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BMJ No 7116 Volume 315 Editorial Saturday 1 November 1997
Teaching medical students in general practice: respecting patients' rightsMore openness would benefit both patients and students See p 1142As health systems put more emphasis on primary care, it follows that primary care settings will increasingly be used for teaching medical students. The study this week by Flynn et al on patients' views about having a medial student present during consultations in general practice confirmed the usual finding that patients are happy to help medical education in this way (p 1142).(1) But patients were not always happy about how the student's presence and involvement were presented. In particular some were concerned about informed consent and confidentiality-the same issues that trouble patients in treatment and research.(2, 3) Changing practice to allay these concerns is important if controversy and distrust are to be avoided-and should also benefit patients and students in other ways. Patients have the right to choose whether to participate in the training of medical students.(4) But in many cases in this study patients' permission to have a student present during the consultation was sought at the last moment, making it difficult to refuse. The authors recommend that consent should be sought when the appointment is made. We think that patients should also be told that they need not decide straight away. They also need further information for properly informed consent. They should, for example, be told the student's sex: many women prefer to see a woman doctor for gynaecological matters.(5) They should also be told the student's exact status: patients are sometimes led to believe that students are more highly qualified or experienced that they actually are.(6) Flynn et al found that patients were more willing to have a student present if the consultation was for a simple physical condition than for an emotional problem or if an internal examination was required. Only patients can judge whether having someone else at the consultation will help or hinder them. So reluctance to have a student present should not result in the patient being labelled as difficult. Part of the problem may be the doctor's; and increasing practitioners' skills in communicating with patients and in conducting examinations(7) should, in the long run, reduce patients' reluctance to have students present. Patients' concerns about confidentiality also challenge current practice. In this study patients did not realise that agreeing to a student's presence would usually mean that the student would see their medical notes and discuss them after they had left the room. Some were disquieted by this. This echoes the dismay felt by some patients when they discover that general practitioners routinely allow medical notes to be read by many others in the practice, without the patient's consent.(3) The Royal College of General Practitioners advises patients to discuss with their general practitioner what should be included in the notes and to hold a copy of them.(8) But until all patients are aware that they must take the initiative, patients and doctors will understand confidentiality differently. So when patients are asked for consent they should also be asked to consent or decline to the student seeing their notes. Openness is essential. In 1996 the NHS Executive endorsed the updating of medical curricula to give greater weight to communication skills and to working in partnership with patients.(9) Partnership in the education of students would entail moving away from a position where the patient is observed by the student and discussed afterwards to an active mode where the patient joins in discussion during the consultation. One American study suggests that students like to see patients first, on their own.(10) Similarly, some patients might like to see the student alone after the consultation as well, to discuss whether they had achieved their purpose for the consultation. Alternatively, the general practitioner could explicitly guide the student through the consultation, inviting the patient to comment at each stage. In this study patients found out more about their condition when a student was present, and patients in hospital say the same thing.(11) But patients could probably learn even more about their condition and about how to make their own approaches more effective if they took part in discussion and analysis of the processes of the consultation. If patients' concerns could be met, and the benefits to them increased, their willingness to help with medical education would be safeguarded. Furthermore, students' education would be improved: they could develop an understanding of patients' experiences and purposes and begin to learn how to work in partnership with them in their own later practice. Charlotte Williamson Patricia Wilkie References
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