What Can Hidden Video Teach Us About Our Healthcare System?

Dr. Gretchen Berland, an assistant professor at the Yale University School of Medicine and former documentary filmmaker, writes in the New England Journal of Medicine of an extraordinary experiment she has conducted over the past 10 years. It involved giving videocameras to people in wheelchairs, and asking them to document their daily lives (samples of the videos can be seen here). The footage provides insight into the struggles faced by the disabled in conducting daily activities; it also provides a penetrating view of what happens during visits to the doctor, replete with considerable potential for communication breakdowns. At best, a common result is that doctors don’t get the full story of a patient’s condition; at worst, the patient can wind up receiving inadequate or improper care. Berland describes her findings as follows:

By the time Galen Buckwalter‘s physician knocked on the exam-room door, Buckwalter’s video camera had been recording for nearly 40 minutes. He had booked the appointment because his shoulders were hurting, and the camera recorded his view of the examination table, the comments he made while waiting and, eventually, a largely transactional and superficial exchange with his physician. Two weeks later, in his home, the camera would record a strikingly different take on his shoulder pain – a growing problem that, Buckwalter worried aloud, might cost him even more of his cherished independence.

As an internist, I was disturbed by the contrast between those two scenes, the second revealing the depth of Buckwalter’s concerns and fears, none of which were apparent during the conversation with his doctor. In the later tape, Buckwalter’s struggle is palpable. If such stark contrasts are common, how much do I really know about my own patients? Probably far less than I care to admit.

Berland candidly assesses a major flaw in our healthcare system, the various shortcomings of which Dubner has discussed before. Incomplete communication during visits only adds to the existing soup of unnecessary treatments, huge expenses, and potentially deficient coverage. Surely there must be ways, besides a basic “Yes/No” survey on a clipboard, to streamline the process of initial doctor visits so that patients feel comfortable giving physicians the bigger picture. Perhaps an online log that patients can fill out and doctors can review before the appointment, describing conditions and symptoms in detail, or even documenting pain levels for the few days prior to the visit? Any other ideas?


Other ideas? How about more time to interact with the doctor and discuss the problems or utilizing something akin to a system of case managers to interact with the patient not only in the intake process but also to follow up regarding the course of treatment? More expensive perhaps but probably more effective too.


I wonder if having patients give full histories to nurses and letting the nurses convey the salient points would work. That way, someone hears the full story, but it doesn't require as much of the doctor's time.

It would still be prone to human error, of course, but at least a nurse is more suited to the job than a piece of paper.


re: call center.... and on the plus side..we could outsource to india.

Michael D

I think the online log is a great idea, but does not remove the problem of ineffective communication. I always wondered why the diagnosis process was not more automated. Diagnostics (simply put) involves the piecing together of symptoms or variables to arrive at a conclusion. The doctor is relying on experience and/or knowledge, neither of which may be complete. Why not have a web site for your health profile? (lets forget about privacy issues for now) It would be a repository of your full medical history. Guided questions could be flow-charted based on current symptoms and past medical history. The time spent with the doctor would more focused, since the data is now standardized and summarized before the visit. The appropriate actions would then take place (further testing, medications,etc) based on the output of the web site. Progess could then be tracked online and appropriate next steps recommended.


Brian Burke

I read an article within the past year about how although we hold doctors to high standards, there is more to the story. Patients have to do a good job of helping the doctor during the visit. I would bet it can be frustrating to be a doctor trying to extract relevant information form a patient.

Sean Barrett

Was it hidden video or not? I see the word "hidden" but not in the blog post nor in the linked article.


"I wonder if having patients give full histories to nurses and letting the nurses convey the salient points would work. That way, someone hears the full story, but it doesn't require as much of the doctor's time."

At my university health services, I was "screened" by a nurse with unusual insect bites on my body. The nurse took down my information and concern about bedbugs, and then asked if I "went running outside at night." I said yes, regularly, but that I had been doing so for longer than the bites... and she dismissed me without my seeing the doctor at all.

It turns out I had bedbugs.

Galen Buckwalter

As the patient noted above, my attempt was to discuss the need for more time from physicians along with better patient reporting.

But the effect of the physician-patient power differential and of years of paternalistic treatment on disabled persons, and I suspect many other long-term patients, is powerful. Many of us have been trained to under-report. If you are not stoic you must be neurotic--an attitude I have experience many times just since writing the NEJM piece.

M Davidson

In my experience, a doctor appt for which I have fully prepared elicits a better outcome. If I wait to marshall my thoughts until I'm face to face with the doctor or nurse, I generally forget to mention something.

Some of the techniques like the "pain scale" which are used by the medical profession for communication of symptoms could be effectively used by patients.

Also, the role of the nurse could be used more effectively: she (or he) and we treat her position as being more a technician and less as caregiver. She and the doctor should draw upon her compassion, insight, and social skills as well as the checklists and procedures she is expected to use.


Jen Smith

Gaylen your words resonate with me and anyone I have ever known with a disability or chronic illness. I would go farther than stating the attitudes are paternalistic - they are downright patronizing. And being patronized by medical professionals is extremely debillitating so under-reporting is the norm.


#4 - I was misdiagnosed first by a physician's assistant and then by a nurse practitioner. I didn't know what was wrong, but I knew they weren't getting it right - tried to tell them that but they were certain about it. The doctor wouldn't see me although I requested it.

When I went to another doctor who saw me himself, he instantly knew what the problem was, ordered an MRI the next day, and we scheduled surgery for a few days later.

Nurses aren't doctors. They can do many things, but I don't want them diagnosing me. Mine was a textbook case and yet they both got it wrong.


I've seen the movie, which can be found here: http://www.thirteen.org/rolling/index.php - it does a remarkable job of showing how normal these triumphant people are. I think the problem with American medicine is systemic: the smartest kids in school are nudged toward medicine, a profession that commands the highest paychecks. The god-complex starts early and is reinforced throughout. However, their job is actually nothing more than a glorified technician, following flow charts with very little interpersonal skill or critical thinking required. In socialist countries, physicians earn a reasonable wage that keeps them in touch with the people they serve - resulting in smaller egos and more humility. Our elitist nerds just can't relate to the masses.

John B.

It is intersting that in all of the comments none of the commenters have taken the insurance industry to task for their part in what was seen in the filming. While there are many parts to the healthcare industry including the caregiver, and the care location owner and the patient of course, it is the payer that is the ultimate customer. The payer is the entity that dictates what will be paid for or not and to whom they will pay it. This has led to an experience that is dictated by what will be paid for moreso than one that reflects what may be best for the patient.

The doctor is paid the least and dictated to the most in the equation. We have all experienced the need to get a preauthorization for care, which is really a second guess of the medical school educated and hospital trained physician by a nurse working for the insurer following a checklist. The caregiving nurse is also expected to do housekeeping and other not so savory duties in addition to the care that they got in the business to deliver. Their time is even more stretched and reliance on them to capture history is not paid for.

The technology exists today to let the patient control their own record and determine who has access to update it and or review it. The part of the equation that is delaying that possibility is the one who has the most to lose by controlling the information. Big Insurance, Harry and Louise. Control of the information enables the insurer to have an advantaged position when negotiating payment arrangements with any hospital or doctor. Since the insurer is the customer of either of those entities, they make the rules. In this equation, the patient is simply a consumer who should be discouraged from consuming.

We fix this by changing the rules not blaming the caregiver. Vote and be vocal.


Jeanne P.

I can't believe that nobody has commented on the video by Vicki Elman! Her first video just ignited something in me. There is so much going on there, where to begin commenting?

So it's too much trouble and so much work to help a person you are PAID to service use the bathroom! So typical of our underpaid and overworked staff in the nursing homes. (Obviously one can tell I've had experience with nursing homes!) So, despite this being uncomfortable for this woman, she is basically at the mercy of the staff! ARGGG! Seeing this video just confirms my belief that all school age children should visit nursing homes! We need change and change will only happen with knowledge and knowledge is not served when we ignore those people living in nursing homes. They NEED a voice and we are doing ourselves a disservice when we don't educate our youth (or ourselves - have you ever visited a nursing home?) on this sector of our population.

Further disturbing was the second video where she was left alone, outside. I can't stop thinking about her and what was the end result of that video.

What a powerful experiment! I sincerely hope some good will come from this.



Please check your assumptions and rethink your thinking.

For a solution you offered:

"Perhaps an online log that patients can fill out and doctors can review before the appointment, describing conditions and symptoms in detail, or even documenting pain levels for the few days prior to the visit?"

What makes you think the quality of information doctors need to make good assessments would somehow be improved by having patients type up their thoughts in an online log? Would "going online" somehow make patients more informative to their doctors? Are all patients equally literate? Would the act of pecking their keyboards make patients more accurate in describing ailments?

Please! Gimme a break!!!

Then you ask:

"Any other ideas?"

Well, here's one: How about HOUSE CALLS???

Doctors used to go to people's homes to examine them and speak to them about their ailments. It might just be that medicine -- in proper practice -- requires SOMETHING LIKE THIS to be effective.

My Great Aunt was a doctor who made house calls in the slums of Philadelphia, mid 1900s. The economic model for healthcare delivery in her time required it. The economic model for healthcare delivery in our time does not allow it.

Which leads to doctors who must practice an impersonal art, no longer connected to its purpose.

Worse than that, the new model creates patients -- all of us -- who have no "market voice."

"Online" is not a solution for everything. "Medicine" is a special case in economics. It may just be that the art and science of healthcare requires social structures that don't fit easily into market-based thinking.



This issue parallels quite nicely with the call center industry. The way to reduce costs is not to make interactions short, but to deal with real customer issues as quickly and efficiently as possible (on the first time). Yes, there are a lot of people out there who want comfort medicine, but there are a lot of people who keep going back to the doctor's office.

If efficiency was measured by per-patient-issue-resolved rather than by doctor-facetime-per-visit, a much different picture would emerge.


Perhaps a big part of the problem is that we use doctors for things that nurses and med techs could handle at least as well. If doctors were able to concentrate on cases of life-threatening illness, and weren't required to treat less serious conditions, patients could get better care in both cases.
Reasons this won't happen:
1) legal exposure
2) the patients themselves don't want "second-class" treatment even if it's measurably better.
3) the drug companies would fight any non-medicinal treatments tooth and nail
4) The AMA would fight for its monopoly

Ben G Thomson

Agree with #2, dd that "having patients give full histories to nurses and letting the nurses convey the salient points" is a good idea. I've been to two doctors in the same specialty, same office, for two different problems - both had somebody take the time to get my full story before the doctor appeared.


Brian Burke brings up an important point. As a patient it is in your interest to communicate effectively with your care giver especially as you know that your time with him is limited.

Having said that, in the dark ages (oh, about 30 years ago) a full medical history was considered a cornerstone of diagnosis. The clip-boards that have proliferated in the doctors' offices recently, are an abomination. There is no substitute for taking your own history. A nurse or even another doctor will not do. With experience one develops shortcuts and the time to take the history decreases but cannot be eliminated altogether.

dan s.

This also raises the issue about something I've come to believe is the greatest asset of today: being able to communicate - to speak for yourself.