Possibilities for patient involvement in medical education:

Lessons from Leicester

Professor Liz Anderson

Questions to ask ourselves

• Are there different perceptions on what engagement means for patients/service users, students and faculty staff?

• What does an authentic involvement mean for patients/service users, students and faculty staff?

• What do students want?

Paracelsus certainly recognised the value….

‘….a good physician should be ready to learn from midwives, gypsies, nomads, brigands and others who live outside the law. He should inquire among all classes of people, seeking out everything that might contribute to his knowledge; he should travel widely, undergo many adventures, and learn, learn the while.’

(Paracelsus, 1493- 1541)

Medical Education 1999;33:688-694

Results

Patients as teachers(i) as experts in their condition

– showing managing disability– clinical aspects etc.

(ii) as exemplars of their condition(iii) as facilitators of the development of professional skills and attitudes

Results

• How patients benefitted from participation– through talking– through learning about their condition– through learning about the training of doctors– by recognition of helping students' learning– by feeling useful in providing practical help to

students– receipt of appreciative gifts

Medical Education 2010: 44: 64–74 doi:10.1111/j.1365-2923.2009.03530.x

Problems

• How to move beyond short projects• Integration within Faculty• On-going research required

– Impacts on patients; students; curriculum

Our Story• Recognition that patients perspectives are

radically different from professionals

Inequalities in health

• 1995: ‘Health in the Community’

Stage 1. ImmersionStudents meet patients and carers in

their care setting to listen to their experiences of health and social care

and to explore their priorities. Interprofessional groups range from 2 to

4 students. Each small group then interviews all agencies caring for their

patient to analyse their roles and responsibilities and priorities.

Stage 2. Reflection After each experience the student teams reflect on what they have learnt supported by facilitators. They are encouraged to relate

profession specific theories and policies to issues they identify. Reflections enable students to learn about each professional

domain.Stage 3. Analysis

The student team consider all aspects of the care package, including

constraints on service, unmet needs, best practice to produce solutions to identified problems. In particular they

compare patient and professional priorities to look for a fit or mis-match.

They prepare a feedback to the

PHCT.

Stage 4. FeedbackStudent teams present their findings and

solutions and their recommendations to improve care and care delivery

Debate and discussion lead to awareness of gaps in service delivery and care. Solutions can lead to changes as professional teams action

the highlighted shortfalls in provision. Managers are in powerful positions to change and

overcome practice barriers.

Inequities in Health

• 1998: ‘Shaping our Future Medical Workforce’ DOH- ‘Learning from Lives’

Disability

Social model of disabilityTeaching led by disabled people

Leicester Centre for Integrated Living

1998-2008

Anderson, ES. & Smith, R. (2010). Learning from Lives together: lessons from a joint learning experience for

medical and social work students. Health and Social Care in the Community,18(3), 229-240.

What next?

• Patient involvement– Steering groups– Shaping teaching– Available in their own homes

Next Steps:• Partnerships to design new teaching

Research: Higher Education Academy UK 2008-2011

Stage One: Move to integrated model– Patients involved in the design of a teaching

event in which they support the teaching

Stage Two: Progress to empowerment– Patients move on to take on leading roles in

teaching

MethodExploratory Action Research Design;

• reflective problem solving• collaborative• takes place in the social learning context• seeks to understand learning processes

‘to improve education by changing it and learning from the process’

Kemmis & McTaggart 2005

Action Research Cycle: Stage One

Step 1:PlanningSteering group Consultations

Step 2: ObservingPilot with

n= 40 students and n= 10 patients

Step 4: Implement changes

Pilots, n= 69 students, additional, n=13 patients

Step 3: ReflectionCoffee morning wide patient engagement

Step 5: Embed

The Patient Designed Learning Away day: First Model

Students hear service user story

Students discuss and reflect

Students identify improvements

Student recommendations influence practice

Students and service users discuss the key

messages for professional practice

Interprofessional student groups have conversations with two service users

Students discuss what they learned

Students present their learning in accessible formats to the participating service users and their peers

Students take their learning into practice

22

The “Listening Workshop”

Patients Comments

‘ I think this is a wonderful idea it should be compulsory before anyone is let out there on “real” people. Practise on us, listen to

what we have to say then the same mistakes won' won’t be made’, mother disabled child.

‘The whole experience of sitting down and talking to someone who’s been through it is completely and utterly different to just reading it in a book and more memorable because of it and will be more useful I hope..’ disabled adult.

Patients Giving Feedback: comment

‘It did leave you thinking what have I put on my form and are they going to see it straight away? But then I thought about what I had put on the form and it was quite reasonable and that's OK. But I could have been in a position where I thought ‘Oh my God they are going to know exactly what I thought of them’,

mother disabled child.

Student Comment

• Medical student

‘At medical school we are taught to take histories. The patient story is regimented according to the doctor’ s agenda. The Listening Workshop was therefore a challenge. We were told to shut up and listen: less questions, more attention and for the first time in a long time I sat and listened to the patient’s story in the way they wanted to tell it,’ focus groups extract.

NEXT STEPS: Stage Two

• Indications in early work of the desire and ability of some patients to take on a leading teaching roles.– Annually 11 events, some 596 students.

• Second piece of research to consider what a leading role might look like

Action Research Cycle: Stage Two

Step 1:Consultation meeting

Coffee morning with patients and educators

Step 2:Student Focus groups n=25

Interviews: Patients n= 9Staff n=3

Step 4:Focus Groups n=15

Patient workshop n=13

Step 3: Consultation meeting

Coffee morning wide patient engagement

Step 5: Final

Agreement

Patients ViewsNew Roles:1. Co-tutoring: helping to deliver the teaching2. Recruiting: supporting new people as a mentor3. Determining the curriculum4. Organising support groups5. Reading students work6. Student selection7. Confirm to employers who to select

New Roles

1. Co-tutoring: helping to deliver the

teaching

2. Recruiting: supporting new people as a

Mentor

Service user Comments‘A good idea because otherwise you end up being a bit of a specimen… whereas if you’re a co-tutor it kind of forces them to listen to you more’.

‘I don’t think I personally want to be a co-tutor... I do think that as a service user certain people have a huge amount to offer… I am probably perfectly capable of doing it but its just a confidence thing’.

‘I see myself mentoring…I’ve had enough experience doing the workshops talking to students to be able to help other people and advise them’.

Student Comments

‘It would be more helpful for us because any academic who hasn’t themselves been in that position do not actually know what the patients wants to tell’.

‘It would be very useful to back that up having patients teach us because we are here to learn from them’.

‘You know it would possibly improve attendance because you feel worse for letting down a patient who is taking their time to do it’.

‘Our normal tutors are trained to be tutors.. They need to sign our work… so I would rather have a tutor even if it was supervisory’.

UNCERTAINTYDo patients have the authority? This will change the relationship. Will patients have the skills? Vulnerability of patients

VALIDITYYes with support; it’s their

right. Social work students more comfortable with the idea.

Would improve attendance.This event ideal for

leadership

TEACHINGTeaching professionalism. Support for patients needed.Skills for this event.Suggested methods of training

BALANCEStudent agenda versus Service user agenda

“two sides of the coin

Full Report: March 2012

Anderson. ES., & Ford , J. (2012). Enabling Service Users to Lead Interprofessional Workshops to Improve Student Listening Skills. Higher Education Mini Grant, Subject Centre, Medicine, Dentistry and Veterinary Medicine. Project No: MP220. Newcastle. http://www.medev.ac.uk/funding/7/22/funded/

Training ProgrammeNew Roles Co-tutor & Mentor

Four training sessions1. Common Induction: Adult Learning2. Common Induction: Professionalism in teaching3. Specific: Co-Tutor & Mentor4. Specific: Co-Tutor & Mentor (practice)

Process: Shadowing, employment autumn 2012.

Patient Unit

• Agreement visions, payment scales,• Involvements

– Teaching– Student Support– Student recruitment

Ladder of service user involvement (Tew, Gell & Foster, 2004)

LEVEL 5

Partnership

Patients work together with teaching staff across strategic and operational areas with an explicit statement of partnership values. Patients with secure contracts.

LEVEL 4

Collaboration

Patients as full time department members involved as below in THREE major aspects of faculty work. The department has a statement of values. Training and supervision are offered.

LEVEL 3

Growing Involvement

Patients involved in TWO of the following: planning, teaching delivery, student selection, assessment, management or evaluation. Payment at normal visiting lecturer rates. Training and support offered.

LEVEL 2

Limited Involvement

Service users invited in to ‘tell their stories in a designated slot. No opportunity to shape the course. Payment offered.

LEVEL 1

No involvement

Curriculum planned, delivered and managed with no patient involvement.

In Summary

• Unanswered questions concerning the ‘professionalism’ of patients in medical education

• Excellent and the reason for IPE• Challenging, time consuming, worthwhile

Questions to ask ourselves

• Are there different perceptions on what engagement means for patients/service users, students and faculty staff?

• What does an authentic involvement mean for patients/service users, students and faculty staff?

• What do students want?