Intended for healthcare professionals

Rapid response to:

Practice What Your Patient is Thinking

What it feels like to be an interesting teaching opportunity

BMJ 2016; 355 doi: https://doi.org/10.1136/bmj.i6190 (Published 07 December 2016) Cite this as: BMJ 2016;355:i6190

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Rapid Response:

Re: What it feels like to be an interesting teaching opportunity

Reply to Ms Tapp from a fifth year medical student.

Thank you Ms Tapp for sharing your experience. It is always so helpful to hear a patient’s perspective on the way we practice. I regularly see my seniors telling patients that they are ‘extremely interesting’, and have been guilty of saying similar things myself, but your story has changed the way I see this and I will think carefully about my choice of words in future.

In my experience, the overwhelming majority of patients are happy to partake in student education, to a greater or lesser extent, and this has been demonstrated formally across several different medical settings1 2. Unfortunately, this perhaps makes us complacent when involving patients in our learning, as their willingness to be seen by students is all too often assumed. Sadly your story sounds very familiar and I have often discussed with peers how we were uncertain that particular patients felt truly happy with us being around during their consultations or treatment. Evidently there are outstanding problems with the way that student teaching is integrated into patient care and the question of how we address this still remains.

It appears to me that the greatest barriers to best practice are 1) that doctors do not gain proper consent before students are present, perhaps often due to time constraints, and 2) that students do not feel able to interject when this has been forgotten. If a student is, for example, joining a ward round, doctors asking every patient for permission before the ward round begins seems an unrealistic expectation. Even once students are present, doctors often move so quickly between patients that the opening and closing ‘bookends’ of the consultation often get forgotten, and a full introduction of everyone attending the ward round rarely happens. Indeed, a study in gynaecology and urology teaching found that even when students participate in intimate examinations, 58% of medical teachers ‘never’ or ‘seldom’ obtain patient consent before the student is present3.

We ought to challenge our seniors if they fail to meet the expected standards, but unfortunately the medical education system is still somewhat hierarchical. Interrupting a senior or changing the topic of conversation with a patient can be intimidating and often results in a negative response from the doctor. Indeed, with some seniors, even addressing a patient directly without being invited to do so can feel daunting. In an ideal world, students should not be disheartened by bad experiences, however without a change in the culture of medical education, this seems rather optimistic. We need to ensure that educators are aware of the importance of gaining proper consent and encourage more open involvement of students in the doctor-patient conversation. One might hope that with such a change in culture, your student who was the exception and expressed his empathy towards you might become the rule, and this might happen whilst the doctor is still present.

In addition, different medical environments often vary greatly in how effectively they inform patients that there are medical students present. In general practice, we are almost invariably introduced to the patient by the doctor at the beginning of the consultation, and most practices I have attended have a notice up in the waiting room letting advertising that there is a student in that day. Patients are also made aware that seeing the student is optional and that they can ask at reception if they would like the student to leave. This ensures that patients are not surprised when a student is then present and allows them to opt out without the potential awkwardness of having to say this directly to the student. Ultimately, it empowers the patient.

Such notices are almost never present in hospital environments. I personally have never seen such a notice on a ward, nor have I heard from anyone who has, and only very occasionally have I seen then in clinics. To me there seems no reason why similar notices should not be placed around wards and clinics that regularly host medical students. Or perhaps we should go even further and ask each patient at their initial clerking whether or not they are happy to see students so that this can be documented in the notes. Whilst these are by no means perfect solutions (less mobile patients are less likely to see notices and patients may well change their minds after their initial consultation), such measures could at least go some way towards tackling the problem. They could also encourage a change in culture, as a prompt to staff and students to gain proper consent and as a reminder that we ought to be grateful every time a patient participates in teaching, as well as respectful of those who wish to abstain.

1. Mills, J. K. A., Lambert, K. V. & Krupa, J. Medical Students in Breast Clinics—How Welcome Are They and How Can We Improve Their Learning Opportunities? J. Surg. Educ. 72, 452–457 (2015).
2. Santen, S. A., Hemphill, R. R., Spanier, C. M. & Fletcher, N. D. ‘Sorry, it’s my first time!’ Will patients consent to medical students learning procedures? Med. Educ. 39, 365–369 (2005).
3. Tang, T. S. & Skye, E. P. When patients decline medical student participation: the preceptors’ perspective. Adv. Health Sci. Educ. 14, 645–653 (2009).

Competing interests: No competing interests

19 December 2016
Emma Sewart
Medical Student
University College London
Gower Street