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Role of the patient in medical education

September 2008

Patient contact lies at the heart of medical education - all doctors have a professional obligation to be able to interact effectively with and treat patients. This discussion paper examines the roles of the patient in undergraduate, postgraduate and continuing medical education. It aims to raise awareness about the importance of patient-centred learning and outlines the key challenges to patient involvement. The paper highlights examples of current practice and makes recommendations for action. It is aimed at individuals and organisations with strategic and operational responsibility for medical education including medical schools, postgraduate deaneries, general practice directors, CPD organisers and remedial education organisers. It is intended to be of interest to doctors, trainees, medical students and patients.

An executive summary of the paper, as well as the recommendations are outlined below. A full version of the report can be accessed in pdf format via the link on the right of this page.

Executive summary
Patient contact occurs in various formats and settings during both undergraduate and postgraduate training. Clinical observation, supervised practice, and real case-based teaching are all vital for medical students, and on-the-job training necessarily forms the bulk of junior doctors’ learning experiences during foundation and specialist training. Once training is completed, patient contact in education continues through continuing professional development (CPD) and on-the-job learning. Assessment at all stages of education and training can be validated through the use of either real or simulated patient contact.

Patient contact is an integral component of medical education, training and assessment. It provides students, trainees and doctors with an opportunity to learn and to develop their professional skills, attitudes and identity, through both direct interaction and from the observation of their teachers and peers. Patients can also benefit from involvement in teaching and training, both directly by increasing their own knowledge, and indirectly through improved training of the medical workforce. With the shift in emphasis towards patient-centred care, patients now have a much more prominent role in education and training.

Challenges to patient involvement
There are a number of challenges that arise from patient involvement in medical education. These range from practical considerations relating to the organisation of clinical placements to patient concerns about consent and confidentiality. As many of these challenges are an unintended consequence of changes to medical education and healthcare service delivery, they will require flexible and innovative solutions. Medical educators also need to consider how patients can be more actively involved throughout all stages of the educational process.

1. Practical considerations relating to patient contact on clinical placements
The organisation of clinical placements is complicated by reduced opportunities for patient contact (eg shorter inpatient stays and patients being too transient, sick or frail), and by factors such as a lack of awareness among staff and in healthcare institutions of the need to facilitate patient involvement. Patient contact during clinical placements is also adversely affected by a number of organisational factors including increasing student numbers, inadequate teaching environments, service pressures, and insufficient promotion of the learning mission to patients and staff. Improving the quality of clinical placements necessitates the appointment of a clinical placement lead with responsibility for facilitating staff and patient involvement in placements, promoting the learning mission, and ensuring adequate teaching facilities are available. There is also a need for increased partnership working between the UK health departments, medical schools and NHS organisations to ensure resources and systems are in place for adequate patient contact on clinical placements.

2. Integrating the use of real and simulated patients
Real and simulated patients have advantages and limitations to their use in medical education. A range of factors need to be considered when deciding whether to use real or simulated patients including the learning objective or assessment need; the level of standardisation required; the logistics (including costs and availability); the context (eg practice-based or controlled workplace-based); the level of realism required; and local circumstances. While the use of real patients provides validity for teaching and assessment, simulated patients are useful in preparing learners for real patient contact (particularly for examinations or procedures that are sensitive or emotionally difficult) and for assessing particular skills (eg communication skills). It is therefore essential that both simulated and real patients are used for the purposes of learning and assessment in medial education. This should commence from the first year of the undergraduate medical course.

3. Patients with long-term conditions
While clinical placements have been found to provide significant benefit to medical students, they may not provide sufficient learning opportunities in relation to patients with long-term conditions. An educational programme on long-term conditions requires a longer time period than experienced on clinical placements, and should focus on the condition, how it impacts on daily life, the use of healthcare, and self-management. It is therefore important that medical schools ensure that teaching of long-term medical conditions is integrated into the undergraduate medial course through dedicated educational programmes. These should allow students to experience patient contact and continuity of care over a suitable length of time and in appropriate settings.

4. Patient diversity in medical education
In providing a responsive and competent medical workforce, it is essential that students and trainees have contact with a diverse range of patients. Research evidence suggests, however, that there are differences in patient agreement to medical student participation based on the patient’s gender, race, and severity of disease. It is important that medical students and trainees have exposure to, and are adequately trained in treating and communicating with, patients from a wide range of backgrounds. This requires a better understanding of the factors that affect patient attitudes to, and acceptance of, medical student participation.

5. Opportunities for patient contact during postgraduate training
A key area of consideration in postgraduate training is the teaching of communication skills. While this forms a part of all undergraduate curricula, there is debate over their role in postgraduate curricula, and in particular, whether specific communication skills should be taught based on a trainee’s clinical setting or specialty, or if all trainees should be taught the same set of communication skills. Partnership working is therefore required to ensure communication skills teaching is integrated throughout postgraduate medical training. Flexible solutions will also be required to overcome the reduced opportunities for patient contact that have resulted from the introduction of Modernising Medical Careers (MMC) and the European Working Time Directive (EWTD).

6. Ethics, confidentiality and consent
Patients may have a number of concerns over their involvement in medical education in relation to consent and confidentiality, and a lack of information about student and trainee involvement. Not meeting these concerns can impact on patients and on the learning outcomes for medical students, trainees and doctors. It is therefore essential that there is clear guidance on consent and confidentiality for patients, learners and individuals involved in teaching.

Active patient involvement
Increased levels of patient and public involvement in healthcare have arisen from a growing appreciation for the expertise patients have when it comes to their own care and from an increased emphasis on patient-centred care. As a result, there is an increasing focus of patients having a more active role in medical education and training. Most areas of curriculum involving clinical practice could benefit from a patient perspective on the outcomes which are set for students, though areas such as managing long-term conditions, equality and diversity, ethical dilemmas or areas of doctor-patient communication may be particularly important. Patients should therefore be actively involved in the development, review and implementation of undergraduate and postgraduate medical curricula.

The use of patients as teachers has a key role in providing opportunities and benefits for learners. This is particularly important given increasing student numbers and changes to healthcare service delivery. Involving patients as teachers can provide valuable educational benefits to learners (eg enables access to personal knowledge and experience), patients (eg improves their knowledge and provides new insights) and trainers (eg provides additional teaching resources). The roles of patients as teachers can take on different forms including as experts in their condition, as exemplars of their medical condition and as facilitators of students’ professional skills and attitudes. Patients should therefore be actively involved in teaching at the undergraduate and postgraduate level.

Patients can also potentially increase their role in assessment and examinations through acting as assessors. Traditionally, examiners and assessors tend to be clinicians or other healthcare professionals, at both undergraduate and postgraduate levels. Research has shown, however, that the holistic judgements provided by physician examiners can be similar to aggregate scores from trained standardised patient assessors. In particular, aspects of communication, especially those that are non-verbal, are assessed effectively by the patient or the person trained to be the patient. Consideration should therefore be given to integrating the use of patients as assessors in undergraduate and postgraduate assessments.

Recommendations

• A clinical placement lead who is contractually supported should be appointed with responsibility for ensuring:
  - there is adequate time and resources for staff input into clinical placements
  - all staff are aware of the need to facilitate patient contact with students
  - the learning mission is promoted to patients and staff
  - that premises have suitable space and amenities for education, and that these are incorporated at the planning stage for new buildings.
• That the UK health departments work in partnership with medical schools and NHS organisations to ensure resources and systems are in place for adequate patient contact on clinical placements.
• The use of simulated patients and real patients for the purposes of learning and assessment should be integrated from the first year of the undergraduate medical course. The decision to use real or
  simulated patients should be determined by local circumstances and the requirements of the learning or assessment process.
• Medical schools should ensure that teaching of long-term medical conditions is integrated into the undergraduate medical course through dedicated educational programmes. These should allow
  students to experience patient contact and continuity of care over a suitable length of time and in appropriate settings.
• Further research should be undertaken into the factors that affect patient attitudes to, and acceptance of, medical student participation.
• The PMETB should work in partnership with the GMC, the royal colleges and faculties, and the postgraduate deaneries to ensure communication skills teaching is integrated throughout postgraduate medical training.
• The GMC should work in partnership with UK medical schools and healthcare organisations with responsibility for training to:
  - ensure patients, learners and individuals involved in teaching are provided with clear guidelines on participating in medical education. This should include information on what is expected of the
  patient, what is expected of the student, trainee or learner and matters relating to consent and confidentiality
  - share good practice approaches to patient involvement, consent and confidentiality; among medical schools, NHS Trusts and healthcare institutions.
• Patients should be actively involved in the development, review and implementation of undergraduate and postgraduate medical curricula. This process should be monitored and patients should receive adequate training, resources and support.
• Patients should be actively involved in teaching during undergraduate and postgraduate training. This process should be monitored and patients should receive adequate training, resources and support.
• Consideration should be given to the use of patients as assessors in undergraduate and postgraduate assessments. This process should be monitored and patients should receive adequate training, resources and support.
  
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  © British Medical Association 2008