A proposed framework for mitigating the barriers to patient involvement in medical education.
What is medical education?
Medicine is a skill and knowledge-based field influenced by the degree of exposure of trainees to various challenging clinical scenarios. The patient-physician relationship lies at the core of this training model; thus, the participation of patients in the training of future physicians is integral to achieving the goals of medical education (Draper et al. 2008). Anecdotally, I have faced various challenges during my training as a physician and in my current role as an educator. These patient-clinician experiences in medical education will be highlighted in this narrative review.
A patient should be a willing participant in this training model if the desired objectives of instructing medical trainees in the art of healing are to be achieved. Indeed, it is essential to state that the patient should benefit from this association with the medical education system to ensure continuing cooperation in a potentially mutually beneficial relationship. The old educational model of years gone by, characterized by a consenting patient who was, in most cases, vulnerable to the power imbalance between a doctor and patient, is no longer sustainable. Patients are increasingly aware of their privacy rights and may not be willing to share their medical history with medical trainees (Sharma 2018).
This narrative will explore the patient-physician relationship and then seek to dissect the power dynamics in this relationship, seen through a more contemporary lens. This unique power dynamic will serve as the basis for the discussion of barriers to patient participation in the education of medical trainees. A proposed framework will then be outlined to improve patient involvement in the education of future physicians.
The patient-physician power dynamic
Earlier, the patient-physician power dynamic was presented as the basis for exploring the competing interests of these separate but linked entities when it comes to understanding their roles in the education of medical trainees. Traditionally, the physician has been seen as an authority figure with unquestionable expertise in the care of the patient. The patient was, in most instances, perceived as a passive recipient of medical care at the mercy of a gracious expert. The medical education system, as a result, had taken advantage of this disproportionate balance of power. Patients were less likely to voice out objections to being subjects of instruction for medical trainees due to fear of incurring the disapproval of their physician (Sharma 2018). In recent times, patients are certainly more informed and can be active participants in their care. They sometimes research their illness before seeking medical attention and occasionally point out errors in the physician’s proposed management plan (Tan and Goonawardene 2017). This previously assumed power gradient of years gone by is certainly blurry in more contemporary times.
Consequently, the overreliance of medical education systems on the expected willingness of patients to participate in the training of physicians has led to a glaring problem of patient objections to being used as models of medical instruction. The unwillingness of patients to partake in the education of trainees may be due to various reasons, including patient privacy concerns, distrust of student expertise, or a poor patient-physician relationship, to mention a few (Drevs et al. 2014). An excellent patient-physician relationship has been widely reported as an essential component of optimal medical care (Chipidza et al. 2015). Indeed, it is reasonable to assume that patients who trust their physician’s clinical judgment may be more likely to give an affirmative response to a request to participate in trainee education. When patients are made to see various aspects of their privacy as being respected during medical care, it may improve their willingness to share their medical history with trainees (Howe and Anderson 2003).
Patients perception of medical trainee competence
Trainees are sometimes perceived as a nuisance by patients due to concerns about their lack of full competency in medical practice. Some patients may feel more informed about their medical condition than an apprentice physician who is still learning the art of healing. This may result in a unique power dynamic between the trainee and the patient, with the latter feeling arguably more knowledgeable about their medical condition than an “incompetent novice.” Patients who raise objections based on a perceived lack of experience of trainees should be made to see the possible advantage of being evaluated by a trainee. There is evidence that trainees tend to approach clinical problems with a more broad differential diagnostic list. This allows them to ask various questions during their evaluation, which may easily be glossed over by a more experienced clinician (Keifenheim et al. 2015)
Additional set-backs and proposed mitigating strategies.
It is reasonable to grant patients more active roles in the medical education system, instead of their current “passive” roles. For example, patients can be involved in the assessment of interpersonal and professional skills of medical trainees (Stacy and Spencer 1999). More recent evidence suggests patients given active roles in the education of health professionals feel empowered and tend to have a raised self-esteem (Towle et al. 2010). Indeed this may satisfy some patients with a complex patient-trainee power dynamic characterized by the patient feeling more knowledgeable than the trainee. Conversely, some trainees may not feel accountable to the patients they evaluate during educational encounters. This may introduce a power dynamic characterized by the “objectification” of patients as mere models of instruction by trainees. By making patients evaluators of trainee competence, this unfortunate perception of some trainees can be addressed at a very formative stage of their career development. It can further be argued that trainees will treat patients more empathetically and professionally, knowing full well they are being evaluated by their patients.
Physician educators are also potential barriers to patient involvement in medical education as well. Indeed, physician educators may assume that a patient might be inclined to refusing a request to be a model of medical instruction due to their knowledge of the patient’s socioeconomic status. The VIP (very important person) syndrome was first coined by Dr. Weintraub in 1964 and is characterized by special privileges being accorded patients due to their status or wealth (Weintraub 1964). Patients who are VIPs may not be invited to participate in the training of medical trainees. This is an additional patient-trainee power dynamic, which may be exaggerated by supervising physicians. Physician teachers should be made aware of this unfortunate barrier to the involvement of patients in medical education.
Additionally, medical faculty tend to perform dual roles as both practitioners and teachers. The current remuneration model, which is based on quotas of patients seen by physicians during each clinic session, places an immense burden on educators. Additional time is usually needed to facilitate student education, and this may be in conflict with the goals of some health care systems (Seifert and Strobel 2010). Under these circumstances, educators may actively serve as a barrier to patient involvement in student education due to inherent time constraints in their medical practice. Some patients are inevitably never given a chance to partake in medical education.
Unfortunately, medical education systems, especially those positioned in prestigious university-based training programs, have relied on the presumed traditional power dynamic between the patient and physician, brought to the fore earlier in this discussion. Patients expect to be evaluated by medical trainees and may, under certain circumstances, feel compelled to do so since they are under the care of leading medical experts (Sharma 2018). Health institutions that facilitate the patient-physician experience tend to improve overall patient satisfaction scores on surveys and, consequently, improve the quality of patient care. Health systems should provide adequate protected time and optimal clinical settings for trainee education. It can be argued that since healthcare reimbursement is now being increasingly linked to patient satisfaction scores and quality outcomes, health institutions stand to benefit if they facilitate the patient-physician experience. Seeking informed consent from patients well in advance of their clinical encounter will reduce the chance of coercion. Health care institutions should be in charge of mailing out these consent forms to patients. These forms should highlight the roles of all participants in the physician education model.
In conclusion, we have explored the power dynamics between patients, physicians, and trainees in medical education and the role of health care institutions as facilitators of this complex relationship. Solutions to the barriers to patient participation in medical education require a multiprong approach involving all stakeholders (see figure 1.0). This proposed framework is time and capital intensive and requires the full participation of healthcare managers who are arguably more invested in health care profits at the expense of medical education (Gray 1986; Safarani et al. 2018).
Physicians, students, and healthcare systems can also serve as potential barriers to patient participation in medical education. Additional studies on these less studied barriers are therefore required.
References
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Gray, B.H. 1986. Ethical issues in for-profit health care. In: For-Profit Enterprise in Health Care. National Academies Press (US)
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Keifenheim, K.E. et al. 2015. Teaching history taking to medical students: a systematic review. BMC Medical Education 15(159).
Safarani, S. et al. 2018. Financial challenges of teaching hospitals and providing solutions. Journal of Education and Health Promotion 7(15).
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Sharma, M. 2018. ‘Can the patient speak?’: postcolonialism and patient involvement in undergraduate and postgraduate medical education. Medical Education 52(5), pp. 471–479.
Stacy, R. and Spencer, J. 1999. Patients as teachers: a qualitative study of patients’ views on their role in a community-based undergraduate project. Medical Education 33(9), pp. 688–694.
Tan, S.S.-L. and Goonawardene, N. 2017. Internet Health Information Seeking and the Patient-Physician Relationship: A Systematic Review. Journal of Medical Internet Research 19(1)..
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Weintraub, W. 1964. ‘The VIP syndrome’: A clinical study in hospital psychiatry. The Journal of Nervous and Mental Disease 138, pp. 181–193.a
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