The use of patient educators is one of many teaching strategies meant to foster principles of patient-centred care. We previously found that early patient educator exposure helped to shape the understanding of patient-centredness in pre-clerkship learners. We now expand on this work to evaluate whether there is persistence of initial perceptions and to explore general reflections on longer-term impacts of early patient educator exposures once learners are immersed in the clinical phase of their training. In this follow-up study, we conducted group interviews with a sample of learners who wrote reflections as part of their pre-clerkship patient educator experience. We explored how perspectives on patient educators changed over time, and determined which themes identified during pre-clerkship remained relevant to clinical trainees. Audio recordings were transcribed and analyzed thematically using a hybrid inductive and deductive analysis to construct a thematic framework derived through a method of constant comparison. We identified three new themes: "value of early clinical experience", "change in learners' perspectives", and "valuing and applying CanMEDS roles other than Medical Expert". Themes from pre-clerkship that remained relevant included: "patients' perspective humanizes disease", "patients' experiences with navigating the healthcare system", "learners' perceptions of the learning strategy", and "inaccuracies and inconsistencies in the learning experience." Many themes identified in pre-clerkship learners remain relevant in early clinical trainees. Further, insights from pre-clerkship experiences with patient educators evolve as learners experience clerkship with definite shifts in emphasis and new perspectives. This work illuminates the utility of patient educators for those considering this strategy for supporting the development of patient-centredness in undergraduate medical education.

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Context: Dyspnea is a highly distressing symptom that characterizes idiopathic pulmonary fibrosis (IPF), a common idiopathic interstitial lung disease (ILD) with a high symptom burden, poor quality of life, and early mortality. Though opioids are mentioned in guidelines for dyspnea management, guidance on how and when to initiate opioids is lacking. Different pharmacologic strategies are needed to address different types of dyspnea (baseline, incident, and crisis). Due to a longer onset of action, the oral route (swallowed) may be less effective for prevention of incident dyspnea or for rapid relief of crisis dyspnea, prompting the use of alternative drug delivery strategies for self-management. We inadvertently discovered the efficacy of buccal administration of low dose, low volume hydromorphone oral syrup for dyspnea management in ILD, which has not been previously reported in the literature. Case Series: We describe our approach to dyspnea assessment and management in IPF, including use of the Multidimensional Dyspnea Scale (MDDS), a novel instrument yet to be validated that we developed to better identify and categorize dyspnea into the types experienced by a patient with IPF over the course of a day. We then describe how buccal hydromorphone oral syrup is initiated and titrated for dyspnea management in 3 patients at different points in their disease trajectory. Conclusion: Buccal hydromorphone oral syrup is effective for dyspnea management across the spectrum of IPF. When integrated into a patient-centered algorithm for symptom assessment and management, it allows for rapid and easy self-management of dyspnea by patients and their caregivers.

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