Background In fast-paced dermatology clinics, the process of obtaining informed consents for biopsies and providing postprocedure instructions may be incomplete and inconsistent.
Objectives To compare effectiveness of video-based education with that of verbal education for giving informed consent and providing postprocedure wound care instructions in patients undergoing skin biopsies.
Methods In this randomized controlled trial, participants were randomized to receive either video education on portable video devices or conventional verbal instructions regarding skin biopsies. Participants completed a skin-biopsy knowledge assessment, patient satisfaction assessment and evaluation of educational medium. Main outcome measures were differences in the changes in the prestudy and poststudy knowledge assessment scores, patient satisfaction and evaluation of the educational medium.
Results Eight-four patients undergoing skin biopsies at the University of California Davis dermatology clinic participated in the study. Participants in the control group had a nonstatistically significant increase in knowledge score (mean ± SD 1·12 ± 1·74), whereas those in the video group had a statistically significant increase in knowledge score (mean ± SD 1·55 ± 1·71). The difference in knowledge scores between the video and verbal groups was not statistically significant. Participants in both groups were highly satisfied with the biopsy education. On a 10-point scale, the mean ± SD usefulness and appeal of the videos were 9·01 ± 1·5 and 9·01 ± 1·66, respectively.
Conclusions Our study demonstrated a significant increase in knowledge score following video education, but not following oral education. Although between-group comparisons did not achieve statistical significance, portable video media for presenting informed consent and wound care instructions for skin biopsies appear to be more effective and result in higher satisfaction than traditional oral education.
Effective use of technology may provide new ways for physicians to communicate with their patients more efficiently. In dermatology practices, the processes of obtaining informed consent for skin procedures and providing wound care instructions represent two areas where consistent, clear and thorough patient education is essential.
The current consent process prior to a procedure involves a physician and/or medical staff member verbally explaining a procedure, its risks and its benefits to a patient. This process is inadequate,1–5 inconsistent among physicians obtaining informed consent,6,7 and variably comprehensible among patients with different educational levels.8 Incomplete informed consent can result in poor legal outcomes for physicians4 and cause anxiety and confusion among patients. Inadequate patient education for postprocedure care may lead to poor wound healing and higher rates of postoperative infections.9,10
While providing written information can improve patient satisfaction of the consent process,11 some patients may be illiterate or read below the level required to interpret such information. Several prior studies suggest that video-based patient education may lead to greater patient comprehension and satisfaction.12–20 Studies also show that video-based education significantly reduces patient anxiety.21–23 Portable hand-held technology, in the form of mp3/mp4 devices (e.g. iPod™; Apple Inc., Cupertino, CA, U.S.A.), allows for video-based education without the need for a computer or television.24–26
Dermatologists routinely obtain informed consent and provide postprocedure wound care instructions for patients undergoing skin biopsies. In fast-paced dermatology clinics, the process of obtaining informed consents for biopsies and providing postprocedure instructions may be incomplete and inconsistent. In this study, we sought to determine if video-based education delivered through mobile, video-enabled devices improves patient knowledge and satisfaction in the informed consent and postoperative educational processes compared with conventional verbal instructions.
Materials and methods
Study design and population
This randomized controlled study was approved by the Institutional Review Board of the University of California Davis (UC Davis). The clinicaltrials.gov registration number is 200917169-1. All participants were recruited from patients who were evaluated at the dermatology clinic at UC Davis from July 2009 to February 2010. The eligibility criteria required the participants to be 18 years or older, English speaking, and needing a skin biopsy after a dermatologist’s evaluation. The method of skin biopsy included either a shave biopsy or a punch biopsy.
At the start of the study, 84 participants receiving skin biopsies were randomized in a simple 1 : 1 nonstratified randomization scheme to two study groups, with 42 participants in the ‘video’ group and 42 participants in the ‘control’ group. Randomization was performed using the GRAPHPAD PRISM 2009 statistical software (GraphPad, San Diego, CA, U.S.A.); the randomized group allocation sequence was kept in sealed envelopes until each participant was ready to be randomized.
In the video group, dermatologists obtained informed consent for skin biopsies using an educational video that details the following three aspects of a skin biopsy procedure: (i) why and how a skin biopsy is performed; (ii) risks and benefits of the biopsy; and (iii) what happens to the skin specimen after the biopsy. The study investigators developed the video by capturing actual footages of shave and punch biopsy procedures performed by a board-certified dermatologist in the dermatology clinic. Participants undergoing shave or punch biopsies were asked to view a 90-s video specific to their type of skin biopsy prior to giving informed consent for the biopsy procedure. Videos were displayed on a portable mp3/mp4 player with a colour 3.5′′ screen (iPod touch™ or iPhone 3 GS™; Apple Inc.). After the skin biopsy was performed, the participants watched an 85-s video that discussed postbiopsy care (Videos S1–S4; see Supporting Information).
Prior to giving informed consent, participants in the control group received traditional, face-to-face, verbal education about skin biopsies from a board-certified dermatologist or a dermatology resident. All dermatologists were instructed to obtain informed consent as they would in usual clinical practice settings. After the skin biopsy, postbiopsy care was explained by the participants’ dermatologists. After completing the visits, all participants received a written postbiopsy care pamphlet to take home, as part of the standard care at UC Davis dermatology clinic.
Participants in both arms were asked to complete a knowledge questionnaire and a patient satisfaction survey near the end of their dermatology visit. Patient satisfaction was measured with a 0–10 visual analogue scale. In addition, for participants randomized to the video group, usefulness and appeal of the video content were assessed using a 0–10 visual analogue scale.
To our knowledge, no skin biopsy knowledge assessment exists at the current time. For this study, UC Davis dermatologists worked to develop a biopsy knowledge questionnaire with the goal of identifying elements that an informed patient should know about the skin biopsy procedure. This knowledge questionnaire consisted of six multiple-choice questions that evaluated the participant’s understanding of the skin biopsy in the following dimensions – purpose, associated risks, after-care process, and signs and symptoms prompting re-evaluation following the biopsy. One point was given for each correct answer with a total possible score of six. This knowledge questionnaire was pretested in 10 dermatology patients prior to the study for language appropriateness and health literacy. This knowledge questionnaire was administered to all 84 participants to assess their baseline understanding of a shave or punch biopsy.
Statistical analysis was performed by an independent statistician. The sample size calculation was performed before study initiation. With 84 total participants randomized in a 1 : 1 ratio to two study arms (n =42 in each arm), the study had 90% power to detect a mean difference of 1·45 points on the biopsy knowledge test between the two comparison groups, with an SD of 2 and α of 0·05 in a two-tailed analysis.
The video and control groups were compared using independent two-sample t-tests for continuous variables. If the variables did not appear to be normally distributed, a nonparametric Wilcoxon rank-sum test was used. χ2 analysis was used to test for associations between the groups and categorical variables. When a large proportion of cells had counts below 5, Fisher’s exact test was used instead.
The primary outcomes measure was the change in the difference in knowledge scores before and after the consent process between the two groups. These changes in the prestudy and poststudy knowledge scores were then compared between the groups using an independent t-test. Secondary analyses were performed on various satisfaction parameters between the groups using two-sample t-tests.
Eighty-four participants were enrolled in the study, with 42 participants in each study group (Fig. 1). All participants completed prestudy and poststudy biopsy knowledge questionnaires. One participant from the control group and three participants from the video group declined to answer the satisfaction survey. No statistically significant differences in baseline characteristics were detected between the video and control groups (Table 1).
Table 1. Comparison of baseline characteristics between the control and video groupsa
Control group (n =42)
Video group (n =42)
aNo comparisons on baseline demographic factors between the control and video groups had a P-value < 0·05. bχ2 analysis. cindependent two-sample t-test. dFisher’s exact test.
Gender, n (%)b
Age (years), mean ± SDc
62·5 ± 18·5
55·4 ± 15·8
Marital status, n (%)d
Declined to state
Education, n (%)d
1st through 8th grade
9th through 12th grade
1–3 years of college
4 or more years of college
Ethnicity, n (%)d
Asian or Pacific Islander
Declined to state
Biopsy type, n (%)b
Received skin biopsies in the past, n (%)b
Skin biopsy knowledge outcomes
The primary outcomes measure is the change in the skin biopsy knowledge score before and after the intervention – either receiving standard, verbal instructions or viewing the videos. Within-group analyses revealed that the participants in the control group showed a nonstatistically significant increase in knowledge score of 1·12 ± 1·74 points [mean ± SD; 95% confidence interval (CI) for increase 0·58–1·66]. In comparison, participants in the video group showed a statistically significant increase in knowledge score of 1·55 ± 1·71 points (mean ± SD; 95% CI for increase 1·01–2·08).
The video group showed a greater increase in biopsy knowledge score compared with the control group (Fig. 2). However, this difference was not statistically significant in between-group comparisons (P =0·259).
Participant evaluation of educational material
Using a 10-point visual analogue scale, participants in both groups indicated that they were highly satisfied with the biopsy education (mean ± SD: video group 9·45 ± 0·91, control group 9·41 ± 1·02; P =0·876).
Twenty-four participants in the video group had had skin biopsies prior to this study and therefore experienced both modalities of information delivery by the end of the study. These participants were asked if they preferred using video or conventional verbal instructions to learn about informed consent and postbiopsy care. Among them, 12 (50%) preferred video, nine (37·5%) preferred the conventional verbal method and three (12·5%) reported no preference. On a 10-point visual analogue scale, the mean ± SD rating for the usefulness of the videos was 9·01 ± 1·5, and the mean ± SD appeal of the videos was 9·01 ± 1·66.
We showed a statistically significant increase in knowledge score following video education, but not following traditional verbal education, for within-group comparisons. Although the observed difference in the change in knowledge scores between these two groups was not statistically significant, a study with a larger sample size may be helpful to corroborate these findings.
Video education is an effective method for education regarding shave and punch biopsies and postprocedure wound care. The results demonstrate that video education is at least as effective as verbal education, and has the additional advantage of reproducibility. The same information is delivered the same way each time the video is used. Reproducibility of oral education is dependent on appropriate training and is subject to human error. Although scripted oral education has the capability of providing reproducible knowledge dissemination we chose not to use it in our study, because we wanted the results to reflect normal clinic operations. Video consent also has the potential to free up physician and staff time to perform other functions while the video is playing. This is supported by the results of one study demonstrating that videos followed by brief counselling saved physicians’ time without sacrificing knowledge when compared with prolonged counselling.27
Clearly, video education cannot completely eliminate the need for patient interaction prior to shave or punch biopsies, as adequate patient consent requires that patients have the ability to ask questions regarding the indications, alternatives and complications of any procedure they undergo. In our study, patients were given the opportunity to ask questions regarding any aspect of their procedure following education by either means.
One potential concern regarding video consent was whether its impersonal nature might result in decreased patient satisfaction. However, satisfaction was very high in both the oral and video cohorts. Among patients randomized to the video group who had had skin biopsies prior to the study, more patients preferred video over verbal methods. Additionally, the mean ratings for usefulness and appeal of the videos were high, further supporting evidence of high satisfaction with this educational method.
A striking finding from this study was how little patients learn during their visit by either method of education. Knowledge scores improved by a mean of 1·12 in the oral education group, and by 1·55 in the video group. Past studies have demonstrated that patients do not retain much of what is discussed during their physician visits.28–31 Education is one of the fundamental goals of a physician encounter. If recommendations regarding medical care are to be effective, patient education needs to be maximized. One would think that these results demonstrate the importance of supportive documentation for patients to review at home. However, one survey found that 44% of adults aged 65 years or older in the U.S.A. could not perform even basic reading tasks.32 Other educational methods will be necessary to help serve this patient population.
Our study did not assess how video-based education compares with written education; however, a past study that looked at the utility of video-based education for melanoma awareness vs. a group who received a written pamphlet demonstrated significant improvement in knowledge 30 days after viewing the video compared with those who received the pamphlet.12
Although this study utilized hand-held video devices, videos are easily disseminated over the internet. As most Americans now have internet access, online videos that patients could refer back to might help improve their retention and comprehension of postoperative instructions. Increased patient comprehension and retention have been associated with improved clinical outcomes with other healthcare interventions.33 While our study did not assess postprocedure infection rates, it is possible that improved postoperative care following biopsy procedures might result in lowered incidences of surgical site infections.
Videos are useful for education in other medical disciplines outside that of dermatology.21,34,35 A prospective randomized study on the use of videos for preoperative education of patients undergoing regional anaesthesia found that those who watched a video prior to the procedure had significantly less anxiety than those who received verbal education only.21 Indeed, in a review of 25 methodologically sound video studies, Gagliano36 found that one of the most effective uses of videos may be that of role modelling. She found that videos showing actors undergoing proposed procedures diminished patient anxiety and pain, while increasing knowledge, cooperation and coping abilities during self-limited stressful situations.
One thing to consider when constructing videos is to make certain they are culturally sensitive to the target population. A study that used focus groups to construct appropriate videos found that using ethnically diverse actors in the videos and having physicians state the importance of the intervention being recommended made the videos more effective.34
The study results need to be interpreted in the context of its design. First, almost one-third of all participants had a history of previous biopsies; therefore, the change in knowledge scores might have been less significant than if all participants had no prior biopsy experience. Second, because dermatologists giving consent were aware of the study procedures, they might have been educating patients more diligently in the study setting than they would have been in usual clinical practice. Third, verbal education was administered by both attending dermatologists and dermatology residents to reflect real-world settings, where the consent process and education are provided by a diverse group of medical staff. Future studies could examine how the effectiveness of in-person education varies among different groups of healthcare professionals.
In conclusion, patient education is one of the main goals of a physician visit. In addition to improved clinical outcomes, patient education is associated with higher patient satisfaction.37 The use of hand-held video units is an effective method for education regarding shave and punch biopsies and postprocedure wound care. Videos provide highly reproducible dissemination of information with a high degree of patient satisfaction with regards to biopsy instructions and postoperative care. Video education appears to be a promising alternative to traditional oral instruction and may have added benefits of greater efficiency and potentially lower cost.
What’s already known about this topic?
• The current consent process prior to a procedure involves a physician and/or medical staff member verbally explaining a procedure, its risks and its benefits to a patient.
• This process is inadequate, inconsistent among physicians obtaining informed consent, and variably comprehensible among patients with different educational levels.
• Several prior studies suggest that video-based patient education may lead to greater patient comprehension and satisfaction as well as significantly reducing patient anxiety.
What does this study add?
• Video education is an effective method for education regarding shave and punch biopsies and postprocedure wound care.
• Among patients randomized to the video group who had had skin biopsies prior to the study, more patients preferred video over verbal methods.
We thank Lynda Ledo, Francis Hsiao, MD PhD, Ern Loh, MD PhD and Peter Lynch, MD for their review of the manuscript.