Patient‐present teaching in the clinic: Effect on agency and professional behaviour

Abstract

Background/Purpose Although much has been written about the medical learning environment, the patient, who is the focus of care, is rarely the focus in this literature. The purpose of this study was to explore the role of the patient as an active participant with agency in the medical learning environment from the standpoint of the learner, the attending physician, and most importantly, the patient. We hoped to gain insights into the mechanisms that can reinforce professional values such as patient‐centred and respectful behaviours in a patient‐present learning environment. Methods We conducted this study in an ambulatory internal medicine clinic using ‘patient‐present’ clinic visits. All case presentations occurred in examination rooms with the patient. We invited participants (attending physicians, undergraduate and postgraduate learners, patients and family members) to participate in semistructured interviews after each clinic visit to explore the impact of the patient‐present learning environment. We recruited 34 participants in the study; 10 attending physicians, 12 learners, 10 patients and 2 family members. We analysed the data deductively using a conceptual framework of agency. Summary/Results We identified three major insights: (1) Patients felt engaged and valued opportunities to be heard; (2) Attending physicians and learners reported a more respectful learning environment and a positive though challenging teaching and learning experience; and (3) A hidden curriculum emerged in a performance‐based view of professional behaviour. Conclusions Patient‐present teaching engaged patients and enhanced their agency by recasting the patient as the central focus within the healthcare encounter. We identified a tension between performing and learning. This study adds new insights to the concept of patient centredness and professionalism from the perspectives of all participants in the medical teaching and learning environment.

Patient‐present teaching: Recasting roles for patients, learners and educators

“…In their recent study, Castanelli et al 1 closely examined how the trainee-assessor relationship can affect workplace-based assessments (WBAs), focusing specifically on the reciprocal effects of trust and power. From their interviews with trainees, they produced a model for understanding the relationships between supervisors exercising their 'power over', trainee trust in supervisors, and trainees exercising their 'power to'.…”

“…In this issue of Medical Education , Cheema et al 1 explore the impacts of the patient's presence during a teaching and learning experience traditionally conducted behind closed doors. The paper describes a learning environment where the patient's case is discussed between student and physician with the patient present.…”

“…Whilst pleasing to gain participant perspectives about the teaching encounter, we wonder, does holding teaching rounds in front of the patient place a focus on student learning, patient‐centred care, both or unintentionally neither? The paper by Cheema et al 1 illustrates the tension and teaching challenge of simultaneously providing student‐centred learning and patient‐centred care.…”

“…Cheema et al 1 describe a ‘performance’, with physicians and learners portraying their respective roles in front of the patient, collectively seeking to promote patient‐centred care. From enrolment, learners ‘perform’ for educators, examiners and ultimately for clinical supervisors (in this case, physicians), usually with grade attainment in mind.…”

“…A shift in focus from the learner's needs to approaching health care with a patient‐focussed lens is required. Cheema et al 1 contend that patient‐present teaching connects patient and learner to enrich the learning environment for the student. However, the trial did not apparently fulfil the well‐established principles of student‐centred learning.…”