"Patient centred care requires learner centred education"
Dear editor,
I wish to respond to the editorial by Moira Stewart in the BMJ, 24th
February; 322,444-445.
The issue of "patient centred care" is in my opinion a central plank
for the practice of medicine and is thus important for all doctors to
consider. I believe it therefore to be an essential concept for all
involved in medical education as well. When reading Moira Stewart's
editorial one could easily substitute the words "patient centred" for
"learner centred" and "doctor" for "facilitator" and retain the impact of
the article.
I would entirely agree that a better understanding of the patient
centredness could lead to medicine being practised by doctors who are
better able to explore their patients' worlds, thereby enhancing health
outcomes and effectiveness of practice. I believe that learner centred
education is the way to prepare doctors for this. The parallels are in my
opinion compellingly close.
The findings of Little et al which stress the appreciation by
patients who seek to be understood in a whole person way, and to build a
therapeutic relationship with their carer, who is able to address their
concerns and find common ground on which to agree future plans, are I
believe, akin to desirable elements of an effective facilitator: learner
relationship. After all "doctor” also means "teacher".
In my experience of 25 years in medical education and medical
practice in South Africa and the UK I would echo the sentiment that the
term "is becoming widely used, but poorly understood" for medical
education as well as in medical practice. Additionally I feel the phrase
"learner centred" is becoming widely used, but poorly understood in
medical education. I believe that by practising one the other is enhanced
and thus a symbiosis exists between the two phrases, which represents a
deep value system for medicine. This could be summarised as "do unto
others as you wish to be done to". I believe that a learner centred
approach in medical education prepares doctors for patient centred care.
It can further enhance the impact of an educational experience which
"walks its talk", or practises the principles of patient centredness in
education too. This can represent the transfer of values and beliefs into
the learner's world mirroring the whole person approach of patient centred
medicine.
The common misunderstanding that all decisions must be shared with
the patient (or learner) is again a common error in education. The skill
of learner centred facilitation lies in the ability to know when and how
to involve the learner. John Heron describes three modes of hierarchy, co-
operation or autonomy in which a facilitator can operate. He also
describes six dimensions of facilitation, namely planning, meaning,
confronting, feelings, structuring and valuing, in an attempt to broaden
the view of potential arenas in which human interactions occur. At any one
time an interaction could have all these elements present and be in
keeping with a humanistic approach. For example a doctor could plan to see
a patient in their clinic for the purposes of carrying out an
investigation (hierarchical), in discussing the purpose of the
investigation there will be a sharing of understanding (co-operation) and
possibly a discussion about the pros and cons of proceeding (co-operation
or autonomy). The feelings aroused in the patient can be acknowledged and
their own beliefs respected by the doctor (autonomy). Ultimately the
patient will make sense of their situation for themselves, (autonomy).
Heron's approach to facilitation provides a practical way of bridging
medical practice and medical education.
Dr Shake Seigel, general practitioner and medical educator Chairman,
Association of Course Organisers.
1. Stewart M, Towards a global definition of patient centred care.
BMJ 2001; 322:444-445
2. Little P, Everitt H, Williamson I, Warner G, Moore m, Gould C, et
al. Preferences of patients for patient centred approach to consultation
in primary care: observational study. BMJ 2001;322:468-472
3. Heron J., (1989) The Facilitators' Handbook; London, Kogan Page.
Rapid Response:
"Patient centred care requires learner centred education"
Dear editor,
I wish to respond to the editorial by Moira Stewart in the BMJ, 24th
February; 322,444-445.
The issue of "patient centred care" is in my opinion a central plank
for the practice of medicine and is thus important for all doctors to
consider. I believe it therefore to be an essential concept for all
involved in medical education as well. When reading Moira Stewart's
editorial one could easily substitute the words "patient centred" for
"learner centred" and "doctor" for "facilitator" and retain the impact of
the article.
I would entirely agree that a better understanding of the patient
centredness could lead to medicine being practised by doctors who are
better able to explore their patients' worlds, thereby enhancing health
outcomes and effectiveness of practice. I believe that learner centred
education is the way to prepare doctors for this. The parallels are in my
opinion compellingly close.
The findings of Little et al which stress the appreciation by
patients who seek to be understood in a whole person way, and to build a
therapeutic relationship with their carer, who is able to address their
concerns and find common ground on which to agree future plans, are I
believe, akin to desirable elements of an effective facilitator: learner
relationship. After all "doctor” also means "teacher".
In my experience of 25 years in medical education and medical
practice in South Africa and the UK I would echo the sentiment that the
term "is becoming widely used, but poorly understood" for medical
education as well as in medical practice. Additionally I feel the phrase
"learner centred" is becoming widely used, but poorly understood in
medical education. I believe that by practising one the other is enhanced
and thus a symbiosis exists between the two phrases, which represents a
deep value system for medicine. This could be summarised as "do unto
others as you wish to be done to". I believe that a learner centred
approach in medical education prepares doctors for patient centred care.
It can further enhance the impact of an educational experience which
"walks its talk", or practises the principles of patient centredness in
education too. This can represent the transfer of values and beliefs into
the learner's world mirroring the whole person approach of patient centred
medicine.
The common misunderstanding that all decisions must be shared with
the patient (or learner) is again a common error in education. The skill
of learner centred facilitation lies in the ability to know when and how
to involve the learner. John Heron describes three modes of hierarchy, co-
operation or autonomy in which a facilitator can operate. He also
describes six dimensions of facilitation, namely planning, meaning,
confronting, feelings, structuring and valuing, in an attempt to broaden
the view of potential arenas in which human interactions occur. At any one
time an interaction could have all these elements present and be in
keeping with a humanistic approach. For example a doctor could plan to see
a patient in their clinic for the purposes of carrying out an
investigation (hierarchical), in discussing the purpose of the
investigation there will be a sharing of understanding (co-operation) and
possibly a discussion about the pros and cons of proceeding (co-operation
or autonomy). The feelings aroused in the patient can be acknowledged and
their own beliefs respected by the doctor (autonomy). Ultimately the
patient will make sense of their situation for themselves, (autonomy).
Heron's approach to facilitation provides a practical way of bridging
medical practice and medical education.
Dr Shake Seigel, general practitioner and medical educator
Chairman,
Association of Course Organisers.
Alrewas Surgery , Staffs, DE13 7AS
bitty_shake@compuserve.com
REFS:
1. Stewart M, Towards a global definition of patient centred care.
BMJ 2001; 322:444-445
2. Little P, Everitt H, Williamson I, Warner G, Moore m, Gould C, et
al. Preferences of patients for patient centred approach to consultation
in primary care: observational study. BMJ 2001;322:468-472
3. Heron J., (1989) The Facilitators' Handbook; London, Kogan Page.
Competing interests: No competing interests