Placing the Patient at the Centre of the Learning Environment: Effect on Agency for the Learner, the Attending Physician and the Patient

Abstract

Background/PurposeAlthough much has been written about the medical learning environment, the patient, who is the focus of care, has often been excluded from this discourse. The purpose of this study was to explore the role of the patient as an active participant with agency in an authentic 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 patient-present learning environments.MethodsThis study took place in an internal medicine ambulatory clinic using a "patient-present” clinic visit approach. We conducted all case presentations in examination rooms with the patient. We invited participants (attending physicians, undergraduate and postgraduate learners, patients and family members) to participate in semi-structured 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 analyzed the data deductively using a conceptual framework of agency.Summary/ResultsWe identified three major insights: 1. Patients were engaged and valued opportunities to be heard; 2. Attending physicians and learners reported that presenting cases with patients present challenged normal teaching practices, and they differed on whether it supported a more inclusive health care environment; and 3. A hidden curriculum emerged in a performance-based view of professional behaviour.ConclusionsPatient-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.