What this paper adds
Introduction
Methods
Study methods and measure
Study setting
Study analysis
Results
Category
|
Domain
|
Item summary
|
Percent respondents answering in desired patient-centred fashion
|
p
-value
| |
---|---|---|---|---|---|
Year 1/2 in %
|
Year 3/4 in %
| ||||
Role modelling
| Course faculty | Communicate concern and interest in patients as unique persons | 49 | 43 | 0.429 |
Encourage patients’ participation in their own care | 39 | 33 | 0.431 | ||
Take seriously patients’ concerns about their conditions or care | 56 | 49 | 0.418 | ||
Develop good rapport with patients | 58 | 44 | 0.077 | ||
* Explore emotional aspects of patients’ illnesses | 34 | 16 |
0.013
| ||
Clinical mentors | * Communicate concern and interest in patients as unique persons | 57 | 37 |
0.011
| |
Encourage patients’ participation in their own care | 44 | 33 | 0.149 | ||
Take seriously patients’ concerns about their conditions or care | 53 | 44 | 0.264 | ||
* Develop good rapport with patients | 65 | 48 |
0.034
| ||
* Explore emotional aspects of patients’ illnesses | 39 | 22 |
0.018
| ||
Students’ experiences
| Patients as objects | * Preceptor overheard referring to patient as a diagnosis | 5 | 46 |
<0.001
|
* Little attention paid to social history | 12 | 37 |
<0.001
| ||
Patient waits longer than necessary | 3 | 11 | 0.056 | ||
* Students overheard portraying patients as diagnoses rather than unique human beings | 16 | 39 |
0.001
| ||
* Patient’s case discussed in front of patient as if the patient weren’t there | 4 | 24 |
<0.001
| ||
Learning relationships | Students’ stories portray how a patient encounter affected the student(s) personally | 58 | 59 | 0.894 | |
* Student provided with feedback on bedside manner | 39 | 86 |
<0.001
| ||
* Student provided with feedback on listening skills | 29 | 67 |
<0.001
| ||
Advice given to students emphasizes the importance of good communication skills with patients | 70 | 75 | 0.525 | ||
Bad news | Student asked to deliver bad news without any teaching or discussion about a caring approach | 94 | 96 | 0.445 | |
Student asked to answer patient’s questions about bad news without any teaching | 92 | 91 | 0.809 | ||
Support
| – | * Student felt encouraged when an effort was made to develop rapport with patients | 88 | 73 |
0.018
|
* Student felt encouraged when an effort was made to know patients as unique persons | 83 | 66 |
0.013
| ||
* Student felt encouraged when an effort was made to legitimize patients’ concerns | 88 | 67 |
0.001
|
Year 1/2 Medical students
|
Year 3/4 Medical students
| |
---|---|---|
Explicit teaching of patient-centred care |
Patient-centred skills/strategies are taught and assessed in standardized or guided clinical contexts
‘In CFM (Clinical Foundations of Medicine), teaching open-ended questions was a huge eye-opener for me coming into medical school.’ ‘Most of CFM, where we interviewed and got to know patients without any real medical knowledge. Placing the course early in our training emphasized patient-centeredness (because that’s all we could do).’ ‘CFM final interview-testing preceptor was very positive about my interviewing style which diverged from “traditional” interviewing and was much more conversational. He liked how it drew a lot of information from the patient and helped to develop rapport, even though I missed a decent chunk of the history.’ |
Teams created to be or rounds intentionally structured to be patient centred
‘On Medicine, chief rounds at Bayview. Group really gets to know the patient as a person first, before starting to talk about their illness.’ ‘I helped take care of a gentleman on the Aliki (Green) team during my medicine rotation. He was admitted for pre-renal AKI secondary to volume depletion in his nursing home. During attending rounds, I was encouraged to present the entire admission history and physical to the patient and his wife as patient-centred rounds. Though the patient had altered mental status, the patient’s wife was extremely grateful for having been included as part of the care team. It was one of the most memorable and rewarding experiences of medical school thus far.’ |
Role modelling or implicit teaching of patient-centred care |
Students are influenced by practitioners who model patient-centred approaches and interactions
‘I have so many stories of amazing patients with complex lives, situations, challenges, and achievements. My longitudinal clerkship (LC) preceptor was really good at showing how to be friends with your patient while still maintaining the professionalism of the relationship.’ ‘CFM was amazing. My advisor very much values patient-centred care and consistently modelled it for us.’ |
Students are influenced by practitioners who model PC approaches and interactions
‘I worked with my attending who was just incredibly understanding and compassionate with parents of a newborn who were unwilling to vaccinate their child … My attending was truly professional, non-judgmental, and compassionate throughout the encounter.’ ‘ED resident who would squat next to the bedside of every patient so he would be on eye level.’ |
Other factors |
Students need opportunities to independently practice implementing patient-centred skills
‘During LC when taking 30 min interviews independent from supervision. Those were the times when there was the least pressure to get clinical information and then stop, but rather to get to know the patient as a person.’ ‘LC was by far the most patient-centred experience I’ve had, simply because of the longitudinal opportunity to work one-on-one with patients and develop my own communication skills with guidance and support from my preceptor.’ |
Significant time to talk with patients
‘Having the time to talk to patients one on one about their disease and how it has affected their abilities to go on the rest of their lives.’
Interprofessionalism
‘Working with patients and their families, consistent interprofessional collaboration to help patients with issues outside the scope, strictly defined, of their ‘medical’ issues.’ |
Year 1/2 Medical students
|
Year 3/4 Medical students
| |
---|---|---|
Negative role modelling |
Ignore patient concerns
‘Although he never asks the patients about anything besides symptoms … one patient brought up out of the blue that she was stressed about the fact that her husband was in the end stages of lung cancer. My preceptor’s response was to continue asking about side effects from an antibiotic.’
Failure to include the patient in team discussion or teaching
‘My longitudinal clerkship (LC) preceptor frequently talked to me about the patient while the patient was in the room, as if the patient were not in the room.’
Lapses in professionalism
‘When I am in the hospital (shadowing, on a rotation, etc.), I often overhear nurses, residents, and/or attendings make distasteful comments about patients or families who are difficult to work with. Sometimes … within earshot of the patients and families.’ |
Ignore patient or other providers’ concerns
‘Medical professionals ignoring patients’ own words or nodding and seeming to agree when the patient is speaking, but then proposing a different plan of action without acknowledging the patient’s wishes for something different’ ‘Attending kind of side-stepped patients concerns and passed the buck off to her medical oncologist rather than take the time to explain things.’
Lapses in professionalism
‘13 year old girl came in to paediatric ED with increased vaginal bleeding, was uncomfortable seeing me (as a male) and requested a female provider … 2 female PAs were available; the attending, laughed, said she would have to be punished and wait for 20 mins for refusing to talk with me and said to the patient should get over it, she was just having a period. PAs and attending then continued to online shop for 20 mins before one of the PAs went to see the patient.’ |
Students discouraged from being patient-centred |
Regarding the social history
‘The physicians chosen for Preceptor Skills repeatedly told me that Social History is a waste of time and docked my write-up every time I had that section.’
Discounting idealism
‘Basically every lecture where physicians tell us about how one day we will get out of the false pretences of medical school and into the ‘real world’ of medicine.’ |
Spend as little time as possible with patients
‘Multiple instances on surgery when I was encouraged to spend less than 3 min with the patients if at all possible.’ |
Other factors |
Objectification
‘Anatomy was horrible. The instructors saw the cadavers as pieces of objects instead of real, dead people. I was disturbed.’
In time-sensitive situations, attention to a patient’s background, story, or social history is limited
‘Some of my LC experiences have been severely time limited such that I have been forced to ask only “medically relevant” questions that completely forgo engaging the patient as more than a diagnosis.’ |
Objectification
‘Patients were discussed by disease with many negative comments about their BMI.’ ‘Patients became fractures and operations; there was very little interaction with patients (the most interaction was waking the patient up at 4:45 AM to make sure he/she could wiggle his/her toes).’ |