion.
Less commonly considered, is the lack of privacy for the treatment team.7 If there is audio recording, private conversations between the treatment team may no longer be private. These conversations can include personal information about the treatment team. This draws attention to the possibility that even team members may need to provide consent for the recording to take place. Consent is required from health care professionals in recordings where they will be in the video (behavioral or technical skills research), but are not required if recording the health care professionals is not the primary purpose. An opt-out method would provide health care workers the opportunity to remove themselves from a recording, and would cause fewer disruptions than an opt-in method.
Video provides a more objective and reliable account of the operation than self-reported dictations. Video editing allows surgeons to splice together clips of an operation. This creates a shorter version with only pertinent educational highlights. These edited versions can be inherently biased, as they will only show select portions of the case. In these situations, it is best to document changes and ensure the original recording remains unaltered. In cases of medical-legal actions, the unaltered version must be presented or it may be construed that the surgeon is attempting to hide detrimental evidence.7
The Medical Record/Ownership/Security
Altering video footage of a surgical procedure may be considered tampering with the patient's medical record.8 With the advent of electronic medical records, one can easily access patient information and many other sources of outside media. Although it is rare to find the footage of a patient's surgery available on the electronic medical record, recordings made from surgeries must be stored. Because this is a recorded event involving the patient, it is part of the medical record that can be used later for patient care. In this context, it falls under the jurisdiction of hospital records and should be under the same guidelines. If, however, the video has been designated as quality improvement data, it is not part of the patient chart. It is therefore not discoverable by a patient's attorneys in the same way morbidity and mortality conferences are not discoverable.9 This calls into question whether the patient, physician, or hospital owns the recording, as it would be appropriate to have permission from the owner to use and distribute their property.
Similarly, the security of these videos must be addressed. Most health care institutions have very strict guidelines regarding patient records and any identifiable information. However, these videos are routinely stored on personal devices and used in conferences and classrooms where the security is less stringent.
The purpose of video recording a surgical procedure for medical-legal purposes is not considered a main objective, but can aid in a court hearing as evidence. A recording may be utilized in the defense or prosecution of the surgeon when implicated in negligence or misconduct, as it accurately demonstrates the procedure.
Currently, laws protect information collected for quality improvement from being used as evidence in malpractice suits through the right of nondisclosure and confidentiality. However, those measures may be outweighed, at the discretion of the court, by their duty to discover the truth.9,10
Changes in Operative Technique
Recording can support improved attentiveness and meticulousness leading to improved surgical outcomes (Hawthorn effect).10 In addition to increased diligence, it has been suggested it may reduce costs if surgeons know they are being evaluated by their peers. Cameras also allow doctors to review and therefore improve their technique.
It is clear that video recordings are an excellent teaching modality. They allow for trainees to observe and train in procedures where their experience is limited. As medical professionals, we must insist that all legal guidelines are followed and that video recordings are accomplished ethically. For that reason, we recommend the following guidelines:
- Creation of a video/audio recording should have a clearly stated purpose. This may include educational, research, quality improvement, patient request, or others.
- Any patient undergoing a procedure that may include recording should be made aware and properly consented. This includes, but is not limited to the purpose of the recording, the intended audience, and the parts of the procedure recorded.
- Patients, faculty, and staff should be notified that a recording will take place during the procedure and given the opportunity to opt-out.
- If editing is required for visual accuracy or timeliness for a presentation, the alterations should be clearly disclosed to the audience.
- All recordings should be protected with the same security and scrutiny that the hospital and physicians use for patients’ medical records.
There will continue to be ethical challenges with regard to recording in the operating room. These guidelines should be altered to keep pace with growing technology while not interfering with the clinical benefits of recording. These recommendations provide a framework by which a surgeon should address recordings within their operating room.
1. Gambadauro P, Magos A. Digital video recordings for training, assessment, and revalidation of surgical skills. Surg Technol Int
2. Matsumoto S, Sekine K, Yamazaki M, et al. Digital video recording in trauma surgery using commercially available equipment. Scand J Trauma Resusc Emerg Med
6. Middleton P, Price M. The GP Trainer's Handbook: An Educational Guide for Trainers by Trainers. 2011; London: Radcliffe Pub, 278–279.
7. Turnbull AM, Emsley ES. Video recording of ophthalmic surgery–ethical and legal considerations. Surv Ophthalmol
9. Makary MA. The power of video recording. JAMA
10. Henken KR, Jansen FW, Klein J, et al. Implications of the law on video recording in clinical practice. Surg Endosc