Patients as Teachers
“There should be no teaching without the patient for a text, and the best teaching is often that taught by the patient himself.”
— William Osler
The patient’s role as a teacher
It is increasingly being recognised that the patient has a valuable and active contribution to make to the teaching team in the context of general practice. This is an evolving area of research and innovation in the VI teaching practice. It has long been a tradition that teaching within the clinical context with ‘real’ patients is essential to medical education. Patients are generally satisfied with participation in students’ learning. In a small number of cases patients may find student teaching sessions distressing, particularly individuals with mental health conditions.
The patient’s role as a teacher in general practice will vary depending on the stage of the learner. Medical students generally sit in and observe the GP supervisor or registrar consulting with patients. In some practices a medical student may consult with the patient and then present the patient to the GP in a joint consultation. Junior doctors will either parallel consult with a senior GP supervisor or, if the junior doctor is appropriately registered, they may consult independently and review cases with a GP supervisor, as needed. GP registrars will see patients independently and seek advice from a GP supervisor, as required.
Key benefits of patient teachers
In any clinical context with real patients (as opposed to a simulated patient) the patients’ needs must always take precedence over those of the learner.
Benefits to the patient
Patients have unique and often detailed knowledge about their own health conditions. Enabling patients to impart their expert knowledge to a learner can be empowering. Discussing and describing their disease or condition helps patients to feel acknowledged and can provide them with new insights and knowledge. Patients generally welcome the opportunity to share experiences and knowledge with future doctors, passing on what they have learned throughout their journey. It can be meaningful for a patient to feel they are passing on wisdom that will help future patients. Many patients also feel it important that they have an opportunity to provide feedback to learners about their communication skills, because interpersonal skills are important in the doctor–patient relationship.
Benefits for learners
When learners (particularly medical students) interact with real patients with real clinical problems, the learners often recognise the relevance of the more theoretical teaching they received in lectures. Relating theoretical learning to the real patient experience can motivate further learning, particularly as learners recognise and identify gaps in their knowledge.
Deeper learning is enhanced by listening to patients describe their conditions and the ways in which they manage their health and illness. If patients provide students with positive feedback they observe the students’ confidence increase. Students often find the shift to delivering patient-centred care to be quite challenging, particularly as much medical teaching focuses on a disease or case-based learning. When they are given the opportunity to learn from patients, junior doctors can improve their communication skills, develop more professional attitudes and adopt a patient-centred approach to care.
Incorporating the patient in teaching provides students with a real opportunity to see illness through a ‘patient lens’, which, in turn, assists students in building a partnership with the patient and recognising that relationships are important in medicine.
A key benefit of general practice learning is the opportunity to observe the benefit of longitudinal relationships between patient and doctor compared with single episodes of care that are the norm in other clinical learning settings. Patients often affirm that relationship in the way they talk about their GP.
Challenges of engaging patients in teaching
There can be barriers to patient participation in teaching in the general practice. Patients are particularly concerned that:
Quality of care will not be compromised.
There is informed consent
Confidentiality is assured.
There is always an opportunity to refuse or withdraw participation.
There are often time and space issues in teaching practices, with multiple learners competing for learning opportunities. Patients are in a hurry and might resent the extra time a learner needs in a consultation (for example, to take a history). The patient may be impatient if a supervisor takes too much time explaining something to a student. However, student teaching is also an opportunity for patient learning, and most patients welcome the extra information being discussed about their own condition.
Short-term student placements in the general practice can be a barrier to learners participating in the management of patients with chronic illnesses. Some patients enjoy retelling their story to frequent new learners in the practice, while others, particularly those with a rare illness, can become frustrated or fatigued with detailing their history for the umpteenth time. Patients may also be traumatised if they regularly relive traumatic health events.
Language and cultural differences also preclude some patients from participation in teaching. Patient reluctance sometimes relates to the seniority and/or gender of the student, with patients usually more comfortable with a student of the same sex in cases of intimate examinations. Patients often refuse to have a student present for embarrassing or difficult consultations (for example, consultations relating to sexuality, drugs or abuse).
In some studies, mental health problems have been identified as a reason for patients refusing consent for student involvement in their care. Supervisors also note it can be difficult to have a student present in consultation with highly anxious patients, anxious because the student’s presence may enhance the patient’s anxiety, especially if the student discusses inappropriate diagnoses.
Teachers are keen to ensure that teaching enhances patient care without compromise. Students can ask inappropriate questions, appear judgemental or give inappropriate information or advice to patients. Such situations can be problematic for the supervisor and require careful management.
Although there are many potential challenges to involving the patient as teacher, acknowledging these factors allows the teaching team to develop strategies that can overcome the barriers.
Involving the patient in teaching
The whole practice has a role in ensuring that teaching occurs, and that the patient is successfully engaged in the process. Without this support, patient participation can be compromised. Administrative staff are usually responsible for:
informing patients of the teaching needs in a practice;
obtaining patient consent;
arranging appointments to ensure there is sufficient teaching time; and
managing patient comments and concerns as they arise.
Patient teacher roles outside the consultation
Patients can also be engaged in more formal teaching environments outside the consultation. Patients sometimes participate in workshops as voluntary patients presenting with their own real issues, or as simulated patients who have been given a script to follow. As well as expanding the learner’s clinical knowledge, these activities help students to learn and implement interpersonal skills that enhance medical practice (for example, listening) and provide a safe opportunity to gain competence and confidence.
Patients can also be involved in other aspects of teaching, including curriculum development, especially in areas such as medical ethics, doctor–patient communication, equality and diversity, and the management of chronic conditions. Patients have also been involved in assessment processes, often as a patient in an examination, or giving 360-degree feedback to a student or registrar as part of their evaluation.
Patient consent
Carers may also contribute to student learning, particularly issues related to service delivery and access.
Patient consent is an important issue to consider when successfully engaging patients in the learning process.
In Australia, requirements for patient consent to interact with medical students are set out by the Medical Board of Australia. The code of conduct stipulates that the GP supervisor should be:
Making the scope of the student’s role in patient care clear to the student, patient and other members of the healthcare team
Informing your patients about the involvement of medical students and obtaining their consent for student participation, while respecting their right not to consent.1
Patients generally prefer to be told at the time they book an appointment that a student or junior doctor will be present in the consultation. At this point, the patient should be given the opportunity to decline participation. Patients view consent as an ongoing process, not just a once-off event, so consent should be sought each time a student will be sitting in on their care. Patients should also be given an opportunity to see their own doctor alone, if preferred.
Many patients prefer to receive written information about a learner’s involvement in their care. It can be helpful to have information sheets about the teaching practice for patients to read in the waiting room. Information sheets can not only promote your practice as a teaching practice, but can also provide information about how patients can assist teachers, and invite them to become involved in training future doctors. The information sheet should also outline consent policies and thank patients for their participation in teaching.
Ensure that the practice has signage identifying its status as both a university teaching practice and a GP registrar training practice. Display any certificates of recognition or accreditation received from training organisations so that patients recognise your practice as a high-quality practice that has been trusted as a place for students to learn medicine.
The behaviour of practice staff will influence the giving of consent. Firstly, it is inappropriate to ask the patient for consent in the presence of the student. Patient consent is more likely to be provided if full information is presented in a respectful manner. Patients usually consider that verbal consent is sufficient, unless there is physical contact or a procedure involving risk or discomfort. In such situations, written consent is expected. Patients prefer to be given time to provide consent. Patients also need to be aware that they can change their mind at any stage, without being disrespected by their doctor. Many patients want to please their doctor and not make a fuss, therefore being able to recognise a patient’s discomfort and create an environment where they can feel comfortable to refuse consent is very important.
The reception staff need to be positive in their approach to managing patient consent, as this is crucial in promoting students and newer registrars to patients. Presenting the junior learner in a positive light and promoting patient confidence is important in encouraging patient involvement in teaching. Some examples include:
We have a lovely new doctor at the practice recently out of the hospital, who is very up to date.
Why don’t you see our wonderful student while you are waiting, and Dr Jones will join the consultation when he finishes with his current patient?
A medium-sized practice set in a regional centre has two GP supervisors, four other GPs, two GP registrars and two medical students on rotation. There are also three practice nurses.
The practice has a sign at the entrance promoting its role as a university teaching practice and as a GP registrar training practice. Its practice information sheet highlights that GP registrars are fully qualified doctors undertaking general practice postgraduate training. Patients are informed that they may be asked to see medical students, but will always be asked for their consent prior to the event. A specific consent sheet is available, if required.
The practice has also developed a list of patients who are prepared to attend the practice when requested to act as patient teachers for medical students. These patients have signs and symptoms of diseases that may be useful for medical student teaching and are also patients who are willing to participate in the teaching process.
Promoting patient-learner relationships
Both patients and learners in the practice might have initial reluctance to be involved in patient as teacher models. Promoting your learner to the patient, and the patient to your learners is important to establishing effective patient as teacher models. Some strategies to promote patient–learner interactions and relationships are listed below.
During the consultation
Teaching your learner with a patient present often enhances your reputation with that patient, demonstrates to the patient the complexity of your thinking, and reinforces how you respect their wishes and their rights in any situation. It is excellent modelling for a student or registrar.
Reinforce that patients are contributing to the learning and development of GPs of the future. Let your patients know you have confidence in your students and registrars and encourage your patient to return to the students and more junior members of the team for follow-up consultations. Inviting your new student or registrar to join your consultation to provide a second opinion provides an opportunity to introduce them to patients—this also demonstrates to patients that you value the opinion of the new doctor.
Over time, you can develop a list of patients who are happy to be seen by registrars and medical students
Engaging patients with chronic diseases
When you see long-term patients with chronic illness, invite them to return to be reviewed by your student or registrar. Emphasise that you believe the patient has a lot to teach your new doctor. Call your registrar in, introduce the patient and registrar to one another, and request the registrar follow up your patient for the next few visits. Provide clear information about the goals of the current consultation. This teaches the registrar about follow-up of chronic conditions and reassures the patient that there is a reason to see your registrar.
Health assessments
Ask your elderly patients or those with chronic illness to return for a health assessment conducted by your student and registrar. Conducting a thorough health assessment can be a good way for a registrar to build rapport with patients and provides the patient with opportunities to contribute to a GP registrar’s broader knowledge of the patient’s issues. Additionally, ‘a fresh approach with fresh eyes’ can be very useful for both the patient and you as the supervisor.
Nurse consultations
Ask your practice nurse to consult the GP registrar for opinions on patients or clinical issues. This allows a GP registrar an opportunity to meet patients in the practice who consult with the practice nurse. The practice nurse may also invite the medical student to assist with a consultation, providing an opportunity for the learner and patient to engage.
Home visits
Schedule the GP registrar to undertake routine home visits and nursing home visits as early as possible to build relationships with practice patients. The GP registrar may also take medical students on these visits.
Promoting team management
Get registrars and students referring to “our” patients rather than “your” patients. Use language that makes them part of the team and take responsibility. This is very important for registrars, who often see the patients as “your” patients and think their role is only to deal with the urgent problem and send the patient back to you. In the hospital setting, registrars rarely have an opportunity to have long term follow-up with a patient, so it is important to promote the GP registrar’s self-identification as a member of the ongoing health care team and as sharing responsibility. It also encourages patients to identify with the learners in the practice as part of the “team” looking after them.
Preventive health
Enable students and registrars to be holistic caregivers and engage patients in dialogue about general health issues. Discuss opportunistic prevention and how to raise preventive health care with patients. Two lifestyle charts (one for adults and one for children) that are presented by the RACGP in the Redbook2 provide an excellent resource for approaching preventive care with patients. These charts could be placed on the desktop as a laminated hard copy or as a soft copy on the computer for learners to use as a resource. Encourage students and junior registrars to use these charts in a formalised way during patient consultations, progressing through the chart together while waiting for the supervisor. This enhances the learner–patient consultation and gives learners insight into lifestyle challenges and issues for patients
Safety and quality of care
The private nature of a GP practice is a very different context for learning compared to the hospital setting. Considerations of patient safety and quality of care are important. In general practice, a GP registrar works in a ‘solitary’ consulting room as a lone practitioner, unlike the hospital setting in which the registrar is observable and part of a larger treating team. It is often the case that a medical student may be in a consulting room alone with a patient, especially if parallel consulting is being utilised as a teaching method in the practice.
It is very important to have good knowledge of the capabilities, competence and confidence of your learners. The only way to fully evaluate learners in the practice is to undertake some direct observation of their consultations with patients and perform a random case audit of the learner’s medical notes. It is crucial to evaluate the learner early in a new placement. Patients themselves will often give clear cues as to the performance of a learner and their satisfaction with the consultation.
Students and junior doctors require clear instructions about requesting assistance early. Provide a clear indication as to the point you prefer to become involved in the patient’s care. Junior doctors and junior registrars need clear guidance about scope of practice and when they must ask for help or a second opinion. Provide a list of high-risk scenarios as a guide to learners, and remain open, available and respectful at all times to encourage appropriate help-seeking. This is the best way to ensure safety and quality for your patients.
Suggested further reading
Medical Board of Australia (MBA). Good Practice: A Code of Conduct for Doctors in Australia. Australia: MBA, 2014. http://www.medicalboard.gov.au/Codes-Guidelines-Policies/Code-of-conduct.aspx (accessed September 2017).
This code of conduct is essential reading.
The Royal Australia College of General Practitioners (RACGP). Guidelines for preventative activities in General Practice. 9th edn. Melbourne: RACGP, 2016. http://www.racgp.org.au/your-practice/ guidelines/redbook/ (accessed September 2017).
Medical students and GP registrars should become familiar with this resource.