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Criteria for selection of articles Medical education only (undergraduate and postgraduate) 1970 onwards English language Descriptions and research studies of educational programmes or courses No conference papers, letters, or discussion papers Patients engaged in an active teaching role Definitions Patient A health service user, carer, or person with a particular condition or illness, not acting a role (other than themselves), who is engaged in an active teaching role. Active teaching role Facilitating learning and assessing or evaluating the acquisition of knowledge, skills, and attitudes necessary to be a competent practitioner. Teaching activities Patients could be involved in one or more of the following: Imparting knowledge Teaching skills Developing awareness Giving feedback on practice Assessing students

 

Table  Articles used in systematic review of studies of patients as teachers
 

Study	Location	Stage	Subject	Patients’ roles	Patients’ training	Duration	Patients’ evaluation	Learners’ evaluation	Authors’ views on patients as teachers
Bell et al, 1997[1]	University of Toronto, Canada	Undergraduate and postgraduate	Examinations of joints	Patient educators: demonstration of joint examination, feedback and evaluation	People with arthritic diseases: anatomy and full body joint examinations; demonstrating joint examinations; evaluating skills	I.5 hour joint examination by patient educator	Not stated	Not stated	Pilot study suggests that patient partners in arthritis programme is an effective educational tool
Blasco et al, 1999[2]	University of Minnesota, USA	Postgraduate paediatrics	Paediatrics: developmental disabilities	Parents as teachers: shared expertise regarding their child and their experiences, including health related services	Interview, written information, phone contact. Parent group recruits, prepares, and supports families	Part of month’s disabilities rotation for paediatric residents. Two family visits: each for 2-4 hours	17 families: mainly positive, rated experience 7.4/10. Difficulties generally related to logistics	Complained about logistics but positive about programme: 11/18 residents rated PAT experience: 4.6 for quality of experience, 4.4 for quality of teaching and 4.0 for processing discussion (out of 5)	Experience of patients as teachers represents a unique opportunity for parents and physicians-in-training to improve their mutual understanding
Branch et al, 1999[3]	University of Texas, USA	Postgraduate 2nd and 3rd year residents	Musculoskeletal examination skills during ambulatory clinic rotation	Arthritis educators: trainer, evaluator of musculoskeletal examination skills, instructor in joint examination techniques	25 hours training, plus home study. Arthritis educators assessed, 90% score to become arthritis educators. Skill tested twice yearly to ensure reliability	1:1 examination and evaluation sessions during weeks 1 and 6 of ambulatory clinic rotation	Not stated	Not stated	Intervention improved residents’ musculoskeletal examination skills significantly and more effectively than standard clinic teaching
Branch et al, 1998[4]	University of Texas, USA	Undergraduate 2nd clinical year	Musculoskeletal examination skills	Arthritis educators: demonstrator and evaluator of correct joint examination techniques	6 weeks: home study with manual, class instruction, 1:1 training, musculoskeletal examination supervision, have to achieve 90%	1:1 session with arthritis educator demonstrating musculoskeletal examination. Evaluated by different educator 2 weeks later.	A valuable experience, used their disease in positive way. Demonstrating physical findings, sharing personal experiences was a meaningful life experience.	Intervention was very positive experience. Over 98% of students felt arthritis educators helped improve their musculoskeletal examination skills, over 97% felt educators’ feedback was helpful.	Intervention improved students’ information retention, confidence, examination skills significantly compared with standard educational approach
Butterworth et al, 1999[5]	University College London, UK	Undergraduate 2nd clinical year	Psychiatry: dementia	Carers: during carer’s presentation, four carers talked with medical students, one acted as facilitator	Not stated	One session	Welcomed chance to speak about experiences, felt their caring had meaning and value. Finding that they had contributed to doctors’ training considered therapeutic	Found session extremely moving, interesting and useful. (High mean scores of 4.6 for clarity, 4.4 for interest and 4.4 for relevance (out of 5))	Teaching method fits with ethos of problem-based learning approach, particularly General Medical Council’s advice to integrate learning with patients’ and families’ experiences
Curry et al, 1996[6]	Northwestern University, USA	Undergraduate 1st clinical year	Communication skills: part of 2 year course on patient, physician, and society	Patient instructors: giving feedback on communication skills practice	Not stated	Communication skills:1 hour weekly for 11 weeks, patient instructors present at physical examinations but their role is unclear.	Not stated	Evaluation not specific to participation of patient instructors	Patient instructors were one element of course where active learning was key to acquiring knowledge, attitudes and skills
Davidson et al, 2001[7]	University of Florida, USA	Undergraduate 2nd clinical year	Introductory course in physical assessment	Physical examination teaching associates: standardised patients with expanded role, observing student performance, providing feedback, grading physical examination skills at end of year	4 hours training before student sessions	Four observations of 2/3 students’ physical examinations, feedback to students, tested each other’s groups’ examination performances	Not stated	Not stated	Trained standardised patients can effectively teach normal physical examination to medical students and are less expensive alternative to traditional small-group teaching
Elliot, 1987[8]	The Oregon Health Sciences University, USA	Undergraduate 2nd clinical year	Physical examination skills	Patient instructors: subject and evaluator of students’ physical examination skills	6 hours physician training	Not stated	Not stated	Not stated	Patient instructors potentially may be a valid alternative method to certify mastery and identify students who require further skills training
Fisher et al, 2001[9]	Lambeth, Southwark & Lewisham Health Authority, London, UK	Continuing professional education, primary care professionals in cardiac care and mental health	Clinical effectiveness in cardiac care and mental health	Patients: teachers, definers of effectiveness, educating professionals about how they should care for and treat patients	Not stated	Patients met 20 general practitioners and 6 nurses twice to listen to patients’ views	Appreciated process, meetings interesting, useful. On second occasion, difficulty in acting as representatives rather than individuals with own stories to tell	Process seen as meaningful, with an impact on participants’ perspectives on mental health problems	Using patients as teachers led to local health care delivery improvements and changed professional behaviour. Provided a practical, cost effective intervention to improve quality and empower patients
Gall et al, 1984[10]	University of Arizona, USA	Undergraduate and postgraduate	Rheumatological care	Patient instructors: models for musculoskeletal examinations, teaching and assessing rheumatological care	30 hours 1:1 teaching with checklists, manual, videotapes; practice sessions to master skills, knowledge	Not stated	Project was worthwhile, enjoyable, patient instructors would continue even if not paid. Found programme tiring when they were ill	Positive response; several students and physicians volunteered for further patient instructor encounters	Patient instructors form integral part of Preparation for Clinical Medicine curriculum serving as evaluation and teaching resources in continuing education of practising professionals
Gruppen et al, 1996[11]	University of Michigan, USA	Undergraduate 2nd clinical year	Rheumatoid arthritis (RA): examination of joints of whole body	Arthritis educators: teacher, demonstrator, (also used as evaluator of residents in outpatients)	50 hours training on 3 weekends over 6 weeks, plus 50 hours home study with video tapes	3 x 2-hour small group sessions, plus 2-hour panel discussion	Greatly enjoyed working with students, felt able to utilise their disease to teach valuable information	Praised arthritis educators for ability to explain RA physical signs and to teach joint examination procedure, reached better understanding of RA’s impact on patients’ lives	Arthritis educators can effectively teach fundamental musculosketal examination skills and encourage sensitivity to impact of chronic arthritis on other patients’ daily lives
Hendry et al, 1999[12]	University of Sydney, Australia	Undergraduate 4th clinical year	Arthritis education: musculoskeletal examination skills	Patient partners: teacher of examination skills, subject of physical examination, and provider of feedback	3 day workshop run by trained Texan patient partners, taught by University of Texas Rheumatologists	Tutorial with groups of 7-8 students	Felt more confident and enjoyed teaching. Training had prepared them well, felt useful and had greater control over examination.	Valued patient partner tutorials, less intimidating than traditional tutorials, time to develop confidence in sense of touch. Patient partners were systematic and thorough, felt they were keen to teach students.	Patient partners are at least equal to consultant rheumatologists in teaching musculoskeletal examination techniques for arthritis
Kelly et al, 1998[13]	St. Bartholomew’s & Royal London School of Medicine & Dentistry, UK	Undergraduate 1st and 2nd year	Factors and circumstances influencing patients’ health and health care	Patient partners: experts, teachers, assessors, accredited partners	Not stated	Patient partner attachment: first year students met patient partners 5 times over 8 weeks; second years meet patient partners more often	Enjoyed sharing knowledge; felt their expertise had been acknowledged	Considered their respect for patients had increased, gained depth of understanding from being with their patient partners outside clinical setting	Patient partners developed new skills and confidence which added to value of experience, became strong advocates for scheme’s development
Livingstone et al, 1978[14]	University of Manitoba. USA	Undergraduate 2nd clinical year	Teaching of pelvic examination	Clinical teaching associates: patient instructors, professional patients and teachers, evaluators	30 hour course: anatomy, physiology, history taking, breast and pelvic examination techniques, communication	21/2 hours: examination techniques’ demonstration, pairs with two students, one clinical teaching associate as "patient," other as instructor, reviewed performance	Not stated	Clear preference for initial teaching of pelvic examination by clinical teaching associates over teaching by physicians.	Results indicate that method produced a student with superior technical and communication skills with whom female patient feels more comfortable
Plymale et al, 1999[15]	Universities of Kentucky and South Carolina, USA	Undergraduate, postgraduate, surgery and primary care residents	Cancer: structured clinical teaching	Standardised patients, cancer survivors: interviewee in standardised clinical instruction module feedback on performance, sharing personal experiences	One hour 1:1 overview of standardised clinical instruction module’s purpose and structure, instruction on presenting illness in standardised way	Module lasts 2-3.5 hours, with series of 15 minute stations	Evaluation positive, willingness to participate in future. Participation provided sense of empowerment, opportunity to make difference, help others in future.	Residents and medical students rated highly benefit of using cancer survivors recognised survivors’ expertise and willing to learn from them.	Cancer survivors’ personal contributions provided trainees with valuable insights into patients’ experiences with disease
Riggs et al, 1982[16]	University of Arizona, USA	Undergraduate and postgraduate	Rheumatoid arthritis	Patient instructors: patient, teacher, evaluator	Anatomic terminology training, musculoskeletal examination techniques, interaction skills with health professionals.	Not stated	3 left; other 5 motivated, but fatigued. Intellectual/emotional growth, more self-confident and appreciative of physicians. Enjoyment and sense of worth in teaching	Not stated	Need to include patient as a medical team partner. Patient instructors became successful healthcare team members, educating health professionals. Need regular monitoring to identify negative impacts and remedy difficulties
Robins et al, 1997[17]	University of Michigan, USA	Undergraduate 2nd clinical year	Male genitorectal examination	Standardised patient instructors: teacher, evaluator	Taught proper examination techniques, giving constructive feedback. Rehearsed feedback with 3rd year students.	45 minute examination session (with 3 students)	Not stated	93% rated session "excellent" or "very good." Immediate, respectful feedback was helpful. Confidence in performing examination increased after experience as standardised patient instructor	Practising genitorectal examination on standardised patient instructor, in carefully orchestrated session, is effective in reducing students’ anxiety about crossing personal boundaries and increasing confidence in examination performance
Schrieber et al, 2000[18]	University of Sydney, Australia	Undergraduate 1st clinical year	Rheumatoid arthritis: musculoskeletal examination skills	Patient partners or patient educators: teaching hand and wrist examination skills, informal assessment	Trained in musculoskeletal examination techniques in Searle patient partners in arthritis programme	80 minute tutorial	Not stated	Not stated	Patient partners: equal or superior to doctors (not trained in musculoskeletal medicine/ orthopaedics) teaching examination techniques, effective communication skills teachers, unique ability to use personal experiences
Smith et al, 2000[19]	Flinders University of South Australia, Adelaide, Australia	Undergraduate 2nd clinical year	Musculoskeletal medicine examination techniques	Patient partners or patient educators: providing tuition in musculoskeletal medicine clinical skills and feedback	Trained to teach examination of musculoskeletal examination’s components	Part of 4 week clinical skills teaching block	Not stated	Appreciated patient partners’ teaching, greater feedback on examination technique than from rheumatologists. Valued opportunity to understand disease effect on patients	Patient partner teaching is as effective a method of teaching clinical skills in musculoskeletal medicine as traditional resident based teaching
Stillman et al, 1980[20]	University of Arizona, USA	Undergraduate 2nd and 3rd clinical year	Physical diagnostic skills: cardiovascular and pulmonary	Patient instructors: patient, teacher, evaluator of physical diagnosis skills	Several sessions including audiotaped teaching with lay-language instructor’s home study manual. Extra reference material provided	Single session (time period not specified)	Not stated	95% rated sessions helpful in identifying examination technique strengths and weaknesses and diagnostic accuracy. Most appreciated relaxed atmosphere, cooperative patients, patient instructor’s instructive, immediate feedback	Patient instructors can be used to evaluate objectively students’ physical diagnosis skills
Thomson, 1984[21]	University of Auckland, New Zealand	Postgraduate	Doctor-patient communication skills in family practice	Consumer examiners (non-doctors nominated by consumer organisations): assessors for a New Zealand summative postgraduate examination of family practice competence	Consumer examiners observe videotapes of simulated candidates’ performances	Two 15 minute role play consultations (consumer examiner as observer)	Not stated	Not stated	Consumer examiners seen to be reliable examiners with different perspective on performance. May be valuable resource for training and assessment of medical practitioners’ communication skills
Vail et al, 1996[22]	New York University, USA	Undergraduate 3rd clinical year	Ambulatory care of HIV positive patients	Patient volunteers: teacher (1:1 with student) of interviewing, physical examination, patient counselling skills	Discussion with physicians, 3 hour workshop, including discussion with 4th year student	4 half-day sessions over 4 weeks, students paired with patients	Felt empowered. Saw themselves as teachers, making contribution to medical education. Gained insight into provider’s struggles, learnt how to get most out of going to the doctor	Profoundly affected by experience, particularly by relationship with patients	The model is practical and may be useful in teaching about other chronic diseases in the ambulatory setting
Weisser et al, 1985[23]	West Virginia University, USA	Undergraduate 2nd clinical year	Interpersonal communication skills relating to emotional and psychological issues (for example, sudden infant death syndrome, sexual assault)	Patient moderators (patient, close relative or survivor of known patient): moderator, playing active part in conduct and direction of student seminar	Not stated	Weekly 2 hour session	Appreciated opportunity, hoped their involvement would result in others avoiding trauma they endured through health professionals’ thoughtless actions	Seminars filled void in education, directed attention to important patient concerns, stimulated consideration of patients’ problems in a broader perspective.	Patients, a virtually untapped educational resource, were proven to be an expedient, knowledgeable and enthusiastic cadre of teachers

 

Extra references

1. Bell MJ, Badley EM, Glazier RH, Poldre P. A pilot study to determine the effect of patient educators on medical students’ and residents’ skills in joint examination. Acad Med 1997;72:919.
2. 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.
3. 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;12:61-9.
4. Branch VK, Lipsky PE. Positive impact of an intervention by arthritis educators on retention of information, confidence, and examination skills of medical students. Arthritis Care Res 1998;11:32-8.
5. Butterworth M, Livingston G. Medical student education: the role of caregivers and families. Psychiatric Bull 1999;23:549-50.
6. Curry RH, Makoul G. An active-learning approach to basic clinical skills. Acad Med 1996;71:41-4.
7. Davidson R, Duerson M, Rathe R, Pauly R, Watson RT. Using standardized patients as teachers: a concurrent controlled trial. Acad Med 2001;76:840-3.
8. Elliot DL, Hickman DH. Evaluation of physical examination skills. JAMA 1987;258:3405-8.
9. 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.
10. Gall EP, Meredith KE, Stillman PL, Rutala PJ, Gooden MA, Boyer JT, et al. The use of trained patient instructors for teaching and assessing rheumatologic care. Arthritis Rheum 1984;27:557-63.
11. Gruppen LD, Branch VK, Laing TJ. The use of trained patient educators with rheumatoid arthritis to teach medical students. Arthritis Care Res 1996;9:302-8.
12. Hendry GD, Schrieber L, Bryce D. Patients teach students: partners in arthritis education. Med Educ 1999;33:674-7.
13. Kelly D, Wykurz G. Patients as teachers: a new perspective in medical education. Educ Health 1998;11:369-77.
14. Livingstone RA, Ostrow DN. Professional patient-instructors in the teaching of the pelvic examination. Am J Obstet Gynecol 1978;132:64-7.
15. 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.
16. 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;57:550-6.
17. 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;9:264-9.
18. Schrieber L, Hendry GD, Hunter D. Patient partners in the teaching of graduate medical program students. Arthritis Rheumatism 1999;42) September supplement):S116.
19. Smith MD, Henry-Edwards S, Shanahan EM, Ahern MJ. Evaluation of patient partners in the teaching of the musculoskeletal examination. J Rheumatol 2000;27:1533-7.
20. Stillman PL, Ruggill JS, Rutala PJ, Sabers DL. Patient Instructors as teachers and evaluators. J Med Educ 1980;55:186-93.
21. Thomson AN. Reliability of consumer assessment of communication skills in a postgraduate family practice examination. Med Educ 1994;28:146-50.
22. 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.
23. Weisser Jr RJ, Medio FJ. The patient as teacher. J Med Educ 1985;60:63-5.

 

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