"User involvement is a sine qua non, almost, in medical education": learning with rather than just about health and social care service users

Evaluating Medical Students' Perceptions of Patient-Led Transplant Surgery Education 1-2 Years Later

INTRODUCTION

Medical students value the opportunity to learn from patients as a supplement to traditional faculty-led education; however, long-term follow-up to understand the educational impact of these experiences is lacking. We surveyed medical students who conducted non-medical virtual encounters with transplant recipients or living donors to understand the impact on students' patient care approach after 1-2 y.

METHODS

Students who completed their surgery clerkship from July 2020 to September 2021 were surveyed about this nonmedical patient encounter in January 2023. Quantitative and qualitative survey data were analyzed using descriptive statistics and inductive thematic analysis, respectively.

RESULTS

Of the 27 respondents (46% response rate), 44.4% completed the experience 1 y ago and 55.6% completed the experience 2 y ago. Nearly all respondents (96.3%) agreed that this experience was an effective way to learn about organ donation and transplantation and that learning from patients was beneficial to their development as a doctor. Over 50% felt this experience changed how they provide care to patients. Qualitatively, students reported that this activity cultivated their empathy for patients, provided unique insight into patients' illness experiences, and enhanced their understanding of the longitudinal patient-surgeon relationship.

CONCLUSIONS

Utilizing patients as teachers in transplant surgery not only taught medical students more about organ donation and transplantation but also built empathy and highlighted unique, non-clinical aspects of the patient experience that persisted over time. This is one of the first studies to evaluate patient-led teaching of this type over a year later and assess its unique influence on medical student development.

A challenge-based interdisciplinary undergraduate concept fostering translational medicine

Translational medicine (TM) is an interdisciplinary branch of biomedicine that bridges the gap from bench-to-bedside to improve global health. Fundamental TM skills include interdisciplinary collaboration, communication, critical thinking, and creative problem-solving (4Cs). TM is currently limited in undergraduate biomedical education programs, with little patient contact and opportunities for collaboration between different disciplines. In this study, we developed and evaluated a novel interdisciplinary challenge-based educational concept, grounded in the theoretical framework of experimental research-based education, to implement TM in undergraduate biomedicine and medicine programs. Students were introduced to an authentic clinical problem through an interdisciplinary session with patients, medical doctors, and scientists. Next, students collaborated in groups to design unique laboratory-based research proposals addressing this problem. Stakeholders subsequently rewarded the best proposal with funding to be executed in a consecutive interdisciplinary laboratory course, in which mixed teams of biomedicine and medicine students performed the research in a fully equipped wet laboratory. Written questionnaires and focus groups revealed that students developed 4C skills and acquired a 4C mindset. Working on an authentic patient case and the interdisciplinary setting positively contributed to communication, collaboration, critical thinking, and creative problem-solving skills. Furthermore, students were intrinsically motivated by (i) the relevance of their work that made them feel taken seriously and competent, (ii) the patient involvement that highlighted the societal relevance of their work, and (iii) the acquisition of a realistic view of what doing science in a biomedical research laboratory is. In conclusion, we showcase a widely applicable interdisciplinary challenge-based undergraduate concept fostering TM.

Patients' perspectives on their motivations for participating in non-clinical medical teaching and what they gain from their experience: a qualitative study informed by critical theory

In 2019-2021, we engaged in a project aimed at developing, implementing, and evaluating an educational intervention actively involving patient-teachers in undergraduate medical education at Université Laval, Quebec, Canada. Patient-teachers were invited to participate in small group discussion workshops during which medical students deliberate on legal, ethical, and moral issues arising from medical practice. Patients were expected to bring other perspectives, based on their experience with illness and the healthcare system. Little is still known about patients' perspectives on their participation experience in such context. Informed by critical theory, our qualitative study aims to document,: (i) the motivating factors for patients' participation in our intervention; and (ii) what patients gained from the experience. Data collection was based on 10 semi-structured interviews with patient-teachers. A thematic analysis was conducted using NVivo software. Motivators for participation arose from: (i) perceived consistency between patients' individual characteristics and those of the project, and (ii) conceiving the project as a means to reach individual and social goals. What patients gained mainly refers to (1) the appreciation of a positive, enriching, motivating yet uncomfortable and destabilizing experience; (2) a deconstruction of biases against the medical field and critical thinking about their own experience; (3) new knowledge, with a potential impact on their future interactions with the healthcare system. Results reveal patients as non-neutral thinking and knowing subjects, engaged in the participation experience as active teachers and learners. They also highlight the empowering and emancipatory nature of the learning gained through patients' participation experience. These conclusions prompt us to promote transformative interventional approaches that question the pervasive power issues in medical teaching and value patients' specific knowledge in teaching and learning the Art of Medicine.

Effectiveness of patients' involvement in a medical and nursing pain education programme: a protocol for an open-label randomised controlled trial including qualitative data

INTRODUCTION

Pain is a multidimensional experience that varies among individuals and has a significant impact on their health. A biopsychosocial approach is recommended for effective pain management; however, health professionals' education is weak on this issue. Patient involvement is a promising didactic methodology in developing a more holistic perspective, however there is a lack of reliable evidence on this topic. The aim of the present study is to evaluate the effectiveness of patient involvement in pain education in undergraduate medicine and nursing students.

METHODS AND ANALYSIS

An open-label randomised controlled trial including qualitative data will be conducted. After an introductory lesson, each student will be randomly assigned to the intervention group, which includes an educational session conducted by a patient-partner along with an educator, or to the control group in which the session is exclusively conducted by an educator. Both sessions will be carried out according to the Case-Based Learning approach. Primary outcomes will be students' knowledge, attitudes, opinions and beliefs about pain management, whereas the secondary outcome will be students' satisfaction. The Pain Knowledge and Attitudes (PAK) and Chronic Pain Myth Scale (CPMS) will be administered preintervention and postintervention to measure primary outcomes. Students' satisfaction will be measured by a questionnaire at the end of the session. Two focus groups will be conducted to evaluate non-quantifiable aspects of learning.

ETHICS AND DISSEMINATION

The protocol of this study was approved by the independent Area Vasta Emilia Nord ethics committee.Adherence to The Declaration of Helsinki and Good Clinical Practice will ensure that the rights, safety and well-being of the participants in the study are safeguarded, as well as data reliability. The results will be disseminated through scientific publications and used to improve the educational offer. A version of the anonymised data set will be released for public access.

TRIAL REGISTRATION

Trial was not registered on ClinicalTrials.gov as the interventions being compared only concern educational programmes and the outcomes considered do not refer to any clinical dimension.

Reimagining Preparedness of Health Professional Graduates Through Stewardship

Issue: Preparing health professional students for practice matters and is an important objective of health professional education. But although health professional courses grow in number and continue to graduate entry-level practitioners annually, there are signs that health professional education is not quite hitting the "purpose" mark. Preparedness is a term encountered often in health professional education, but it is besieged with challenges. Those challenges relate to whether graduates are prepared for their future careers and how preparedness for practice is understood; understandings of preparedness influence what curriculum, teaching, and learning prepares graduates about and for. Evidence: There is a wealth of the literature that suggests that graduates are not prepared for practice or believe they are not. This literature tends to grow rather than diminish, with arguments about preparedness materializing time and again. Preparedness means different things to students, academics, and practitioners and this creates misunderstanding as well as lessening the construct's value to research, education, and practice. What it means to be prepared is in fact not a static construct but changes in response to the needs of individuals and communities and broader societal context. When preparedness is defined as competence in skills or knowledge, graduates will be ill equipped to operate in the chaotic, ambiguous times we now face as competencies tend to oversimplify and reduce the demands of practice. Implications: Preparedness is only one purpose that could be attached to the educational formation of university graduates. It is time we expand our thinking about what is valuable and necessary to learn in order to become health professionals equipped to address the health and social care problems now and to come. Furthermore, continuing to address the challenges of preparedness for practice in the same ways as we have done for decades will not result in change; new and different educational approaches are required to meaningfully reimagine health professional education. We need to value education as a scholarly field in its own right, as much as we do evidence-based healthcare. A concept that prompts us to think and act in these reinvigorated ways is stewardship, which I offer as an expansive way to think about the purposes and desired outcomes of health professional education. Stewardship is an idea that sustains and cares for the professions, and therefore is highly relevant to the preparation of healthcare practitioners.

A theoretical systematic review of patient involvement in health and social care education

Patient involvement in health and social care education lacks theoretical underpinning, despite increasing calls for rigour. Theories help explain how learning is advanced and offer guidance for how faculty work with patients who become involved in curriculum delivery. We conducted a systematic review to synthesise how theory shapes our understanding of patient involvement in health and social care education. Three databases were systematically searched. Studies demonstrating explicit and high-quality application of theory to patient involvement in teaching and learning or involvement within a community of health and social care educators, were included. A narrative synthesis was undertaken using Activity Theory as an analytical lens to highlight the multifaceted components of patient involvement in professional education. Seven high-quality, theoretically underpinned studies were included. Four studies applied theory to pedagogy, showing how deep learning from patient involvement occurred. Despite a growing body of studies which attempt to use theory to explain learning, many were descriptive, lacked theoretical quality and were therefore excluded. Three studies applied theory to illuminate the complexity of involving patients in the educational system, showing how patients can be supported and valued in teaching roles. This review highlights that more work is required to identify the mechanisms through which patient involvement enhances learning and, to explore what involvement within the education community means for faculty and patients. Our understandings of patient-educator partnerships for learning could be progressed by further high-quality theory driven studies, which include the patient voice.

Twelve tips for patient involvement in health professions education

Moving towards person-centered care, with equal partnership between healthcare professionals and patients, requires a solid role for the patient in the education of students and professionals. Patients can be involved as teachers, assessors, curriculum developers, and policy-makers. Yet, many of the initiatives with patients are isolated, small events for targeted groups and there is a lack of patient involvement at the institutional level. To support educators in involving patients, both at the institutional level and at single educational encounters, we offer twelve practical tips. This paper came about through an innovative collaboration between healthcare professionals, educators, teachers, and patients. These tips can be used as a tool to start or reinforce patient involvement in health professions education and provide guidance on how to make it a sustainable part of the curriculum. The article involves organizational conditions for success, tips for sustainable partnerships, ideas for curriculum design and proposes concrete teaching strategies. Finally, besides practical tips, we stress that involving patients in education is not business as usual, and paradoxically this needs to be acknowledged before it can become business as usual.

Patients as experts in the illness experience: Implications for the ethics of patient involvement in health professions education

In response to calls to increase patient involvement in health professions education (HPE), educators are inviting patients to play a range of roles in the teaching of clinical trainees. However, there are concerns that patients involved in educational programs are seen as representing a demographic larger than themselves: their disease, their social group or even patients as a whole. This leads to difficult ethical challenges related to representation, including problems of tokenistic inclusion and of inadvertently essentializing marginalized groups. We propose that conceptualizing patients as experts in their illness experience can help resolve these dilemmas of representation equitably and effectively. Just as clinical experts are involved in HPE to share their expertise and represent their clinical experience, so too should patients be invited to participate in HPE explicitly for their expertise in their illness experience. This framing clarifies the goals of patient involvement as technocratic rather than tokenistic, mandates meaningful contributions by patients, and helps frame patient involvement for learners as the presentation of expert perspectives.

Something special, something unique: Perspectives of experts by experience in mental health nursing education on their contribution

WHAT IS KNOWN ON THE SUBJECT

●Expert by Experience participation in mental health services is embedded in mental health policy in many countries. The negative attitudes of nurses and other health professionals to consumer participation poses a significant obstacle to this policy goal. ●Involving mental health Experts by Experience in the education of nursing students demonstrates positive attitudinal change.

WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE

●The paper presents perspectives from Experts by Experience about the unique knowledge and expertise they derive from their lived experience of mental distress and mental health service use. As a result, they can make a unique and essential contribution to mental health nursing education. They utilize this knowledge to create an interactive learning environment and encourage critical thinking. ●The international focus of this research enriches understandings about how Experts by Experience might be perceived in a broader range of countries.

WHAT ARE THE IMPLICATIONS FOR PRACTICE

●Mental health policy articulates the importance of service user involvement in all aspects of mental health service delivery. This goal will not be fully achieved without nurses having positive attitudes towards experts by experience as colleagues. ●Positive attitudes are more likely to develop when nurses understand and value the contribution experts by experience bring by virtue of their unique knowledge and expertise. This paper provides some important insights to achieving this end.

ABSTRACT

Introduction Embedding lived experience in mental health nursing education is increasing, with research findings suggesting the impact is positive. To date, research has primarily targeted the perspectives of nursing students and academics from the health professions. Aim To enhance understanding of the unique knowledge and expertise experts by experience contribute to mental health nursing education. Methods Qualitative exploratory research methods were employed. In-depth individual interviews were conducted with experts by experience who delivered a coproduced learning module to nursing students in Europe and Australia. Results Participants described their unique and essential contribution to mental health nursing education under four main themes: critical thinking, beyond textbooks; interactive and open communication; understanding personal recovery; and mental health is health. Conclusions These findings present an understanding of the unique knowledge and expertise Experts by Experience contribute to mental health education not previously addressed in the literature. Appreciating and respecting this, unique contribute is necessary as Expert by Experience contributions continue to develop. Implications for Practice Mental health services purport to value service user involvement. Identifying and respecting and valuing the unique contribution they bring to services is essential. Without this understanding, tokenistic involvement may become a major barrier.

A qualitative study of patients' and caregivers' perspectives on educating healthcare providers

BACKGROUND

Patients/caregivers can be actively involved in the education of healthcare providers (HCPs). The purpose of this study was to explore patients'/caregivers' perspectives on their involvement and roles in the education of HCPs.

METHODS

We invited patients/caregivers to participate in one-on-one semi-structured interviews. We analyzed the interview data using conventional content analysis to identify themes.

RESULTS

In terms of patient/caregiver involvement in the education of HCPs, we identified that patients/caregivers perceive that it: (a) is challenging because of power-differentials between themselves and HCPs; (b) requires patient training; (c) needs to start early in HCPs' education processes; (d) can improve patient-HCP partnerships; and (e) requires compensation for patients. With regards to the roles that patients can play in educating HCPs, we found that patients/caregivers want to: (a) teach HCPs about patients' expectations, experiences and perspectives through case studies, storytelling, and educational research; (b) provide direct feedback to HCPs; and (c) advise on curricula development and admission boards for HCPs.

CONCLUSIONS

Understanding patients'/caregivers' perspectives on this topic can help educational leaders and HCPs improve active patient/caregiver involvement in the education of HCPs. We need to listen to patients'/caregivers' voices in order to make effective changes in current and future health professions education.

Ignitions of empathy. Medical students feel touched and shaken by interacting with patients with chronic conditions in communication skills training

OBJECTIVE

To explore what and how medical students learn from patients with chronic conditions in the context of communication skills training.

METHODS

Semi-structured interviews and focus groups with 32 medical students. Interviews were recorded, transcribed, analyzed inductively and organized into four main narrative themes.

RESULTS

Learning from patients provided medical students opportunities to see the world through the patients' eyes, understand the diversity of patients' needs, and recognize the importance of matching patients' and doctors' perspectives. Consequently, students expressed emotional responses on challenges in interactions with the patients related to performing the role as 'medical expert'. Difficulty empathizing became visible in the students' interaction with patients.

CONCLUSION

The patients' authentic contributions provided the students with unique opportunities to engage with their own emotions and capacity for empathy. However, for students to benefit from this affective practical training, they need guidance to balance professional and personal aspects in encounters. There is a need to introduce the 'doctor as person' in medical education.

PRACTICE IMPLICATIONS

Patients with chronic conditions strengthen students' learning of empathy as part of transformative learning. Doing so with patients is a challenging way of learning. Thus, faculty and educators must provide explicit guidance for students to benefit.

Patients' and parents' perspectives of and experiences with assessing nursing students' paediatric clinical practice

PURPOSE

To explore patients' and parents' involvement in the formative assessment of undergraduate nursing students' paediatric clinical practice.

METHODS

We conducted semi-structured interviews with paediatric patients between 14 to 18 years old and parents who received care from a nursing student while admitted to a paediatric tertiary care hospital in Canada. We analysed the data using qualitative content analysis as well as Lincoln and Guba's criteria for establishing trustworthiness. The Consolidated criteria for reporting qualitative studies (COREQ) checklist was completed for the quality appraisal of this article.

FINDINGS

Three categories emerged from the data: 1) how patients and parents are currently involved in the formative assessment of nursing students' paediatric clinical practice; 2) how patients and parents would prefer to be involved in the formative assessment of nursing students' paediatric clinical practice; and 3) the potential benefits and challenges of involving patients and parents in the formative assessment of nursing students' paediatric clinical practice.

CONCLUSION

This study provided an understanding of patients' and parents' past encounters with nursing students and the elements of care that they have assessed as well as those that they would prefer to assess and provide feedback on, while considering the potential benefits and challenges of their involvement. The findings of this study will assist clinical instructors in determining how and when to involve patients and parents in the assessment of nursing students. Academic institutions offering nursing programmes should consider the study findings when improving or changing formative assessment strategies.

Role of active patient involvement in undergraduate medical education: a systematic review

OBJECTIVES

To identify the scope of active patient involvement in medical education, addressing the current knowledge gaps relating to rationale and motivation for involvement, recruitment and preparation, roles, learning outcomes and key procedural contributors.

METHODS

The authors performed a systematic search of the PubMed database of publications between 2003 and 2018. Original studies in which patients take on active roles in the development, delivery or evaluation of undergraduate medical education and written in English were eligible for inclusion. Included studies' references were searched for additional articles. Quality of papers was assessed using the Mixed Methods Appraisal Tool.

RESULTS

49 articles were included in the review. Drivers for patient involvement included policy requirements and patients' own motivations to contribute to society and learning. Patients were engaged in a variety of educational settings in and outside of the hospital. The vast majority of studies describe patients taking on the role of a patient teacher and formative assessor. More recent studies suggest that patients are increasingly involved in course and curriculum development, student selection and summative assessment. The new body of empirical evidence shows the wide range of learning objectives was pursued through patient participation, including competencies as professional, communicator, collaborator, leader and health advocate, but not scholar. Measures to support sustainable patient involvement included longitudinal institutional incorporation, patient recruitment and/or training, resource support and clear commitment by faculty. The importance and advantages of patient involvement were highlighted by students, faculty and patients themselves; however, organisations must continue to consider, monitor and take steps to mitigate any potential harms to patients and students.

DISCUSSION

This systematic review provides new knowledge and practical insights to physicians and faculty on how to incorporate active patient involvement in their institutions and daily practice, and provides suggested action points to patient organisations wishing to engage in medical education.

Purposeful involvement of experts by experience

BACKGROUND

There is a growing requirement from professional bodies in the UK that health and social care education must include the voice of experts by experience (EbE). Active steps have been taken at the international level in order to truly embed their involvement. In parallel with this development, there is compounding evidence collated globally that links interprofessional education (IPE) to improved health outcomes. As the involvement of EbE plays a central role in IPE there is an increased expectation for teachers to be able to successfully involve EbE in IPE and other health education.

ISSUE

Although there is some guidance available to teachers on how to involve EbE in pre-registration health and social care education, less guidance is available on how to involve EbE in complex educational interventions, such as IPE. Hence the need for faculty member development.

APPROACH

The Centre for Interprofessional Practice (CIPP) has involved nearly 350 EbE in a variety of IPE since 2005. This review draws on insights from the CIPP to identify a number of practice points for teachers who wish to involve EbE in IPE, or as part of education for their specific profession. The practice points are endorsed by EbE and discussed in light of initiatives and evidence reported by others in the literature. To help contextualise and make use of these practice points they were grouped according to the presage-process-product (3P) model. This article can inform faculty member development aimed at new or senior educators, and our insights are equally applicable to both uni- and interprofessional contexts.

Innovation in early medical education, no bells or whistles required

BACKGROUND

Despite a paucity of evidence to support a multitude of educational innovations, curricular leaders are pressured to find innovative solutions to better prepare medical students for an evolving twenty-first century health care system. As part of this effort, this study directly compared student-rated effectiveness scores of six different learning modalities.

METHODS

Study participants included 286 medical students enrolled in the second-year rheumatology core at a single academic medical center between 2013 and 2017. Students were surveyed at the end of the core with a 15-item questionnaire, and student perceived effectiveness of six different learning modalities were compared.

RESULTS

The modality that outperformed all others was Live Patient Encounters (LPE), with significantly higher student-rated effectiveness scores when compared to the referent modality of Problem-Based Learning (PBL). Using a 5-point Likert scale with responses ranging from "not effective" to "highly effective," LPE received a mean effectiveness score of 4.77 followed by Augenblick (4.21), PBL (4.11), Gout Racer video game (3.49), Rheumatology Remedy e-module (3.49), and simulation knee injection (3.09).

CONCLUSIONS

Technologically advanced novel learning strategies were outperformed in this study by the more traditional active learning modality of LPE. This finding highlights the importance of testing innovative learning strategies at the level of the learner. Three additional conclusions can be drawn from this result. First, conflation of technology with innovation may lead to a myopic view of educational reform. Second, human factors seem to be responsible for the success of LPE and may have far-reaching educational rewards. Third, further applications of LPE should be tested in non-rheumatologic curricula. The relevance of this study is innately tied to the humanities-based application. While a formal qualitative analysis was not performed in this study, preliminary results suggest that live, structured patient interactions in the pre-clinical years of medical education may not only promote the learning of important educational objectives but also foster professional development, empathy, reflection, leadership, agency, and interpersonal skills. This "win-win" scenario (if true) would stand out as a rarity among strategic educational initiatives.

Planning, implementation, and evaluation of multicomponent, case-based learning for first-year Indian medical undergraduates

Didactic lecture is an effective method to quickly pass on a high volume of information to a large number of students. However, if not well designed, lectures can be monotonous and provide only passive learning, with little scope for higher order learning skills. To address this drawback of lectures, we supplemented it with case-based learning (CBL), which has been shown to promote self-learning. After giving an overview of gastrointestinal physiology through lectures, CBL on peptic ulcer disease was implemented for first-year Bachelor of Medicine, Bachelor of Surgery students. The present study aimed to evaluate the students' and teachers' opinions on the notion of supplementing lectures with CBL. In previous reports, discussion using clinical cases was primarily employed as the solitary component for conducting CBL. In the present study, three different but mutually exclusive components, such as case discussion, concept map, and critical thinking exercise on a specific topic in gastrointestinal pathophysiology, were integrated to form the multicomponent CBL (MC-CBL). Students reported that MC-CBL could promote application of the knowledge learned in lectures in a more appropriate context (92.42% positive response), enhance their learning efficiency (98.46% positive response), promote their active participation in the learning process (98.48% positive response), and help them in integrating physiological concepts with clinical science (98.46% positive response). Teachers observed that MC-CBL could promote active learning, analytic, and problem-solving skills of students. In conclusion, MC-CBL appeared to be an effective supplement for the lectures, providing an opportunity for the students to relate the knowledge learned during lectures.

Patient Involvement in Education of Nutrition and Dietetics Students: A Systematic Review

A client-centred approach sits at the core of modern healthcare. Exploration of the patients’ role within the education of nutrition and dietetic students has not previously been undertaken. This review aimed to synthesise the learning outcomes that result from involvement of patients in nutrition and dietetic student education, and to consider whether these interactions promote patient-centred care. Five electronic databases were searched, supported by hand-searching of references of included studies. Screening of title/abstract and then full text papers was undertaken; key characteristics and outcomes were extracted and synthesised narratively. The likely impact of interventions was evaluated using Kirkpatrick’s Hierarchy; study quality was assessed using the Medical Education Research Study Quality Instrument and Critical Appraisal Skills Programme checklist. Of 7436 studies identified through database searching, and one additional study located through hand searching of reference lists, the final library consisted of 13 studies. All studies reported benefits for student learning from patient involvement, while one paper identified patient benefits from student interventions. Patients as recipients of care mostly contributed in a passive role in student education activities. Quality assessment identified methodological limitations in most studies. Patient involvement in the education of dietitians supports skill development and therefore progression to professional practice. Although nutrition and dietetics education has a focus on client-centred care, the translation of these concepts into an interactive student educational experience has been investigated to a limited extent. Collaboration with patients in student education is an area for further development.

Perspectives of Patients With Mental Illness on How to Better Teach and Evaluate Diversity Education in the National Health Service

INTRODUCTION

Diversity education is a mandatory requirement for all mental-health practitioners and health care professionals in the UK National Health Service. Wide variability exists in the development, delivery, and evaluation of diversity education across health care settings, with limited evidence to suggest the optimal approach for teaching this subject. This study aimed to explore the perspectives of patients with mental illness on how to better teach and evaluate diversity education in the National Health Service.

METHODS

A participatory research approach was used with five mental-health patient organizations. Forty-two patients with mental illness took part in three participatory workshops. Data were analyzed through template analysis.

RESULTS

The findings indicated that a focus on the nuances and dynamics of clinical relationships would be beneficial. Specifically, the relationship considered most important to examine with respect to diversity education was the "practitioner-self" relationship.

DISCUSSION

Reconstructing the relationship-centered care model with the addition of the practitioner-self relationship may be better suited to theoretically informing future developments in diversity education. Further research is needed to understand what educational approaches contribute toward a relationship-centered care outlook and how relationship building behaviors, particularly those relevant to the practitioner-self relationship are best developed in diverse settings.

'I will never ever go back': patients' written narratives of health care communication

CONTEXT

Although communication with patients is essential to health care, education designed to develop patient-centred communication often ignores patients' voices. Patient stories may offer a means to explore patient experiences to inform patient-centred communication skills education design.

OBJECTIVES

Our research questions were: (i) What are the features of patients' health care communication narratives? (ii) What differences exist between patient narratives evaluated as positive and those evaluated as negative? (iii) How do patients narrate emotion in their narratives?

METHODS

This interpretivist research was underpinned by social constructionism. We employed a narrative approach to design an online questionnaire that was advertised to patients in the community. Analysis of the stories that were generated involved analysis of what was written (i.e. framework analysis) and of how it was written (i.e. attending to linguistic features).

RESULTS

Participants shared 180 written narratives about previous health care professional (HCP) communication interactions. Narratives commonly included those of female patients seeking help for musculoskeletal or psychological concerns, which most frequently had occurred within the previous 6 months with male general practitioners in community settings. Framework analysis revealed four key themes: (i) patient actions during consultations; (ii) patient actions afterwards; (iii) lasting legacy, and (iv) interpersonal factors. Patients in narratives evaluated as positive actively engaged during and after interactions, had ongoing positive relationships with HCPs and felt valued in these relationships. Patients in narratives evaluated as negative were either passive or active during the interaction, but mostly failed to return to the HCP and felt devalued in their interaction. Further analysis of the linguistic features of select narratives revealed rich constructions of positive and negative emotions emphasising the lasting legacies of these interactions.

CONCLUSIONS

Analysis of patient narratives provides a detailed way of exploring patients' experiences, emotions and behaviours during and after consultations. Educational implications include emphasising the importance of valuing the patient, and of seeking and acting on patient feedback to calibrate HCPs' patient-centred communication practices.

Dilemmas of Representation: Patient Engagement in Health Professions Education

The role of the patient in bedside teaching has long been a matter of consideration in health professions education. Recent iterations of patient engagement include patients as storytellers, members of curriculum planning committees, guest lecturers, and health mentors. While these forms of patient engagement are reported to have many benefits for learners, educators, and the patients themselves, there is concern that such programs may not be representative of the diversity of patients that health care professionals will encounter throughout their careers. This problem of representation has vexed not only educators but also sociologists and political scientists studying patients' and the public's involvement in arenas such as health services research, policy, and organizational design.In this Perspective, the authors build on these sociological and political science approaches to expand our understanding of the problem of representation in patient engage-ment. In doing so, the authors' reconfiguration of the problem sheds new light on the dilemma of representation. They argue for an understanding of representation that not only is inclusive of who is being represented but that also takes seriously what is being represented, how, and why. This argument has implications for educators, learners, administrators, and patient participants.

Beyond catharsis: the nuanced emotion of patient storytellers in an educational role

CONTEXT

As health care organisations seek to cultivate patient and family-centred care, patient storytelling has emerged as a valued educational resource. However, repeatedly harnessing patient perspectives to educate health care professionals may have consequences. We need robust insight into what it means to be a patient storyteller in order to ensure ethical and appropriate engagement with patients as an educational resource.

METHODS

Constructivist grounded theory was used to explore the experience of patients involved in a storytelling curriculum as part of hospital staff continuing education. All 33 storytellers were invited by e-mail to participate in the study. Twenty-six storytellers responded to the invitation, and 25 could be scheduled to participate. Using theoretical sampling, semi-structured interviews were conducted and analysed in a process that was inductive, iterative and comparative.

RESULTS

Participants described the central role of emotions in their storytelling experience, which varied from 1 to 25 tellings over a period of 1 month to 2 years. These emotions were shaped by the passage of time, repetition of storytelling and audience acknowledgement. However, emotion remained unpredictable and had lingering implications for storytellers' vulnerability.

CONCLUSION

The multiple storytelling experiences of our participants and ongoing educational nature of their role provides unique insight into how emotions ebb and flow across tellings, how emotions can be both a surprise and a rhetorical strategy, and how emotions are influenced by audience acknowledgement. These findings contribute to an emerging conversation regarding the power and politics of selecting and using storytellers for organisational purpose. Implications include how we support patient storytellers in educational roles and how we can sustainably integrate patient storytelling into health professional education.

'Can the patient speak?': postcolonialism and patient involvement in undergraduate and postgraduate medical education

CONTEXT

Patients are increasingly being engaged in providing feedback and consultation to health care institutions, and in the training of health care professionals. Such involvement has the potential to disrupt traditional doctor-patient power dynamics in significant ways that have not been theorised in the medical literature. Critical theories can help us understand how power flows when patients are engaged in the training of medical students.

METHODS

This paper applies postcolonial theory to the involvement of patients in the development and delivery of medical education. First, I review and summarise the literature around patient involvement in medical education. Subsequently, I highlight how postcolonial frameworks have been applied to medical education more broadly, extrapolating from the literature to apply a postcolonial lens to the area of patient engagement in medical education.

CONCLUSION

Concepts from postcolonial theory can help medical educators think differently about how patients can be engaged in the medical education project in ways that are meaningful and non-tokenistic. Specifically, the positioning of the patient as 'subaltern' can provide channels of resistance against traditional power asymmetries. This has curricular and methodological implications for medical education research in the area of patient engagement.

Developing and Translating a New Model for Teaching Empowerment Into Routine Chronic Care Management: An International Patient-Centered Project

Background:

Health professional education has been criticized for not integrating patient expertise into professional curricula to develop professional skills in patient empowerment.

Objective:

To develop and translate a new expert patient-centered model for teaching empowerment into professional education about routine chronic care management.

Methods:

Eight Finnish patients (known as expert patients), 31 students, and 11 lecturers from 4 European countries participated in a new pilot intensive educational module. Thirteen focus groups, artefacts, and an online student evaluation were analyzed using a thematic analysis and triangulated using a meta-matrix.

Results:

A patient-centered pedagogical model is presented, which describes 3 phases of empowerment: (1) preliminary work, (2) the elements of empowerment, and (3) the expected outcomes. These 3 phases were bound by 2 cross-cutting themes “time” and “enabling resources.”

Conclusion:

Patient expertise was embedded into the new module curriculum. Using an example of care planning, and Pentland and Feldman’s theory of routine organization, the results are translated into a patient-centered educational model for teaching empowerment to health profession students.

Involving a real patient in the design and implementation of case-based learning to engage learners

Real patients offer unique opportunities to develop authentic, engaging, and transformative learning experiences for students. Patients are widely employed to teach clinical and interpersonal skills in the clerkship phase of their medical education (M3-M4), but have not been extensively included in the preclinical curriculum (M1-M2) when students are focused on acquiring foundational biomedical science knowledge. To maximize learning and help students connect foundational and clinical science concepts to real-world clinical problems, we involved a real patient in the creation and implementation of a case-based learning (CBL) activity in our preclinical curriculum. Using the patient's narrative as a framework, the CBL addressed relevant aspects of physiology, pathophysiology, anatomy, pharmacology, and nutrition, as well as clinical care decisions, health literacy, and medical ethics. The intervention was implemented with the 2019 and 2020 graduating medical school classes during the Gastrointestinal Systems course in the second year of our curriculum. The results of a survey revealed that, overall, a majority of the students agreed or strongly agreed that the activity increased engagement in class, increased the depth of discussion within their teams, increased the depth of discussion between teams, helped students to apply basic science concepts to the clinical material in the case, helped students better understand the disease processes described in the case, enhanced awareness of the complexity of patient care, provided an authentic learning experience, and elicited a feeling of empathy.

Beyond vulnerability: how the dual role of patient-health care provider can inform health professions education

In order to prepare fully competent health care professionals, health professions education must be concerned with the relational space between patients and providers. Compassion and compassionate care are fundamental elements of this relational space. Traditionally, health professions educators and leaders have gone to two narrative sources when attempting to better under constructs of compassion: patients or providers. Rarely have there been explorations of the perspectives of those who consider themselves as both patients and providers. In this study, we interviewed nineteen health care providers who self-disclosed as having had a substantive patient experience in the health care system. We engaged with these participants to better understand their experience of having these dual roles. Anchored in Foucault's concepts of subjectivity and Goffman's symbolic interactionism, the interviews in this study reveal practices of moving between the two roles of patient and provider. Through this exploration, we consider how it is that providers who have been patients understand themselves to be more compassionate whilst in their provider roles. Rather than describing compassion as a learnable behaviour or an innate virtue, we theoretically engage with one proposed mechanism of how compassion is produced. In particular, we highlight the role of critical reflexivity as an underexplored construct in the enactment of compassion. We discuss these findings in light of their implications for health professions education.

The involvement of older inpatients in medical student education

Objectives

To examine older inpatients’ experiences with medical student education, their views on future interactions, and to seek their opinion on the most important curricular topics related to geriatric medicine.

Methods

The study involved 112 non-confused inpatients older than 65 years of age, who completed a uniformed questionnaire on the day of their discharge from a teaching hospital.

Results

The mean age was 81 years, with equal number of male and female participants. 57% interacted with the students during their admission, the majority being interviewed and examined. Almost all (92%) of these patients described their experience as positive, some described it as time-consuming (23%), repetitive (19%) and tiresome (9%). 92% of all participants agreed that the older patients should be part of medical students’ education. Dementia, cardiac conditions, cancer, arthritis, isolation/loneliness were highlighted as the most important topics to teach medical students related to geriatric medicine, while patience and listening were listed as important skills. They suggested practical, easily implemented advice for the improvement of the interaction between students and older patients; including allowing more time for interactions and for students to speak louder.

Conclusions

Older patients felt positively about their interactions with medical students, and believed that older patients should be involved in medical student education. As well as medical conditions such as dementia, cardiac disease and cancer, these patients highlighted isolation and loneliness as important topics for undergraduate geriatric medical education, implying that students should learn about broader aspects of older patients’ health and wellbeing.

'I did try and point out about his dignity': a qualitative narrative study of patients and carers' experiences and expectations of junior doctors

OBJECTIVES

For many years, the voice of patients has been understood as a critical element for the improvement of care quality in healthcare settings. How well medical graduates are prepared for clinical practice is an important question, but one that has rarely been considered from patient and public perspectives. We aimed to fill this gap by exploring patients and carers' experiences and expectations of junior doctors.

DESIGN

This comprises part of a wider study on UK medical graduates' preparedness for practice. A qualitative narrative methodology was used, comprising four individual and six group interviews.

PARTICIPANTS

25 patients and carers from three UK countries.

ANALYSIS

Data were transcribed, anonymised and analysed using framework analysis.

MAIN RESULTS

We identified three themes pertinent to answering our research question: (1) sources of knowledge (sources of information contributing to patients and carers' perceptions of junior doctors' impacting on expectations); (2) desires for student/trainee learning (experiences and expectations of medical training); and (3) future doctors (experiences and expectations of junior doctors). We also highlight metaphorical talk and humour, where relevant, in the quotes presented to give deeper insights into participants' perspectives of the issues. Participants focused on personal and interpersonal aspects of being a doctor, such as respect and communication. There was a strong assertion that medical graduates needed to gain direct experience with a diverse range of patients to encourage individualised care. Participants narrated their experiences of having symptoms ignored and attributed to an existing diagnosis ('diagnostic overshadowing') and problems relating to confidentiality.

CONCLUSIONS

Our findings support the view that patients and carers have clear expectations about junior doctors, and that patient views are important for preparing junior doctors for practice. There is a necessity for greater dialogue between patients, doctors and educators to clarify expectations and confidentiality issues around patient care.

Pre-registration interprofessional clinical education in the workplace: a realist review

CONTEXT

The inclusion of interprofessional education opportunities in clinical placements for pre-registration learners has recently been proposed as a strategy to enhance graduates' skills in collaborative practice.

OBJECTIVES

A realist review was undertaken to ascertain the contexts, mechanisms and outcomes of formal interprofessional clinical workplace learning.

METHODS

Initial scoping was carried out, after which Ovid MEDLINE, CINAHL and EMBASE were searched from 2005 to April 2016 to identify formal interprofessional workplace educational interventions involving pre-registration learners. Papers reporting studies conducted in dedicated training wards were excluded, leaving a total of 30 papers to be included in the review.

RESULTS

Several educational formats that combined students from medicine, nursing, pharmacy and allied health professions were identified. These included: the use of engagement by student teams with a real patient through interview as the basis for discussion and reflection; the use of case studies through which student teams work to promote discussion; structured workshops; ward rounds, and shadowing. Meaningful interprofessional student discussion and reflection comprised the mechanism by which the outcome of learners acquiring knowledge of the roles of other professions and teamwork skills was achieved. The mechanism of dialogue during an interaction with a real patient allowed the patient to provide his or her perspective and contributed to an awareness of the patient's perspective in health care practice. Medication- or safety-focused interprofessional tasks contributed to improved safety awareness. In the absence of trained facilitators or in the context of negative role-modelling, programmes were less successful.

CONCLUSIONS

In the design of workplace education initiatives, curriculum decisions should take into consideration the contexts of the initiatives and the mechanisms for achieving the education-related outcomes of interest.

EQUIP training the trainers: an evaluation of a training programme for service users and carers involved in training mental health professionals in user-involved care planning

WHAT IS KNOWN ON THE SUBJECT?: UK NHS policy highlights the importance of user and carer involvement in health professional training. We know little about service user and carer motivations and experiences of accessing training courses for delivering training to health professionals and how well such courses prepare them for delivering training to healthcare professionals. 'Involvement' in training has often been tokenistic and too narrowly focused on preregistration courses. There is limited data on how best to prepare and support potential service user and carer trainers. WHAT DOES THIS PAPER ADD TO EXISTING KNOWLEDGE?: This study adds to the international literature by highlighting service user and carer motivations for accessing a training course for delivering training to health professionals. Service users and carers wanted to gain new skills and confidence in presentation/facilitation as well as to make a difference to healthcare practice. We also learned that service users desired different levels of involvement in training facilitation - some wanted to take a more active role than others. A one-size-fits-all approach is not always appropriate. Encountering resistance from staff in training was a previously unidentified challenge to service user and carers' experience of delivering training in practice and is a key challenge for trainers to address in future. Professional training involvement can be enhanced via specialist training such as the EQUIP training the trainers programme evaluated here. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: When training service users and carers to deliver training to mental health professionals, it is important that service users are equipped to deal with resistance from staff. It is important that service user and carer roles are negotiated and agreed prior to delivering training to healthcare professionals to accommodate individual preferences and allay anxieties. Training for service users and carers must be offered alongside ongoing support and supervision. Mental health nurses (and other health professionals) will be better able to involve service users and carers in care planning. Service users and carers may feel more involved in care planning in future.

ABSTRACT

Introduction Limited evidence exists on service user and carer perceptions of undertaking a training course for delivering care planning training to qualified mental health professionals. We know little about trainee motivations for engaging with such train the trainers courses, experiences of attending courses and trainees' subsequent experiences of codelivering training to health professionals, hence the current study. Aim To obtain participants' views on the suitability and acceptability of a training programme that aimed to prepare service users and carers to codeliver training to health professionals. Method Semi-structured interviews with nine service users and carers attending the training programme. Transcripts were analysed using inductive thematic analysis. Results Participants' reasons for attending training included skill development and making a difference to mental health practice. Course content was generally rated highly but may benefit from review and/or extension to allow the range of topics and resulting professional training programme to be covered in more depth. Trainees who delivered the care planning training reported a mix of expectations, support experiences, preparedness and personal impacts. Implications for Practice Mental health nurses are increasingly coproducing and delivering training with service users and carers. This study identifies possibilities and pitfalls in this endeavour, highlighting areas where user and carer involvement and support structures might be improved in order to fully realize the potential for involvement in training.

The Big D(eal): professional identity through discursive constructions of 'patient'

CONTEXT

Professional identity formation has become a key focus for medical education. Who one becomes as a physician is contingent upon learning to conceptualise who the other is as a patient, yet, at a time when influential ideologies such as patient-centred care have become espoused values, there has been little empirical investigation into assumptions of 'patient' that trainees take up as they progress through their training.

METHODS

Our team employed a critical discourse analysis approach to transcripts originally produced from a micro-ethnography of medical student learning on an acute care in-patient paediatric ward. The dataset included 20 case presentations and 14 sign-over rounds taken from a 3-week observation period. We paid specific attention to how trainees used language to talk about, refer to and categorise patients.

RESULTS

Identified discourses included patient-as-disease-category, patient-as-educational-commodity and patient-as-marginalised-actor. These discourses conceptualise 'patient' as an entity that is principally biomedical, useful for clinical learning and spoken for and about. Medical student participation in these discourses contributes to an identity that allows them to move further into the professional medical world they are joining.

CONCLUSIONS

We contend that as learners participate in these discourses, they are also performatively produced by them. By making these discourses visible, we can consider how to minimise unintended effects such discourses may cause. Our findings, although limited, offer a glimpse of the effects that those assumptions may have as we look to align better the formation of professional medical identity with the ideals of patient-centred care and socially responsible health care systems.

Learning outcomes for communication skills across the health professions: a systematic literature review and qualitative synthesis

OBJECTIVE

The aim of this study was to identify and analyse communication skills learning outcomes via a systematic review and present results in a synthesised list. Summarised results inform educators and researchers in communication skills teaching and learning across health professions.

DESIGN

Systematic review and qualitative synthesis.

METHODS

A systematic search of five databases (MEDLINE, PsycINFO, ERIC, CINAHL plus and Scopus), from first records until August 2016, identified published learning outcomes for communication skills in health professions education. Extracted data were analysed through an iterative process of qualitative synthesis. This process was guided by principles of person centredness and an a priori decision guide.

RESULTS

168 papers met the eligibility criteria; 1669 individual learning outcomes were extracted and refined using qualitative synthesis. A final refined set of 205 learning outcomes were constructed and are presented in 4 domains that include: (1) knowledge (eg, describe the importance of communication in healthcare), (2) content skills (eg, explore a healthcare seeker's motivation for seeking healthcare),( 3) process skills (eg, respond promptly to a communication partner's questions) and (4) perceptual skills (eg, reflect on own ways of expressing emotion).

CONCLUSIONS

This study provides a list of 205 communication skills learning outcomes that provide a foundation for further research and educational design in communication education across the health professions. Areas for future investigation include greater patient involvement in communication skills education design and further identification of learning outcomes that target knowledge and perceptual skills. This work may also prompt educators to be cognisant of the quality and scope of the learning outcomes they design and their application as goals for learning.

Patients embodied and as-a-body within bedside teaching encounters: a video ethnographic study

Bedside teaching encounters (BTEs) involve doctor-patient-student interactions, providing opportunities for students to learn with, from and about patients. How the differing concerns of patient care and student education are balanced in situ remains largely unknown and undefined. This video ethnographic study explores patient involvement during a largely student-centric activity: 'feedback sequences' where students learn clinical and practical skills. Drawing on a data subset from a multi-site study, we used Conversation Analysis to investigate verbal and non-verbal interactional practices to examine patients' inclusion and exclusion from teaching activities across 25 BTEs in General Practice and General Surgery and Medicine with 50 participants. Through analysis, we identified two representations of the patient: the patient embodied (where patients are actively involved) and the patient as-a-body (when they are used primarily as a prop for learning). Overall, patients were excluded more during physical examination than talk-based activities. Exclusion occurred through physical positioning of doctor-patient-student, and through doctors and students talking about, rather than to, patients using medical jargon and online commentaries. Patients' exclusion was visibly noticeable through eye gaze: patients' middle-distance gaze coincided with medical terminology or complex wording. Inclusory activities maintained the patient embodied during teaching activities through doctors' skilful embedding of teaching within their care: including vocalising clinical reasoning processes through students, providing patients with a 'warrant to listen', allocating turns-at-talk for them and eye-contact. This study uniquely demonstrates the visible nature patient exclusion, providing firm evidence of how this affects patient empowerment and engagement within educational activities for tomorrow's doctors.

How patient educators help students to learn: An exploratory study

INTRODUCTION

Benefits of the active involvement of patients in educating health professionals are well-recognized but little is known about how patient educators facilitate student learning.

METHOD

This exploratory qualitative study investigated the teaching practices and experiences that prepared patient educators for their roles in a longitudinal interprofessional Health Mentors program. Semi-structured interviews were conducted with eleven experienced health mentors. Responses were coded and analyzed for themes related to teaching goals, methods, and prior experiences.

RESULTS

Mentors used a rich variety of teaching methods to teach patient-centeredness and interprofessionalism, categorized as: telling my story, stimulating reflection, sharing perspectives, and problem-solving. As educators they drew on a variety of prior experiences with teaching, facilitation or public speaking and long-term interactions with the health-care system.

CONCLUSIONS

Patient educators use diverse teaching methods, drawing on both individualistic and social perspectives on learning. A peer-support model of training and support would help maintain the authenticity of patients as educators. The study highlights inadequacies of current learning theories to explain how patients help students learn.

Identifying Opportunities for Peer Learning: An Observational Study of Medical Students on Clinical Placements

Phenomenon: Peer assisted learning (PAL) is frequently employed and researched in preclinical medical education. Fewer studies have examined PAL in the clinical context: These have focused mainly on the accuracy of peer assessment and potential benefits to learner communication and teamwork skills. Research has also examined the positive and negative effects of formal, structured PAL activities in the clinical setting. Given the prevalence of PAL activities during preclinical years, and the unstructured nature of clinical placements, it is likely that nonformal PAL activities are also undertaken. How PAL happens formally and informally and why students find PAL useful in this clinical setting remain poorly understood.

APPROACH

This study aimed to describe PAL activities within the context of clinical placement learning and to explore students' perceptions of these activities. An ethnographic study was conducted to gather empirical data on engagement in clinical placement learning activities, including observations and interviews with students in their 1st clinical year, along with their supervising clinicians. Thematic analysis was used to interrogate the data.

FINDINGS

On average, students used PAL for 5.19 hours per week in a range of activities, of a total of 29.29 hours undertaking placements. PAL was recognized as a means of vicarious learning and had greater perceived value when an educator was present to guide or moderate the learning. Trust between students was seen as a requirement for PAL to be effective. Students found passive observation a barrier to PAL and were able to identify ways to adopt an active stance when observing peers interacting with patients. For example, learners reported that the expectation that they had to provide feedback to peers after task observation, resulted in them taking on a more critical gaze where they were encouraged to consider notions of good practice. Insights: Students use PAL in formal (i.e., tutorial) and nonformal (e.g., peer observation and feedback on the ward; discussion during lunch) situations in clinical education and find it useful. The educator is crucial in fostering PAL through providing opportunities for learners to practice together and in helping to moderate discussions about quality of performance. Student engagement in PAL may reduce passivity commonly reported in clinical rotations. Further directions for research into PAL in clinical education are identified along with potential strategies that may maximize the benefits of peer to peer learning.

Women in medical education: views and experiences from the Kingdom of Saudi Arabia

CONTEXT

Although research from Western contexts suggests that considerable inequalities for female medical educators exist in the workplace, we do not yet know the views and experiences of women within non-Western contexts. By examining the influence of context, intersecting identities and language use, this study explores female medical educators' views and experiences of gender, career progression and leadership in academic medicine in the Kingdom of Saudi Arabia (KSA).

METHODS

We conducted individual interviews employing narrative interviewing techniques with 25 female medical educators from five schools in the KSA (June to December 2014). Data were analysed using framework analysis and drew on intersectionality theory.

RESULTS

Participants expressed their views and experiences of career progression, leadership and gendered workplace cultures. Women's experiences of career progression and leadership in the KSA were influenced by their gender and varied according to their career stage, work environment and specialty. Participants discussed the gendered organisational cultures of academic medicine in the KSA in terms of gender inequalities (e.g. females being overlooked for leadership positions), gender stereotypes (e.g. women perceived as more likely to take part in shared leadership) and gendered specialties (e.g. surgery being male dominated). We revealed women's more tacit understandings about gender, career progression and leadership by examining how they talk (e.g. metaphoric, pronominal and emotional talk). Finally, participants constructed multiple intersecting personal (e.g. female, mother and young) and professional identities (e.g. doctor, teacher and leader) for themselves through their narratives.

CONCLUSION

This study provides important new insights into female medical educators' experiences of career progression and leadership in a non-Western context. Investment in the future of women's careers in the KSA through faculty development initiatives and equality and diversity policies is now essential to help close the gender gap.

Towards a pedagogy for patient and public involvement in medical education

CONTEXT

This paper presents a critique of current knowledge on the engagement of patients and the public, referred to here as patient and public involvement (PPI), and calls for the development of robust and theoretically informed strategies across the continuum of medical education.

METHODS

The study draws on a range of relevant literatures and presents PPI as a response process in relation to patient-centred learning agendas. Through reference to original research it discusses three key priorities for medical educators developing early PPI pedagogies, including: (i) the integration of evidence on PPI relevant to medical education, via a unifying corpus of literature; (ii) conceptual clarity through shared definitions of PPI in medical education, and (iii) an academically rigorous approach to managing complexity in the evaluation of PPI initiatives.

RESULTS

As a response to these challenges, the authors demonstrate how activity modelling may be used as an analytical heuristic to provide an understanding of a number of PPI systems that may interact within complex and dynamic educational contexts.

CONCLUSION

The authors highlight the need for a range of patient voices to be evident within such work, from its generation through to dissemination, in order that patients and the public are partners and not merely objects of this endeavour. To this end, this paper has been discussed with and reviewed by our own patient and public research partners throughout the writing process.

Developing a patient focussed professional identity: an exploratory investigation of medical students' encounters with patient partnership in learning

Patient encounters are central to the provision of learning opportunities for medical students and their development as medical professionals. The primary aim of the study reported in this paper was to discover how partnering medical students with patients with chronic illness in undergraduate learning influenced the development of a patient centred professional identity and professionalism. An exploratory interpretive research design was used to address the research aim within a patient partner program (P3). Three qualitative data collection methods were used: (1) focus groups (2) extended response questionnaire and (3) semi-structured interviews. Data were coded and analysed thematically. The professional identity of medical students is constructed along traditional lines in the preclinical years. Patient-partnership offers a disruption to this development by way of an intersection with patients with chronic illness which potentially allows meaningful construction of what a patient-centred identity should be. This point of reflection provides an opportunity to engage at a higher level in medical identity development and professionalism. The findings discussed in this paper further stimulate the patient-centred agenda by understanding the conflict associated with the student-patient nexus in medical education and its potential for building professionalism and a patient-centred professional identity. To continue the drive for a patient-centred professional identity there must be ongoing engagement with patients in medical education, preferably commencing early in a student's journey so that it becomes the expected norm. This study has highlighted that a true patient-centred emphasis is being encountered too late in their socialisation process.

The Role of the Teaching Hospital in the Effective Clerkship

A teaching hospital is a place where both patient care and learning occur together. To identify the role of the teaching hospital in an effective clerkship, we first determined the features of workplace learning and the factors that affect learning in the workplace, and then we proposed a role for the teaching hospital in the clinical clerkship. Features of learning in a clerkship include learning in context, and learning from patients, supervising doctors, others in the team, and colleagues. During the clerkship, medical students learn in three-way learner-patient-teacher relationships, and students’ participation in the tasks of patient care is crucial for learning. Factors that influence learning in the workplace are associated with tasks, context, and learner. Tying the three factors together, we proposed a role for the teaching hospital in the three categories: involvement in the tasks of patient care, engagement in the medical team, and engagement in the learning environment and system. Supervising doctors and team members in a teaching hospital support students’ deep participation in patient care, while improving the learning environment through organizational guidelines and systems. Gathering both qualitative and quantitative data for the evaluation of a teaching hospital is important.

Medical students' learning from patient-led teaching: experiential versus biomedical knowledge

The aim of this study was to explore how medical students perceive the experience of learning from patient instructors (patients with rheumatism who teach health professionals and students) in the context of coupled faculty-led and patient-led teaching session. This was an explorative study with a qualitative approach based on focus group interviews. Analysis was based on a prior developed model of the characteristics of learning from patient instructors. The authors used this model as sensitizing concepts for the analysis of data while at the same time being open to new insights by constant comparison of old and new findings. Results showed a negotiation both between and within the students of the importance of patients' experiential knowledge versus scientific biomedical knowledge. On one hand students appreciated the experiential learning environment offered in the PI-led sessions representing a patient-centred approach, and acknowledged the importance of the PIs' individual perspectives and experiential knowledge. On the other hand, representing the scientific biomedical perspective and traditional step-by step teaching, students expressed unfamiliarity with the unstructured experiential learning and scepticism regarding the credibility of the patients' knowledge. This study contributes to the understanding of the complexity of involving patients as teachers in healthcare education and initiates a discussion on how to complement faculty-led teaching with patient-led teaching involving varying degrees of patient autonomy in the planning and delivering of the teaching.

The view from over there: reframing the OSCE through the experience of standardised patient raters

CONTEXT

Ratings awarded by standardised patients (SPs) in UK objective structured clinical examinations (OSCEs) are typically based on humanistic (non-technical) skills and are complementary to clinician-examiner ratings. In psychometric terms, SP ratings appear to differ from examiner ratings and improve reliability. For the first time, we used qualitative methods from a constructivist perspective to explore SP experiences of rating, and consider how these impact our understanding of assessment.

METHODS

We used constructivist grounded theory to analyse data from focus groups and individual semi-structured interviews with 38 SPs and four examiners. Inductive coding, theoretical sampling and constant comparison continued until theoretical saturation was achieved.

RESULTS

Standardised patients assessed students on the core process of relationship building. Three theoretical categories informed this process. The SP identity was strongly vocational and was both enacted and reinforced through rating as SPs exerted their agency to protect future patients by promoting student learning. Expectations of performance drew on individual life experiences in formulating expectations of doctors against which students were measured, and the patient experience was a lens through which all interactions were refracted. Standardised patients experienced the examination as real rather than simulated. They rated holistically, prioritised individuality and person-centredness, and included technical skill because the perception of clinical competence was an inextricable part of the patient experience.

CONCLUSIONS

The results can be used to reframe understanding of the SP role and of the psychometric discourse of assessment. Ratings awarded by SPs are socially constructed and reveal the complexity of the OSCE process and the unfeasibility of absolute objectivity or standardisation. Standardised patients valued individuality, subjective experience and assessment for learning. The potential of SPs is under-used their greater involvement should be used to promote real partnership as educators move into a post-psychometric era. New-generation assessments should strive to value subjective experience as well as psychometric data in order to utilise the significant potential for learning within assessment.

Patients as educators: interprofessional learning for patient-centred care

BACKGROUND

Patients with chronic conditions have unique expertise that enhances interprofessional education. Although their active involvement in education is increasing, patients have minimal roles in key educational tasks. A model that brings patients and students together for patient-centred learning, with faculty playing a supportive role, has been described in theory but not yet implemented.

AIMS

To identify issues involved in creating an educational intervention designed and delivered by patients and document outcomes.

METHOD

An advisory group of community members, students and faculty guided development of the intervention (interprofessional workshops). Community educators (CEs) were recruited through community organizations with a healthcare mandate. Workshops were planned by teams of key stakeholders, delivered by CEs, and evaluated by post-workshop student questionnaires.

RESULTS

Workshops were delivered by CEs with epilepsy, arthritis, HIV/AIDS and two groups with mental health problems. Roles and responsibilities of planning team members that facilitated control by CEs were identified. Ten workshops attended by 142 students from 15 different disciplines were all highly rated. Workshop objectives defined by CEs and student learning both closely matched dimensions of patient-centredness.

CONCLUSIONS

Our work demonstrates feasibility and impact of an educational intervention led by patient educators facilitated but not controlled by faculty.

Staff Perspectives of Service User Involvement on Two Clinical Psychology Training Courses

This study investigated both negative and positive staff perspectives of service user involvement on two clinical psychology training courses as part of an ongoing process of service evaluation. Ten clinical psychology staff from two training courses were interviewed over the telephone by a current trainee clinical psychologist using a semi-structured interview method. Data were coded into textual units of meaning and then analysed using content analysis. The categories most cited by participants regarding the positives of service user involvement were that service user involvement ‘develops trainees' learning’ and ‘challenges power differences’. For opportunities of service user involvement to provide benefits to the training courses, most participants cited ‘meaningful versus tokenistic involvement’, followed by ‘strategic involvement’. Regarding negatives and barriers, those most cited were ‘differences of opinion or agendas' and ‘lack of resources’. Whilst the findings suggested that the service user involvement initiatives on both courses have been well received, research is needed into how service users also experience the process. Interventions that facilitate staff reflection and processing of multiple perspectives were also recommended, particularly with regards to negative experiences of service user involvement.

Phenomenological analysis of patient experiences of medical student teaching encounters

CONTEXT

It is important to know how patients are affected by becoming opportunistically involved in medical student education. In previous studies, researchers rather than patients set the research agenda and expert patients or people well known to teachers were more often involved than ordinary people.

OBJECTIVES

This study aimed to explore how ordinary patients experience undergraduate medical teaching when they become involved in it opportunistically and to derive practical insights from the lived experiences of these patients.

METHODS

The research was conducted in line with a conceptual orientation towards communities of practice theory and used phenomenology as a way of exploring patients' lived experiences in depth. Minimally structured interviews were carried out with 10 patients following ordinary out-patient or general practice appointments in which students were being taught. Template analysis was used to generate provisional themes and a process of phenomenological reduction was used to distil individual respondents' lived experiences to their essence.

RESULTS

The presence of students in ambulatory consultations was normal. Nine respondents described transactional relationships in which they remained outside the community of practice of which the doctor and student were members. Only an intimate problem would engage them deeply enough for a student's presence to 'bother' them. One patient's personal and professional background led her to regard doctors' handling of consultation dynamics as factors contributing to whether teaching consultations were negative or positive experiences. When doctors' sensitive and inclusive behaviour drew her into a triadic relationship with the student and doctor, she experienced mutual benefits with students. When it did not, she felt objectified and alienated.

CONCLUSIONS

Provided they receive the clinical care for which they are attending a consultation and are treated respectfully, patients may sometimes willingly become 'objects' from which students learn. They may, however, become more deeply engaged in teaching consultations in which they participate actively in a triadic relationship of mutual benefit with a doctor and student. Teaching consultations call for doctors to be sensitive and adaptable.

Do too many cooks spoil the broth? The effect of observers on doctor-patient interaction

CONTEXT

The presence of additional medical personnel in consultations alters the focus of the doctor-patient interaction. Patients feel excluded from the interaction and relegated to the role of a non-person or prop, which leads to a loss of autonomy. Previous research has considered the psychological effects of the presence of additional persons on the interaction, but few studies have considered how these additional persons affect the performances of the consulting doctor and patient in the interaction.

METHODS

A linguistic study drawing on the methods of discourse analysis was conducted to consider how the presence of additional medical personnel in the consultation alters doctors' responses to patients' questions, their management of patient-initiated topics, and their use of invitations to ask questions.

RESULTS

When additional professionals were present in the consultation, the consultations were significantly longer than control group consultations (p = 0.04) and significantly more patient-initiated topics remained unresolved at the close of the consultation (p = 0.04). In consultations in which students were present, markedly fewer patient questions were answered than in control group consultations, and there was a notable reduction in the number of overt invitations to ask questions (both differences approached significance). There was, however, a significant reduction (p ≤ 0.01) in the proportion of patient-initiated topics that were deferred when students were present in the consultation.

CONCLUSIONS

Previous research has identified a loss of patient focus when a patient sees doctors en masse. The results from the present study suggest that the presence of additional medical personnel can distract the focus of a consultation away from the patient, particularly when the additional participants are professionals rather than students. Further research is required to develop a greater understanding of multiple-doctor-patient interactions. A training programme should be developed to train consulting doctors at teaching hospitals to manage these multiple-doctor-patient consultations more effectively.

Active patient involvement in the education of health professionals

CONTEXT

Patients as educators (teaching intimate physical examination) first appeared in the 1960s. Since then, rationales for the active involvement of patients as educators have been well articulated. There is great potential to promote the learning of patient-centred practice, interprofessional collaboration, community involvement, shared decision making and how to support self-care.

METHODS

We reviewed and summarised the literature on active patient involvement in health professional education.

RESULTS

A synthesis of the literature reveals increasing diversity in the ways in which patients are involved in education, but also the movement's weaknesses. Most initiatives are 'one-off' events and are reported as basic descriptions. There is little rigorous research or theory of practice or investigation of behavioural outcomes. The literature is scattered and uses terms (such as 'patient'!) that are contentious and confusing.

CONCLUSIONS

We propose future directions for research and development, including a taxonomy to facilitate dialogue, an outline of a research strategy and reference to a comprehensive bibliography covering all health and human services.