Learning in practice

Developing the role of patients as teachers: literature review

Geoff Wykurz, principal lecturer community development and primary care ^a, Diana Kelly, education adviser ^b. 

^a Department of Community and Collaborative Practice, School of Integrated Health, University of Westminster, London NW1 3ET, ^b Department of Medical and Dental Education, Guy's, King's and St Thomas's Schools of Medicine, Dentistry, and Biomedical Sciences, London SE1 9RT

Correspondence to: G Wykurz wykurzg{at}westminster.ac.uk

	Abstract

Top Abstract Introduction Methods Results Conclusions References

Objectives: To identify the roles and settings in which patients participate as teachers in medical education and the benefits to learners, their educational institutions, and participating patients.
Design: Review of publications from 1970 to October 2001 providing descriptions, evaluations, or research of programmes involving patients as teachers in medical education.
Data sources: 1848 references were identified from various electronic databases. Applying inclusion criteria to abstracts generated 100 articles, from which 23 were selected after independent scrutiny.
Results: 13 articles discussed the role of patients in teaching physical examination skills, mostly musculoskeletal examination. Patients also taught pelvic and male genitorectal examination skills. Teaching roles varied, and 19 articles referred to patients' involvement as assessors. 18 articles described patients' training, with some patients being assessed. Reports of learners' experiences were all positive, many valuing the insights and confidence gained from practising skills on patients in a teaching role. Some learners preferred being taught by trained patients rather than doctors. Patients who were consulted enjoyed their teaching role. Several articles commented on the high quality of patients' teaching. Remuneration varied from payment of expenses to an hourly rate. Motivation for recruiting patients included the desire to reduce costs and the value attributed to the consumers' perspective.
Conclusion: Involving patients as teachers has important educational benefits for learners. Patients offer unique qualities that can enhance the acquisition of skills and change attitudes towards patients.

What is already known on this topic Patients have a crucial role in medical education, but their involvement tends to be passive Simulated and standardised patients are commonly used as alternatives to real patients in teaching communication skills and clinical examinations What this study adds The value of involving patients in an active teaching role, where learners can benefit from patients' experience and expertise, is being recognised The experience of being taught by a trained patient can increase confidence, reduce anxiety, and generate new insights When patients are given adequate support, training, and remuneration, they can become colleagues in medical training, not just a teaching resource

	Introduction

Top Abstract Introduction Methods Results Conclusions References

Doctors acknowledge that they continually learn from patients, gaining new insights that influence their practice.¹ As patients' expertise is harnessed to teach other patients in primary care in the United States and United Kingdom, patients are taking on a more active teaching role in medical training. ^{2 3} Although patients have always had a role in the education of doctors, the shift into a more active role is new. It has been suggested that the added value of using real patients in medical education requires further scrutiny.⁴ To explore the value of involving patients as teachers in medical training we undertook a systematic review.⁵ It examines published literature to identify the roles and settings in which patients participate as teachers and to discover the benefits for learners, the patients who participate, and the educational institutions involved.

	Methods

Top Abstract Introduction Methods Results Conclusions References

Data sources
We systematically searched the databases AMED, British Education Index, CINAHL, Embase, ERIC, Medline, PsycINFO, Web of Science, and also Science Citation Index and Social Science Citation Index. Search terms were used on their own and in combination, using a wildcard (indicated by "$"): "patient$," "health service user$," "consumer$," "teach$," "educat$," "learn$," "instructor$," "student$," "undergraduate$," "postgraduate$ medical," "participation," "partner$," "active partner$," "medical education," "medical school."

Selection of studies
We selected research and evaluation studies plus descriptive accounts of programmes using patients as teachers from a search covering 1970 to October 2001 (for a summary of selection criteria and the reviews included see box on bmj.com). We included articles if patients and carers were "active" teachers, facilitating learning and assessing the acquisition of knowledge, skills, and attitudes associated with medical practice. We excluded programmes that asked "patients" to take the role of a patient or express symptoms of conditions they did not have, including many that used "standardised" and "simulated" patients.⁶ We also rejected articles, conference abstracts, letters, and discussion papers that were not written in English. The search generated 1848 hits, of which all but 100 were rejected as they did not meet the selection criteria. Full copies of these 100 items were acquired for further scrutiny. We applied the selection criteria independently and chose 29. The original 100 items were also read by two independent assessors, whose views on disputed papers led to a final selection of 23 studies for analysis.

	Results

Top Abstract Introduction Methods Results Conclusions References

Key features of the reviewed articles can be found in the table on bmj.com. Most articles were published during the 1990s; 15 are from the United States and the remainder from the United Kingdom, Australia, Canada, and New Zealand.

Stage and subject of training
Nineteen programmes were undergraduate programmes and seven involved patients as teachers in postgraduate training. One study described a programme in continuing professional education to improve family practitioners' effectiveness,⁷ and in another, consumer organisations nominated non-medical examiners to assess doctors' communication skills for membership of the Royal New Zealand College of General Practitioners.⁸

Thirteen studies focused on physical examination skills, with most concentrating on musculoskeletal examination. Patients also taught pelvic examination skills and male genitorectal examination skills. ^{9 10} Other topics included children's developmental disabilities, dementia, and cancer.^11-13 Three programmes were devoted to communication skills, and two involved learning from patients in community settings. ^{11 14}

Patients' roles and training
Patients' roles included giving a presentation, facilitating seminars, demonstrating to small groups, providing personal tuition, and giving feedback on performance (see box 1). Nineteen studies involved patients as assessors. The articles did not always make explicit the duration of learners' training in a specific topic or the proportion of time that patients were involved as teachers. Most initiatives seemed to involve patients in a discrete element of a programme lasting one or more sessions.

Eighteen articles described patients' training, which varied in style, duration, and intensity. Training could entail individual or group instruction, practice with students, use of audio or video tapes, and home study. Some patients teaching musculoskeletal examination skills received up to 50 hours of training, with additional home study.¹⁵ Patients teaching physical diagnosis skills for cardiovascular and pulmonary examinations were given an instructor's manual written in lay language.¹⁶ In one programme, arthritis educators had to attain 90% in a test to become an evaluator.¹⁷

Evaluation of patients' involvement
Most articles refer to learners' views about the patients' role in their training, but not all seek the patients' perspective on their experiences. Patients who were consulted referred to their experiences as positive and enjoyable. They appreciated sharing their knowledge, using their condition to facilitate learning, and contributing to doctors' training. Some patients felt empowered by their experience. ^{12 18} Others referred to their increased learning and the value of their training.

Reports of learners' experiences were all positive. Some preferred the teaching they received on specific topics from trained patients to the teaching received from doctors. Many commented on gaining new insights and confidence when practising examination skills on patients who gave constructive feedback. Such training increased their respect for patients and deepened understanding of the experience of disease.

Benefits and challenges
Articles emphasised the positive contribution of patients in a teaching role, with one reporting that lay examiners from consumer organisations could reliably assess the communication skills of general practitioners.⁸ Authors commented on learners' increased confidence and reduced anxiety when undertaking physical examinations. Several commented on the high quality of patients' teaching, with one article referring to patients working as instructors as "true colleagues in medical care."¹⁹ Another study concluded that using patients as teachers improved local delivery of health care, changed professional behaviour, and was cost effective.⁷

Some articles indicated potential difficulties patients where were involved as teachers. Patients' emotional wellbeing and physical stamina were sometimes of concern where they might experience stress when sharing potentially painful issues or undergoing repeated examinations. This required monitoring to resolve difficulties that might lead to patients leaving the programme. The sustainability of reviewed programmes required resources to train patients, maintain their skills, and ensure that the faculty was committed to working in partnership with patients in their teaching role.¹⁴

Recruitment, remuneration, and status of patients
Motivation for recruiting patients as teachers and assessment of their value seemed to vary between programmes. Several recruited selectively to ensure that patients met specific criteria based on their teaching ability. Some viewed the programmes as a cheaper alternative to traditional methods,²⁰ others valued the consumer perspective.⁸ Patients were recruited by doctors, from a standardised patients' pool, or for their professional (albeit not medical) background. Some received remuneration in the form of compensation whereas others received an hourly rate. Payment was associated with the status given to the patient-teacher, which could influence the programme's success. One article was coauthored by the chairperson of a carers' organisation, which implies a close partnership.¹³

Value of involving patients as teachers
This review shows that meeting real patients with firsthand experience of a condition, who have knowledge and teaching skills, offers learners important educational benefits (see box 2). This was particularly evident in physical examination teaching by trained patients. Learners found the experience less intimidating and developed confidence in examination skills. Through instruction and constructive feedback, the developing rapport between learners and patients seemed to improve the acquisition of physical examination and communication skills and respect for patients. Patients' teaching of musculoskeletal examination skills for arthritis was at least as good as that of consultants.

Most authors emphasised the positive contribution of patients as teachers. Although this may reflect publication bias,²¹ the authors provided explicit evidence of the patients' value. The disadvantages that emerged do not seem to negate the principle of involving patients as teachers but highlight the responsibilities of programme directors who choose to involve them. To benefit from being involved as teachers, patients must be adequately trained, supported, and remunerated.

The process of choosing patients for their teaching roles was not always clear in the articles; this raises the issue of how far the patients who were selected represent "communities" associated with the programmes. Teaching ability seemed to be an important criterion in the selection of suitable patients. The basis on which this is applied may, however, preclude able people unless recruitment processes are open and transparent, particularly when participation from diverse ethnic groups is sought.

This review has been restricted by being limited to English language articles. There may be other programmes where patients see themselves as active teachers, although this may not be explicit in the course design. In an article omitted from this review, patients were recruited as subjects for students' community projects but viewed themselves as teachers.²²

Our review seems to be the first published review of patients as active teachers and indicates the diverse settings in which they have been engaged. Most of these have been in secondary rather than primary care, but there does not seem to be anything intrinsic to the programmes described that would preclude adopting them in training programmes in primary care.

	Conclusions

Top Abstract Introduction Methods Results Conclusions References

Patients are a valuable resource as potential teachers in all stages of medical education. If patients are given appropriate support, training, and remuneration, evidence shows that, in specific settings, patients offer unique qualities that can improve the acquisition of physical examination skills and communication, instil confidence, and change attitudes towards patients.

Our review generated only 23 articles giving details of programmes in which patients had an active teaching role. This implies that the potential of this untapped resource has yet to be fully realised. As government programmes recognise the importance of using patients' experience and expertise to enhance programmes for self management that are led by users, those responsible for medical training could usefully explore opportunities for using patients as teachers.

	Acknowledgments

The authors wish to acknowledge the value of the 1999 study by Louden et al on educating medical students for work in culturally diverse societies in JAMA that we used as an exemplar for the review. We also thank Martin Hewitt who undertook the literature search and the independent assessors, Gillian Hewitt and Kate Briggs. Thanks also to Janet Richardson, Ivan Koppel, and Sue Morrison for their comments on the draft.

Contributors: Both GW and DK contributed equally to the writing of this review and share equal responsibility for its content.

	Footnotes

Funding: None.

Competing interests: None declared.

A box, a table, and extra references appear on bmj.com

	References

Top Abstract Introduction Methods Results Conclusions References

1.	Salter RH. Learning from patientsunfashionable but effective. Postgrad Med J 1996; 72: 385[Free Full Text].
2.	Holman H, Lorig K. Patients as partners in managing chronic disease. BMJ 2000; 320: 526-527[Free Full Text].
3.	Department of Health. The expert patient: a new approach to chronic disease management for the 21st century. London: DoH, 2001.
4.	Spencer J, Blackmore D, Heard S, McCrorie P, McHaffie D, Scherpbier A, et al. Patient-orientated learning: a review of the role of the patient in the education of medical students. Med Educ 2000; 34: 851-857[CrossRef][Web of Science][Medline].
5.	Khan KS, ter Riet G, Glanville J, Sowden AJ, Kleijen J. Undertaking systematic reviews of research on effectiveness CRD's guidance for those carrying out or commissioning reviews. 2nd ed. York: NHS Centre for Reviews and Dissemination, University of York, 2001. (CRD report No 4.)
6.	Collins JP, Harden RM. AMEE medical education guide No 13: real patients, simulated patients and simulators in clinical examinations. Med Teacher 1998; 20: 508-521[CrossRef].
7.	Fisher B, Gilbert D. Patient involvement and clinical effectiveness. In: Gillam S, Brooks F, eds. New beginnings towards patient and public involvement in primary health care. London: King's Fund, 2001.
8.	Thomson AN. Reliability of consumer assessment of communication skills in a postgraduate family practice examination. Med Educ 1994; 28: 146-150[Web of Science][Medline].
9.	Livingstone RA, Ostrow DN. Professional patient-instructors in the teaching of the pelvic examination. Am J Obstet Gynecol 1978; 132: 64-67[Web of Science][Medline].
10.	Robins SL, Alexander GL, Dicken LL, Belville WD, Zweifler AJ. The effect of a standardized patient instructor experience on students' anxiety and confidence levels performing the male genitorectal examination. Teach Learn Med 1997; 9: 264-269.
11.	Blasco PA, Kohen H, Shapland C. Parents-as-teachers: design and establishment of a training programme for paediatric residents. Med Educ 1999; 33: 695-701[CrossRef][Web of Science][Medline].
12.	Kelly D, Wykurz G. Patients as teachers: a new perspective in medical education. Educ Health 1998; 11: 369-377.
13.	Gruppen LD, Branch VK, Laing TJ. The use of trained patient educators with rheumatoid arthritis to teach medical students. Arthritis Care Res 1996; 9: 302-308[Medline].
14.	Stillman PL, Ruggill JS, Rutala PJ, Sabers DL. Patient instructors as teachers and evaluators. J Med Educ 1980; 55: 186-193[Web of Science][Medline].
15.	Branch VK, Graves G, Hanczyc M, Lipsky PE. The utility of trained arthritis patient educators in the evaluation and improvement of musculoskeletal examination skills of physicians in training. Arthritis Care Res 1999; 12: 61-69[CrossRef][Web of Science][Medline].
16.	Plymale MA, Witzke DB, Sloan PA, Blu AV, Sloan DA. Cancer survivors as standardized patients: an innovative program integrating cancer survivors into structured clinical teaching. J Cancer Educ 1999; 14: 67-71[Medline].
17.	Vail R, Mahon-Salazar C, Morrison A, Kalet A. Patients as teachers: an integrated approach to teaching medical students about the ambulatory care of HIV infected patients. Patient Educ Counseling 1996; 27: 95-101[CrossRef][Web of Science][Medline].
18.	Riggs GE, Gall EP, Meredith KE, Boyer JT, Gooden A. Impact of intensive education and interaction with health professionals on patient instructors. J Med Educ 1982; 57: 550-556[Web of Science][Medline].
19.	Davidson R, Duerson M, Rathe R, Pauly R, Watson RT. Using standardized patients as teachers: a concurrent controlled trial. Acad Med 2001; 76: 840-843[Web of Science][Medline].
20.	Butterworth M, Livingston G. Medical student education: the role of caregivers and families. Psychiatric Bull 1999; 23: 549-550.
21.	Gomm R, Needham G, Bullman A. Evaluating research in health and social care. London: Sage, 2000.
22.	Stacy R, Spencer J. Patients as teachers: a qualitative study of patients' views on their role in a community-based undergraduate project. Med Educ 1999; 33: 688-694[CrossRef][Web of Science][Medline].

(Accepted 29 July 2002)