The growing role of patients in medical education
Should more medical schools employ expert patient teachers?
The use of plastic dummies to assess how medical students carry out a pelvic examination is a thing of the past at Oxford University. At this medical school, the speculum examination in the gynaecology objective structured clinical examination (OSCE) station is carried out by lay women, instead of using plastic models. Since August 2015, students have been assessed on their abilities to interact with and conduct a vaginal examination on clinical teaching associates (CTAs). These trained expert patients teach intimate examinations using their own bodies and give students feedback that you just don't get from a plastic pelvic model.
Although assessment led by CTAs is novel, examination teaching by CTAs is not new. They have been teaching vaginal examination for several years in Oxford, and similar programmes have been running in the United Kingdom and the United States for decades. Researchers from King’s College London found in 2003 that students taught by gynaecology CTAs had higher assessment scores than those taught using only traditional teaching methods.
The expert patient will see you now
Medical education has always included patients, but traditionally in a more passive role rather than as an active teacher. However, the idea that patients are experts who can interact with medical professionals as equals goes back at least as far as the 1980s—with the rise in the concept of the “expert patient” who brings expertise on their own body, life, and health to the consultation.
The CTA programme is just one model of patient led teaching. The Patient | Carer Community, which is based at the University of Leeds, includes carers’ perspectives as well as those of patients. Their experiences form a powerful part of some teaching sessions. Patient involvement in education can go beyond teaching into course design, student selection, and assessment. The degree of patient involvement can range from a one-off invitation for local patients to tell their stories, up to more formal partnerships, including employment of patients and carers (see box).
Ladder of involvement (abridged)
Level 1—No involvement
Level 2—Limited involvement
Some outreach into community; patients invited in to tell their stories with payment for their time
Level 3—Growing involvement
Regular contribution of patients/carers to multiple aspects of a course or module (planning, delivery, student selection, assessment, management, evaluation). Paid for time at normal visiting lecturer rates.
Involvement of patients/carers in at least three aspects of training. Paid for time at visiting lecturer rates. Provision of training and support to patients and carers.
Patients, carers, and teaching staff work together across all areas of a course with all decisions made jointly. Some service users and carers employed on secure contracts.
In Oxford, the university has involved the patient group The Miscarriage Association in developing learning outcomes for gynaecology teaching. As part of the course, women who have had a miscarriage speak to the students directly about their experiences. The university and the Miscarriage Association are collaborating in the revision and redevelopment of an OSCE station around patient driven outcomes for miscarriage, reflecting what the patients experienced and what they thought was done well and what could be done better by future doctors.
Feedback about CTAs
The CTA pelvic examination sessions at Oxford University are popular. Angela Sheard, a final year Oxford medical student, says: “It made a big difference to me to have a lot of input from patients who had been through the system themselves and were keen to share with us what went well, what didn’t.
“During some of the sessions I thought that a genuine three way discussion was taking place, with views from medical students, patients and doctors being shared in the same space—with the chance to inform each other.”
Emma Lewis, a CTA who also mentors students in writing patient led reflections, says: “The CTA programme has consistently high satisfaction ratings, and students often thank us fervently at the end of sessions.” Patient led teaching in other institutions also has high student satisfaction ratings. A survey of medical students at the University of Leeds found that students thought patient led teaching was more memorable.
The new Oxford OSCE for pelvic examination replaced a consultant examined station, which entailed taking consent for an examination and smear from an actor, then performing the examination on a plastic model, concluding with a further discussion with the actor. Angela Sheard thought that the old examination was unrealistic: “Our current OSCE station on speculum exams which we have to perform on a model pelvis is quite different to an actual clinical scenario.”
Performing the examination on the CTAs changed her practice, she says. “There were some small changes that I made to how I explained the procedure at the start of the examination . . . that made a big difference to my confidence that the patient was comfortable with the examination.”
How do patients and carers feel about being involved in teaching?
I asked some of the members of the Patient | Carer Community (PCC) to answer a brief questionnaire about their experiences. Many said they found the sessions personally valuable, as well as valuable to the students. Joannie Tate became involved in teaching students some years after an incident, and her subsequent disability, left her unable to work. She says her work in the PCC has been worthwhile: “This involvement has widened my outlook; my confidence and ability have grown. I am able to do things . . . that I never thought I could do.”
Several patients and carers have been involved in teaching for a few years keep returning. David Blythe, one of the PCC patients says: “After seeing how it improved understanding, I was hooked on the idea of patient involvement and very impressed in the level of respect and support each of us received.” Patients and carers were keen to encourage the students to take a holistic view. Tate says her main message for students is to “look and listen to the patient not the illness.”
The patient and carer tutors can also see how their involvement benefits the students. Ken Watson, another PCC member, describes seeing one student develop over the course of a patient led session: “One young female student wasn’t very confident and then there was a re-run of the exercise, and in this she was completely different, which in turn suggests that confidence in what they are doing is a major part of their training. I feel that this can only be achieved by real doctor-patient role playing.”
Challenges in including patients and carers in teaching
Learning from patients and their experiences can be powerful for students but can be emotionally challenging. In the session run in Oxford in partnership with members of The Miscarriage Association some students left the session early, visibly upset. It’s an emotionally charged topic, even if you do not have personal experience of the issues. Mental health topics may be particularly distressing for some students. In feedback from a teaching session in Scotland about self harm, members of the Highlands Users Group (a group of patients with mental health conditions) said they thought it had been challenging for the students, who were not used to discussing self harm so openly and frankly.
Another question is how to pay patients and carers for their time and inconvenience. As academic staff are paid for their teaching time, it seems only fair to pay the patients as well. This also reflects parity of esteem between patient and academic members of teaching staff. In addition to the degree of involvement in the course, pay for patient and carer tutors features on the ladder of involvement (see box) proposed by Tew and colleagues. In Oxford, the CTAs are paid commensurate with their time and expertise. The “professionalisation” of patient and carer educators has worried some people. As patients become more practised at telling their story, they may, over time, become less representative of the general patient or carer population.
What lies ahead?
Patient led teaching is popular and has been endorsed in the General Medical Council’s guidance on medical education “Promoting excellence: standards for medical education and training.” Patient and public involvement in medical education is likely to increase. Other groups, such as the British Medical Association, recommend including patients as educators in undergraduate and postgraduate training. This reflects a shift away from a paternalistic “doctor knows best” culture.
Something about the patient led sessions just cannot be emulated. Emma Lewis, a CTA, says: “Students seem to get something special out of the sessions . . . We can give real time feedback that they can’t receive in any other context.”Alice Buchan, final year medical student
University of Oxford, UK
I thank Rosamund Snow, Emma Lewis, Jools Symons, James Matejtschuk, Jane Moore, and the Patient | Carer community for their help.
Competing interests: None declared.
Provenance and peer review: Commissioned; not externally peer reviewed.
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- General Medical Council. Promoting excellence: standards for medical education and training. July 2015. www.gmc-uk.org/Promoting_excellence_standards_for_medical_education_and_training_0715.pdf_61939165.pdf.
- British Medical Association, Medical Education Subcommittee. Role of the patient in medical education. 2008. www.bma.org.uk/-/media/files/pdfs/developing%20your%20career/becoming%20a%20doctor/role%20of%20patient.pdf.