Can patients teach students?

It's time to change the role of patients

What can patients teach medical students? Nothing - after all, you are learning medicine, acquiring knowledge and skills that only doctors and scientists are competent to teach. Obviously you have to learn about patients, but to be taught by them elevates them to an inappropriate status. If you reject this hypothesis you are presumably prepared to consider that patients can teach you something, but what?

Patients are obviously essential to the process of learning to be a doctor, but their role in medical education is usually passive. They have the status of a learning resource, providing you with opportunities to practise newly acquired skills. However, there is a distinction to be made between "learning from" patients and being "taught by" patients. The shift from passive to active involvement in your education brings potential benefits.

How was it for you?

Being taught by patients can offer insights into the patient's experience that you may not discover through traditional teaching. Hendry, Schrieber, and Bryce describe an innovative programme where patients with arthritis teach and assess musculoskeletal examination skills to students without a doctor present.¹ These patients are trained and enthusiastic teachers who are comfortable with being examined several times. Medical students taught by these "patient partners" felt more able to establish a rapport with the patients and appreciated the quality of the feedback they received on their experience of the physical examination. The experience enabled students to develop their confidence and competence.

Learning from experts

Doctors are experts, but so are patients. Their expertise is different, but complementary. Wilson argues that people with a long.term illness have a wealth of expertise about their condition and support services, but considers this resource to be underutilised.² She argues that students have much to gain from the insights of those living with a condition, from the individual and from their carer(s). Family placements are not uncommon in medical education, but Blasco, Kohen, and Shapland describe a "parents as teachers" programme for paediatric residents, where parents of children with neurodevelopmental disabilities and other chronic disabling conditions shared the design of the training.³ Students visited family homes and schools, rating the quality of the experience highly. Students have valued the experiences that have been shared when the patient has been given responsibility for planning the learning programme.⁴

Equal partners?

Developing an open attitude to learning from patients prepares you for working in partnership with patients, an important feature of professional practice. In the United Kingdom, recent NHS policy encourages health professionals to "treat patients as equal partners in the decision making process."⁵ It is argued that part. nership with patients "delivers better results for individual patients and better health for the population." Not everyone agrees that partnership can be "equal." Kirkham highlights the differences in power and responsibilities.⁶ Nonetheless, doctors face the challenge of working collaboratively with their patients.

Good practice has to be grounded in evidence based research. This need not confine patients to research subjects, however. Goodare and Lockwood argue that involving patients "as colleagues" in clinical research improves its quality.⁷ Macaulay et al present an argument for "participatory research" that values community expertise in investigations, working in partnership with local people.⁸

Difference and diversity

Doctors have a duty not to allow their personal views to prejudice the treatment given to their patients.⁹ This places a responsibility on doctors to make the effort to acknowledge personal prejudices and assumptions and challenge their validity. Some medical schools have organised programmes based in the community that prepare students to work in culturally diverse communities.^10,11

Ethnicity is one dimension of "difference," but there are others. Martin argues that people with learning disabilities should be considered as partners in the doctor.patient relationship, which demands additional effort to communicate.¹² Medical students discovered that they could learn valuable new skills when they were commissioned by a group of people with learning difficulties to produce a leaflet on HIV.¹³

Learning from patients or people?

The meaning attributed to the term "patients" can influence willingness to be taught by them. Unfortunately, the term "patient" implies passivity at best and "sufferer" or "victim" at worst, which risks placing people in an "inferior" position relative to that of the medical professional.¹⁴

Hogg argues for a relationship between health professionals and patients based on a concept of patients as "citizens."¹⁵ This implies a status that neither defines people as passive recipients of medical attention nor limits them to the role of consumers, but describes them as individuals with a stake in society, with rights and responsibilities, who have a legitimate role in influencing the delivery of health services.

Conclusion

Teachers learn from their students. Doctors learn from their patients. Our ability to learn is determined by our willingness to recognise that we can learn from a variety of people and situations; to see the opportunity when it arises and seize it. Professors, consultants, other health professionals, fellow students, and patients all have something to contribute to your education and training to be a competent and effective doctor. What each person teaches you will be different, but valuable.

Geoff Wykurz, principal lecturer in community development and primary care, University of Westminster
Email: wykurzg@westminster.ac.uk


studentBMJ 2000;08:259-302 August ISSN 0966-6494

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