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J Shoulder Elbow Surg (2013) -, 1-6

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The use of video before arthroscopic shoulder surgery toenhance patient recall and satisfaction: a randomized-controlled study

Daniel J. Hoppe, MD, MEda,*, Matthew Denkers, MD, FRCS(C)a, Fred M. Hoppe, PhDb,Ivan H. Wong, MD, FRCS(C)c

aDivision of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, CanadabDepartment of Mathematics and Statistics, McMaster University, Hamilton, ON, CanadacDivision of Orthopaedic Surgery, Department of Surgery, Dalhousie University, Halifax, NS, Canada

Background: Historically, the preoperative consultation has consisted of a discussion between patient andsurgeon. There is a growing literature describing efforts to integrate multimedia into surgical patient edu-cation. This study aimed to assess the efficacy of an educational video tutorial on early learning of infor-mation specific to patients undergoing shoulder arthroscopy when it was used as an adjunct to the standardpreoperative consultation.Methods: This study was a surgeon-blinded, randomized controlled trial involving 40 consecutive patientsrequiring shoulder arthroscopy. After a preoperative consultation with an orthopaedic surgeon, patientswere randomized in a 1:1 ratio to either a control group or a treatment group. The treatment group vieweda 10-minute video, which covered the expected preoperative, intraoperative, and postoperative experience.Immediately afterward, both groups completed a questionnaire measuring satisfaction and recall of infor-mation received. All patients completed a second questionnaire at the first postoperative visit that assessedoverall satisfaction with their experience.Results: Thirty-four patients were available for follow-up. The video group (N ¼ 15) answered 87% of theknowledge questions correctly, whereas the control group (N ¼ 19) answered only 56% (P ¼ .000). Therewas stronger agreement in the video group that the preoperative consultation contained an appropriateamount of information (P ¼ .039). Postoperatively, there was agreement that the video was an effectivepreparation tool for all stages of the surgical experience. However, there was no difference between thegroups in satisfaction with their overall surgical experience.Conclusions: Video can enhance patients’ operative experiences and improve their retained knowledgewhen it is used as an adjunct to the preoperative consultation.Level of evidence: Basic Science, Education Methodology Study, Devices to Improve Learning.� 2013 Journal of Shoulder and Elbow Surgery Board of Trustees.

Keywords: Video; satisfaction; arthroscopy; shoulder; patient education; information recall

iew Board: McMaster University/Hamilton Health Sci-

Research Ethics Board #10-276.

*Reprint requests: Daniel J. Hoppe, MD, MEd, Division of Ortho-

paedic Surgery, McMaster University, 1280 Main Street West, Hamilton,

ON L8S 4L8, Canada.

E-mail address: daniel.hoppe@medportal.ca (D.J. Hoppe).

ee front matter � 2013 Journal of Shoulder and Elbow Surgery Board of Trustees.

/10.1016/j.jse.2013.09.008

2 D.J. Hoppe et al.

Historically, explanation of surgical procedures during thepreoperative consultation has consisted of a discussion be-tween the patient and the surgeon.15 This discussion is animportant component of the surgeon-patient relationship, notonly for providing information to ensure that the patienthas a proper understanding of the condition being treated,including the treatment’s inherent complications and risks,but also for obtaining the patient’s informed consent. Un-fortunately, patient retention and recall of information dis-cussed have been shown to be inadequate.8,12,14,24 Moreover,a patient’s perceived lack of information (as distinct from theactual amount of information given) appears to be correlatedwith patient dissatisfaction.17

Various modalities have been implemented in an attemptto augment the verbal interaction between surgeon andpatient, including printed materials, prompt sheets, visualaids such as 3-dimensional models and computer-basedprograms, tailored communication styles, and patient edu-cation groups.16,20,23,26 Another adjunct, the use of video,appears to be a promising approach that takes advantage ofmodern multimedia technology.1,9 Marshall McLuhan, thefather of media theory, coined the phrase ‘‘the medium isthe message’’ and referred to television (and, by extension,video) as a hot medium, meaning it has the ability to pro-vide knowledge in a fashion to which patients can imme-diately relate.18 In addition, video may provide patientswith a virtual experience of their forthcoming surgery,showing the hospital setting, including the operating roomand equipment.

There is a growing literature describing efforts to inte-grate multimedia-based programs into surgical patient ed-ucation.1,4,15,20,22 Some studies have shown an improvementof patient recall with the use of multimedia.2,5,7,19,25

The objective of this study was to assess the efficacy of a10-minute educational video tutorial on early learning andretention of information specific to the preoperative andpostoperative shoulder arthroscopy protocol when it wasused as an adjunct to the standard verbal surgeon-patientpreoperative consultation. Our hypothesis is that video willimprove overall satisfaction with the operative experience.

Methods

Development of the video

The script for the video was developed in an iterative manner. Twosurgeons and a surgical resident met to compare and collate in-formation they thought was important for the patient to know.Considering patients’ educational needs, a list was compiled ofeducational objectives as well as indications, risks, and benefitsfor shoulder arthroscopy. They attempted to determine de-ficiencies in physician-led information by considering commonquestions that patients would ask before surgery or informationthat is poorly remembered. It was agreed that the video wouldemphasize the do’s and don’t’s, reminding patients not to smoke,not to eat after midnight the day before surgery, and not to shave

the shoulder. It was also thought that the video should follow atypical patient from the preoperative clinic visit to the day ofsurgery and then to the follow-up appointment and physiotherapy,including an intraoperative video of a standard shoulder arthros-copy. The video did not contain any new information that was notpresented during the preoperative consultation.

A script was generated and was reviewed by a linguist toremove unnecessary medical jargon. A 10-minute video was thenfilmed by our institution’s multimedia department, using staffactors.

Description of methodology

A single-center randomized controlled trial was conductedinvolving 40 consecutive patients during March 2011 to July 2012from the practice of 2 of the study authors (I.W. and M.D.), bothfellowship trained in sports medicine and working at an academicinstitution. Patients who required arthroscopic repair of either arotator cuff tear or a labral tear were identified by a research as-sistant and enrolled in the study before returning for their pre-operative consultation. Patients were eligible for inclusion in thestudy if they were older than 18 years and were able to participatein and complete the consultation in English without the use of atranslator. They were excluded if they had undergone previousarthroscopic surgery or if they had visual or auditory impairmentthat would prevent them from participating.

At the preoperative consultation, the operative procedure wasdiscussed in detail, including risks and benefits; any questionsabout the surgery were addressed, and informed consent was ob-tained. Patients were randomized to either a control or a treat-ment group by an independent biostatistician in a 1:1 ratio usingcomputer-generated random numbers. Patients in the controlgroup had a standard preoperative consultation with their surgeon.Those randomized to the treatment group also had a preoperativeconsultation but immediately afterward were brought by theresearch assistant to an adjacent examination room where theywatched the video on a computer monitor without any staff pre-sent. The surgeons were blinded to the allocation of groups, andall participants received the same standard of care in their face-to-face meetings.

After this initial consultation, both groups completed a shortquestionnaire to measure both their satisfaction, on visual analogscales (VAS), and their recollection of the information theyreceived, with 8 true or false statements (Table I). A component ofthe survey was adapted from Beischer et al,3 who measured pa-tient satisfaction with a multimedia learning tool on plantarfasciitis.

Patients then underwent shoulder arthroscopy and returned tothe clinic for their first postoperative visit 2 weeks after surgery.At this time, they completed a second questionnaire that assessedsatisfaction with their overall surgical experience. The treatmentgroup also rated the corresponding perceived usefulness of thevideo.

Statistical analysis

Because this was a pilot study, a power analysis was not per-formed. Instead, a sample size of 40 was chosen on the basisof previous studies that have compared the efficacy of multi-media technology on the education of patients.2,11,17 Graphical

Table I Knowledge questions asked in preoperativequestionnaire

1. I can take a shower 5 days after my surgery. (TRUE)2. I can drive 6 weeks after my surgery. (TRUE)3. The preoperative clinic is mandatory. (TRUE)4. I cannot eat after midnight the night before my surgery.

(TRUE)5. Smoking will not affect my surgery. (FALSE)6. My first follow-up is 4 weeks after my surgery. (FALSE)7. I do not need to wear my sling when I sleep. (FALSE)8. I need to inform my family physician about my surgery.

(TRUE)

Table II Percentage of correct responses by group

Average scoreper group (max. 8)

Average percentagecorrect

Control group 4.5 (SD ¼ 1.6) 56.2 (SD ¼ 19.8)Video group 6.9 (SD ¼ 0.8) 86.7 (SD ¼ 10.0)

Video before arthroscopic shoulder surgery 3

and numerical summary measures were used to provide anexploration of the data. Correct answers on the knowledge ques-tions were totaled, normalized to a percentage, and compared forthe two groups by independent samples t tests. VAS data was alsoanalyzed by independent samples t tests. Statistical significancewas judged at the 5% level, and all procedures were two sided.IBM SPSS 20.0 (IBM Corp, Armonk, NY, USA) was used for dataanalyses.

Results

Forty patients were recruited to participate in the study, and20 were allocated to each group. However, 1 patient in thecontrol group and 5 in the treatment group did not attendthe preoperative consultation or undergo surgery. Conse-quently, no data were collected for these patients.

Preoperative questionnaire

Table II shows the combined data for all 8 true or falsequestions. The video group scored significantly better thanthe control group (P ¼ .000) on the knowledge questionsoverall, with a percentage of 87% versus 56%. Moreover, inevery question, the percentage of patients who answeredcorrectly was greater in the video group than in the controlgroup (Fig. 1).

There were two questions for which responses weremeasured with a VAS scale. The first question askedwhether the preoperative consultation contained an appro-priate amount of information to educate the patient aboutsurgery. There was a significant difference in responses(P ¼ .039) between the video group (mean, 8.7) and thecontrol group (mean, 6.8). The second question askedwhether the preoperative consultation was easy to under-stand. There was no significant difference between groups,with a mean of 8.8 and 7.3 in the video and control groups,respectively (P ¼ .104).

Finally, the video group was asked iterative questionsabout the video. All patients agreed that video was aneffective way to learn, and 14 of the 15 available patientsthought that a duration of 10 minutes was ‘‘just right.’’With respect to whether the surgeon or the video was best at

answering questions, 43% thought the surgeon was best,14% thought the video was best, and 43% thought that thevideo provided the same information as the surgeon.

Postoperative questionnaire

Both groups were extremely satisfied with their surgicalexperiences. The control group scored their satisfactionwith a mean VAS of 9.5, whereas the video group had amean of 9.3, showing no significant differences in theirresponses (P ¼ .445). With respect to whether their expe-riences were what they had anticipated, the 2 groups alsoshowed no significant differences (P ¼ .168), with means of8.9 and 7.9 in the control and treatment groups, respec-tively. Of patients in the control group, 54% thought thatthey would have benefited from watching a video.

Figure 2 shows the perceived effectiveness of the videoin preparing patients for the different stages of their sur-gical experience as measured by their questionnaire re-sponses. These included the preoperative clinic, the nightbefore surgery, the day of surgery, the recovery process, andthe follow-up clinic. There was general agreement that thevideo was an effective preparation tool. Finally, for thequestion, ‘‘The video helped me prepare for surgery,’’ theaverage VAS score was 8.3. For the question, ‘‘I wouldrecommend this video to other people having shouldersurgery,’’ the average VAS score was 9.0.

Discussion

We have found that the use of video as an adjunct to thestandard surgeon-patient preoperative consultation im-proves information recall. The 2 questions on which thevideo group scored perfectly asked if they could eat aftermidnight and if smoking would affect their surgery.Misunderstanding in this case may lead to decreased bone-tendon healing and a poorer outcome of surgery, or tocancellation because of the risk of aspiration during anes-thesia.10 There were, however, no patients from this studywhose surgery was canceled for eating before surgery.These results are consistent with those reported by Bea-mond et al2 and Beischer et al.3 Beamond et al2 used a pre-post design to examine the effect of a computer-basedmultimedia tool on 31 patients’ knowledge of first meta-tarsophalangeal joint arthrodesis. The authors found thatthe percentage of correct responses to pre-test and post-testknowledge questionnaires increased from 62% to 87%

Figure 1 Distribution of correct answers by question.

Figure 2 Effectiveness of video at preparing participants foraspects of their surgery.

4 D.J. Hoppe et al.

(P < .001). Similarly, Beischer et al3 showed a knowledgeimprovement from 64% to 87% in a cohort of 41 patientswho watched a multimedia video on plantar fasciitis.However, because the patients re-took the same question-naire in both studies, it is unknown whether the observedimprovement was due to familiarity with the test or theeffect of the video itself.

Only a limited number of randomized trials in ortho-paedic surgery have examined patient recall with the use ofvideo. Rossi et al21 studied the effect of video on 150 pa-tients randomized to video or control and also stratified byeducational level. For both strata, the patients in the videogroup showed significantly higher comprehension.

In a randomized study by Cornoiu et al,5 61 patientsundergoing knee arthroscopy were allocated to 1 of 3methods for providing preoperative informed consent:verbal, pamphlet, or multimedia. Information recall, asmeasured by a 10-item test, was shown to be significantlyhigher for the multimedia group at the time of consent, andthe improvement was sustained until the day of surgery(P < .05), although there were no differences measured at6 weeks. In both this paper and that of Rossi et al,21 theemphasis, however, was on informed consent as the pri-mary variable of interest rather than information retention.

Regarding patient satisfaction, Johnson et al13 examinedboth information recall and satisfaction with the consentprocess in a study of 151 patients undergoing total kneearthroplasty who were randomized to 3 groups: standard ofcare, standard plus video, and standard plus video and nursereinforcement. In contrast to the Cornoiu study, they foundno differences in recall between the groups but did observea significant drop in scores in all groups preoperatively topostoperatively (P ¼ .004). However, Johnson et al used ageneric video produced by the American Academy of Or-thopaedic Surgeons. They may not have seen a differencein outcomes because their video was not specific to theirpatient population and the procedures being performed.

Whereas some studies have attempted to examine apossible link between patient satisfaction and video at thetime of the preoperative consultation,5,13,21 ours is the first

to study the effect of a preoperative video on overall sur-gical satisfaction after surgery. Our results did not showthat the use of a video changed patient satisfaction. Bothgroups of patients were very satisfied with the surgery, andas a result it would be difficult to find any significant dif-ference in satisfaction between the groups. The video wasalso effective at preparing the patients for all stages of thesurgical experience.

The patients who viewed the video thought that theywere provided with significantly more information than thecontrol group. An unexpected observation was that theoffice staff noted a drop in telephone calls during themonths in which this study was conducted. Because we didnot record this information prospectively, it is unclearwhether this was due to reduced calls from the video groupor merely a coincidence. This is a question that would beuseful to answer in a follow-up study.

Finally, we note the work of Doering et al,6 who foundthat video may play a role in decreasing anxiety and stress.In 100 patients undergoing total hip arthroplasty, the groupthat watched a videotape showing a typical patient’s hos-pital stay showed significantly less anxiety on the morningbefore surgery and on postoperative days 1 and 2 than thegroup that did not. They required less analgesic medicationand had significantly lower cortisol excretion. So, theremay be other benefits of a video that contribute to animproved overall surgical experience that cannot bemeasured solely by information recall or satisfaction.

The strengths of this study are that patients were ran-domized, the surgeons were blinded to group allocation,and the video used was specific to our patient populationand arthroscopic shoulder surgery. As well, the language inthe video was scripted with the assistance of a linguist toensure ease and accuracy of understanding.

However, our study does have some limitations. The smallsample size means that it is difficult to make a generalstatement applicable to other surgical settings or procedures.This study had a 15% dropout rate after the patients wereenrolled because they chose to cancel or to postpone surgerybefore the preoperative consultation. The study did not

Video before arthroscopic shoulder surgery 5

measure recall after the initial consultation, so we are unsurewhether the video would have any lasting effect on knowl-edge retention. Also, one could argue that it was not thevideo itself but the repetition of information that wasresponsible for the improved knowledge recall. Although thismay true, it does not negate the positive outcomes or the factthat no additional ‘‘face time’’ was required by the physician.

We believe that these results are promising enough towarrant a larger scale, multicenter study that can beexpanded to include other surgical procedures. It wouldalso be interesting to determine whether the improvedrecall at time of consultation would have any influence onpatient behavior, such as arrival time for surgery, smokinghabits, attendance at follow-up clinics, calls to the physi-cian’s office, and compliance with the preoperative andpostoperative protocols.

Conclusion

In addition to an informed, thorough discussion with thesurgeon, the use of video can enhance patients’ operativeexperiences as well as increase their retained knowledgefrom the preoperative consultation. Video may proveuseful as an adjunct to the preoperative consultation andwarrants further study.

Acknowledgment

We wish to acknowledge Charneal Dixon and BradleyBoake for helpwith patient recruitment anddata collection.

Disclaimer

The authors, their immediate families, and any researchfoundations with which they are affiliated have notreceived any financial payments or other benefits fromany commercial entity related to the subject of this article.

Supplementary data

Supplementary data related to this article can be foundonline at http://dx.doi.org/10.1016/j.jse.2013.09.008.

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