Patient as Educator: A Pearl in Medical Education

doi:10.21203/rs.3.rs-2484722/v1

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Patient as Educator: A Pearl in Medical Education

https://doi.org/10.21203/rs.3.rs-2484722/v1

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Introduction: One of the important goals of modern medical education is to change the role of patients in education from passive to active. One of the new educational methods is the "patient as educator" method. This study was conducted for investigating the effect of using the patient as educator method on medical students.

Methods: his study was conducted in a semi-experimental intervention method with 56 medical studentsof Imam Reza Hospital, Mashhad University of Medical Sciences. 2 menopausal women, as patient educators, participated in the training course on the important points of history taking and examination in menopausal women. Demographic information of the students, including age, gender, and mean of scores, was collected. Then the students were divided into two groups. The control group received the usual method of training in the department. In the intervention group, a one-hour training session was held with the presence of the patient and the history taking and examination by the medical students and then by the patient, feedback was given based on the checklist. One month later, both groups were given an OSCE.

Results: the two groups were homogenous in terms of age, sex, and grade point average (P>0.05). After the intervention, a significant difference between the two groups was observed in the history test, professional behavior and examination between the two groups (P<0.001).

Conclusion: using the patient as educator method can be a suitable method to enhance the skill level of history taking, examination and professional behavior of medical students.

Patient as Educator

Medical

students

Education

A patient-centered approach is associated with better health status and more efficient care. Patient participation through a patient-centered approach increases satisfaction of the patients, adherence to treatment plans and patient safety(1, 2). Patient-centered treatment approach is also intrinsically important regardless of its impact on treatment outcomes, based on ethical grounds (3). Studies in hospital units with different degrees of patient-centeredness show that units that were more patient-centered had better results (4). Also, the patient-centered program was designed for medical students to deal with the patients with chronic diseases, listen to them and also to practice counseling skills (5, 6).

One of the practical examples of patient-centered approach is the participation of patients in the educational programs of students (7). More interaction with patients is considered to be one of the ways of learning better clinical skills (8). In medical education, patients are often used passively, however if the patients' experiences and understanding of the issues related to their disease and its effect on their long-term life conditions are taken into consideration by doctors it will also be effective in the treatment outcomes (9). One of the important goals of modern medical education is to change the role of patients in education from passive to active participants. During their studies, students should first consider patients as human beings with all their existential, family and social dimensions so that they can also choose the appropriate treatment process (10). Among the examples of active participation of patients in curricula, we can mention the use of patients as teachers. A patient as educator is defined as someone who has a special medical condition and can play an active role in the education of learners (11). They can help educational system in areas such as physical examination, interpersonal skills and education about health services (12).

The entity of the patient as an educator was first expressed in the 1960s and since then principles have been proposed to involve patients as educators. In 1970, Barrow and Abrahamson used this method to solve the problem of teaching clinical skills and the evidence obtained showed the high acceptance of this method, its efficiency and cost-effectiveness. This method has been used in teaching technical skills, women's health, screenings, etc. in many universities in the United States of America, Canada and Australia (13). According to Vygotsky's social learning theory, health educators can slowly introduce learners to patient interaction in an authentic yet non-threatening environment and help them get closer to the desired level of achievement (14). In addition, they bring a unique perspective and provide an apt description of the illness experience (13). It is also useful in examining sensitive areas that may cause discomfort (15) and it is also indicated for various aspects of the physical examination as demonstrated by various studies (16, 17). The results of past studies show that the use of standardized patients has an effect on improving the performance of learners as much as training by experienced professors. A standardized patient is an individual with or without illness who has been trained to participate in the role of an educational patient (18, 19). In a study, the use of patient-trainers in the training of musculoskeletal examination showed that their influence is equal to that of professors and can be more structured and consistent (20). Another very important discussion is the impact of the patient-educator method on improving the patient-doctor relationship. Interpersonal and communication skills in clinical consultations have been identified as a core competency in physicians; because this capability can increase patient satisfaction, treatment compliance, symptom relief and cost-effectiveness. The traditional way of teaching these skills in ambulatory care, the oral feedback of peers and professors about the counseling skills and professionalism of trainees, and the effectiveness of written or oral feedback from patients in the education of medical students have not been sufficiently investigated (21, 22).

The information obtained during the history taking and physical examination of the patient along with the reports obtained from the para clinics, is the basis of information for clinical considerations by physicians. Therefore, in the education of medical sciences it is very important to pay attention to the development of students' ability in practical and communication skills along with cognitive and theoretical fields. The clinical training of case description is one of the critical phases of education in which students gradually gain experience by being at the patient's bedside and prepare their minds to solve the patient's problems by using the acquired experiences and reasoning. It plays a major role in improving the professional capabilities of learners (23, 24). In other words, teaching the skill of good history taking, accurate physical examination, and appropriate professional behavior is one of the most important duties of professors and medical education institutes and a vital step towards maintaining and improving the community health and wellbeing. The inability of medical students to acquire the clinical skills of history taking, examination and communication with the patient can be considered as one of the major educational deficiencies (25). Therefore, effective and sustainable learning of this skill is one of the main goals of the medical education curriculum. Also, medical students have stated that their main educational need is to learn the skills of history taking and physical examination (26). For medical students the internship phase is very important because the visit of patients in the clinics, history taking, examination and communication with the patient begins in a practical way (27).

Therefore, this study aims to determine the effect of using the patient as an educator for medical students in teaching them the correct method of history taking in the department of Obstetrics & Gynecology of Imam Reza (AS) Hospital of Mashhad University of Medical Sciences in the academic year 2021, as an example for the medical community.

The current research is a semi-experimental interventional study that was conducted in two groups; intervention and control groups, during the year 2021–2022 in the Department of Obstetrics & Gynaecology at Imam Reza (AS) hospital of Mashhad University of Medical Sciences.

The effect of the teaching method: "Patient as educatorr" on case history taking skills among the medical students has been investigated. In order to conduct the study, the population was randomly sampled from the students in the department (28 people in each group)(Convenience sampling). The project was implemented in three stages.

First stage: patient selection and training

At this stage, the training of patients as educators was done by inviting inpatients or outpatients referring to Obstetrics & Gynecology clinics, as well as public announcements in the department of Gynecology of Imam Reza (AS) hospital under the supervision of Mashhad University of Medical Sciences. In this way, postmenopausal patients were asked to enter the project by obtaining informed consent for cooperation. 5 menopaused women declared their readiness to enter the project. After history taking and checking for the presence of symptoms and specific examination for training, 2 of them, 60 and 65 years old were selected after filling in demographic information. They participated in the training course about menopause and important points in the history and examination of menopausal patients and the usual visits and necessary evaluations during this period, in two weekly sessions each for one-hour duration under the supervision of a gynecologist. Also, a 40-minute educational film was prepared by the project manager in the virtual training center and provided to the patients. Examination of the patients was done by the project manager and scoring was done based on the desired checklist (28). If the required score was not obtained bu\t the patient requested it to be repeated, a re-test would be held after solving the problems. Otherwise, the respective patient would be excluded from the study.

Second stage:

The second stage of this plan was conducted in two designed groups (intervention and control) of trainees/ interns (28 people in each group). The interns were divided into two groups using random blocks of 4. During the 6-week period of trainees' presence in the department; in the first month the patient as educator method was used, and in the second month the usual method was used for clinical training, history description and examination of post-menopausal women. In the intervention group, every 4 to 5 interns performed a medical history taking and clinical examination of the patient educator for half an hour and then these patients after completing the pre-designed checklist gave feedback on important points that were probably neglected by the trainees. In the second group (control group) during the second month, the routine clinic training method was held for the trainees on the important points in the history taking, physical examination and management of the menopausal patient. The time spent was the same for both training methods

The third stage: Conducting the test and analyzing the data

OSCE test of history taking, physical examination and evaluation of postmenopausal woman by filling in the prepared checklist, one month after the educational intervention was performed in the Clinical Skills Center of Imam Reza Hospital (AS) with the presence of the patient In this way, in 4 OSCE test, 4 people filled the patient profile, history taking check list, examination and behavior of the professions mentioned and performed by the students. Then the scores of the two groups were compared. After collecting the data, all the data were entered into SPSS software version 28. In order to check the data, descriptive statistical methods including central indices, dispersion and frequency distribution were presented in the form of appropriate tables. Independent t-test was used to compare quantitative data such as age, history taking score, examination point score, and GPA, and chi-square test was used to compare qualitative variables between two groups, including gender. In all studies, a significance level of less than 0.05 was considered.

In the implementation of the research, the ethical principles of the research and the anonymity of the questionnaires were respected. Before entering the patients into the study and starting any investigation, the educational program in question during the study was fully explained to them. After explaining the purpose of the study and how to conduct it, a written informed consent form was given to the patients to sign if they wished to participate. In addition, the information of the participants was collected with the help of consecutive codes so that the information of the subjects remained completely confidential. This information, both medical and non-medical, was only available to the researchers and no one else had access to it. Patients were allowed to refuse to cooperate with the study whenever they wanted.

In this study, in the control group, 60.7% (17 people) were male and 39.3% (11 people) were female, and in the intervention group, 50% (14 people) were male and 50% (14 people) were female. The result of chi-square test showed that there was no statistically significant difference between the two groups in terms of gender frequency (P < 0.05). Therefore, the two groups were homogeneous in terms of the gender variable (Table 1).

Table 1

Distribution of the frequency of the investigated trainees according to gender in the two control and intervention groups.
groups
Parameters		control		intervention		total
Parameters		number	Percent (%)	number	Percent (%)	number	Percent (%)
Gender	male	17	60.7	14	50	31	55.4
	Female	11	39.3	14	50	25	44.6
	total	28	100	28	100	56	100
P		0.42^a

^a chi-square

The average age of the examined trainees was 24.8 ± 1.7 years in the control group and 25.1 ± 1.5 years in the intervention group. The result of the independent t-test showed that there was no statistically significant difference between the two groups in terms of average age (P < 0.05). The two groups were homogeneous in terms of this variable (Table 2). The average GPA of the examined trainees in the control group was 15.3 ± 1.4 and in the intervention group, 15.5 ± 1.7. The result of the independent t-test showed that there was no statistically significant difference between the two groups in terms of average grade point average (P < 0.05) (Table 2).

Table 2

The average age and average grade point average of the investigated trainees in the two control and intervention groups.
groups
Parameters	control		intervention		P
Parameters	Mean ± SD	number	Mean ± SD	number	P
Age (years)	24.8 ± 1.7	28	25.1 ± 1.5	28	0.629^a
average GPA^b	15.3 ± 1.4	28	15.5 ± 1.7	28	0.807^a
^a Independent t-test– ^b grade point average

The statistical analysis of the data showed that the average scores of the trainees in the OSCE test of menopausal patient history was 25.8 ± 3.8 in the control group and 31.3 ± 1.0 in the intervention group, a total score of 33. The independent t-statistical test showed that the average scores of the trainees in the OSCE test of history taking in the intervention group were significantly higher than the control group (P < 0.001) (Table 3).

Also, the grades of the trainees in the patient examination were 7.1 ± 2.1 in the control group and 9.4 ± 0.5 out of 10 in the intervention group. The Independent t-test showed that the average scores of the trainees in the patient examination section in the intervention group were significantly higher than the control group (P < 0.001) (Table 3).

The scores of trainees in the professional behavior section were 5.7 ± 2.0 in the control group and 8.7 ± 1.1 in the intervention group, out of 10. The independent t-test showed that the average score of the trainees in the professional behavior section was significantly higher in the intervention group than the control group (P < 0.001) (Table 3).

Table 3

Average scores of OSCE test, history taking, and examination of patients and professional behavior of the studied trainees in two control and intervention groups.
Parameters	control	intervention	P^a
Parameters	Mean ± SD	Mean ± SD	P^a
OSCE test	25.8 ± 3.8	31.3 ± 1.0	P < 0.001
patient examination	7.1 ± 2.1	9.4 ± 0.5	P < 0.001
professional behavior	5.7 ± 2.0	8.7 ± 1.1	P < 0.001
^a Independent t-test

The purpose of this study was to determine the effectiveness of receiving feedback from patient educators on medical history taking, examination and professional behavior of medical trainees/interns. In the present study, we found that improvement in the performance level of taking patient history, physical examination and professional behavior of students is created by using this educational method, so that the intervention group performed significantly better than the control group that did not receive feedback from the patient educator.

In order to increase learners’ proficiency in patient-centered care, an opportunity should be created for patients to play an active role in medical education, as the patients convey important messages that cannot be obtained by reading books. Many scientific facts are written in books, but their effect on a person’s life is less expressed. In fact, patients should be respected as valuable educational resources (10). For this purpose, the participation of patients in medical curricula has increased, including teaching clinical skills, evaluating learners and helping to develop the curriculum (12). There is also evidence about the lasting effect of this type of education on the acquisition of technical and communication skills of learners (29).

In accordance with previous studies, medical students in the present study generally had favorable views about patients as educators. For example, students in the present study, like students in others have stated that real contact with the patient increases the context and promotion of knowledge (30). Also, in a study conducted by LuAnn Wilkerson et al. (2010), students independently interviewed a standardized patient in a simulated clinical setting. The standardized patient used a checklist of essential items to score students’ performance in four skills including: history taking, physical examination, counseling and interpersonal communication. The results of this study showed that training in the form of providing patient-centered care is recommended as an approach to improving communication, teaching history taking, and reducing health inequalities (28). The results of our study also showed that patient-centered education has improved the OSCE scores and the description of the students in the intervention group compared to the control group.

Also, initial contact with the patient has been shown to increase students' confidence and help them consolidate their knowledge more than lecture-based training (31). This type of training, with the early interaction of medical students with their patients, increases the motivation and satisfaction in interviewers and facilitates the change of the educational environment from basic sciences to clinical sciences. In addition, it strengthens the feeling of sympathy and responsibility towards patients and helps to strengthen the cultivation of clinical based approach, communication with the patient, and training in history taking and clinical examination (32, 33).

In line with the present study, the results of Yudkowsky et al.'s (2006) study on 79 medical assistants (family and internal medicine) with the aim of identifying factors related to grades in the assessment of communication skills of medical assistants, showed that the assistants who experienced interacting with patients had the standardized scores, they obtained higher scores in communication skills tests (34).

In addition, studies have shown that patient participation in medical education not only improves learners' understanding of patient-centered care, but also increases empathy in clinical education (35). Similar to the present results, in studies where patients were used independently as trainers in a patient care training workshop, the results indicated that patient can be used as a companion in the health care team, including in medical education (36). In addition to this, there are several studies to investigate the more active role of the patients in medical education to help strengthen the experiences of medical students who have used patients as experts in their disease (12, 37).

Jung Ho et al.'s (2009) study, with the aim of patient-centered education through a standardized patient, investigated the OSCE scores of fifth-year students in Taiwan. Fifty-seven medical students were randomly divided into control group (27 people), basic intervention group (15 people) and extensive intervention group (15 people). Both intervention groups participated in two 2-hour patient-centered training workshops. In addition, the extended intervention group also received a 2-hour training session. The control group did not undergo any training. The scores of the students of the extensive intervention group were significantly higher than those of the basic and control intervention groups in the OSCE test of history taking. The results of this study show that patient-centered education can improve the communication skills of medical students in clinical environments (38).

Also, the results of the studies have shown that imparting the knowledge with the patient as an educator is an effective strategy used in medical and nursing curriculum to develop and strengthen professional skills. In this way, learners develop their skills and capability in clinical decision making and interpersonal communication (39). As per the present study, imparting the knowledge and training with the patients as educators has increased the scores of the professional behavior of the intervention group compared to the control group. In general, through this study, trainees showed the significance of the involvement of patients in the process of medical education and learning. In addition, through this study it was confirmed that the patients as educators facilitate learning to the trainees by allowing them to learn in a valid and conducive environment. Also, these results indicate that patient educators can be considered as reliable mentors that provide useful feedback and effective skills to the trainees/interns.

In the present study, we found that the method of" patient as educator"improves the level of clinical performance and students’ perception. Also, these results show that patient educators can be reliable educators who provide useful and effective feedback to trainees in clinical education. This allows trainees to provide useful insight into their performance on an individual basis. Considering the efficacy and specificity of feedback from teaching patients compared to the feedback of professors, feedback from educated patients can be as effective as feedback from professors.

Acknowledgments

This study was ﬁnancially supported by Vice-Chancellor for Research, Mashhad University of Medical Sciences, Mashhad, Iran. (Grant number: 990140) (Ethical Code: IR.MUMS.REC.1399.292).

Disclosure

The authors declare no conflict of interest.

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No competing interests reported.

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Patient as Educator: A Pearl in Medical Education

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Abstract

Introduction

Methods

First stage: patient selection and training

Second stage:

The third stage: Conducting the test and analyzing the data

Results

Discussion

Conclusion

Declarations

References

Additional Declarations

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