Does the teaching of person-centred care in medical school require a little more care itself? Hannah Watson
The dedication to lifelong learning of health and disease begins on day one of medical school. The type of physician a student will become is ultimately shaped by what is taught, how it is taught and the early implementation of best practice. Using professional education to teach and encourage self-directed learning of person-centred care from the very beginning of undergraduate medicine will allow great person-centred care to become second nature. So could the addition of a dedicated person-centred care strand within first year problem based learning sessions aid the development and enhancement of the skills required to provide the best care for patients – is this the missing piece of care?
Person-centred care (PCC) focusses on the needs of a person by allowing their views and priorities to be considered during shared decision making. Although patients do not always experience disease in the same way, their unwavering expectation to receive exceptional individual care remains paramount. Patients who were treated as individuals “felt comfortable and confident when doctors, nurses and other staff were perceived as caring and responsive to their individual needs”. As Osler reminded us, “The good physician treats the disease; the great physician treats the person who has the disease”, to be a great physician, you must understand the whole person.
Person-centred care requires resource
The demand for high quality personalised healthcare is significantly increasing the pressure on medical professionals. A 2018 projection for the UK, estimated there would be an additional 8.6 million 65+ years olds in 2068 and for those in England it was estimated that 14.2 million people would be living with multiple conditions. Managing individual complex illness, experienced by each patient differently, in an ageing population clearly places a huge strain on the NHS and could be viewed as a barrier to sustained delivery of quality PCC. Insufficient staffing levels and experience, time and equipment, may also pose barriers to providing excellent PCC.
To address these issues and alleviate the pressure on the NHS, in 2019, 1500 more medical student places were allocated to UK medical schools. Increasing the number of training healthcare professionals prepares the NHS for a future of treating ever-expanding health problems by increasing professional capacity however, what is being taught must also be innovative and relevant to provide the best care.
Benefits of early PCC teaching implementation
To benefit from PCC, professionals are required to quickly recognise different, and possibly complex, health needs in individuals. This may require a deviation from standard treatment. Achieving what the Kings Fund described as reaching a “compromise” between biomedical-defined priorities for care and patient defined priorities. For example, to avoid problems with concordance and wasted medications compromise has been identified as important when a patient uses multiple medication.
Considering the person holistically whilst using excellent communication skills to build a relationship with the patient has long been recognised as beneficial in achieving compromise in treatment decisions. Four components of doctor-patient relationship have been identified; trust, knowledge, regard and loyalty. To achieve good health outcomes, ideally using the mutual participation model, excellent communication is required because if it is not poor communication has been noted to affect the number of medical visits, the mental health and symptom relief of patients. However, modern practice sees additional challenges to delivering this in practice. For example, the growth of the internet means patients are aware of possible treatment options. Negotiating compromise between what treatment could be given and what should be given is a challenge and a potential conflict zone.
Professionals report lacking skills and confidence in knowing how to best to achieve compromise in practice. For example, the main barrier to providing PCC is fear of making a confident decision for a patient that other professionals may not agree with as it does not strictly follow guidelines. Therefore, we need to think differently about how healthcare professionals are trained. One solution may lie in enhancing early teaching and self-directed learning of undergraduates.
In order for health professionals now and in the future to address this complex situation and to efficiently provide a high-quality PCC, they will need to have the appropriate education, knowledge and experience. To gain these skills and the confidence to apply them, implementing the idea of PCC through professional education as early as possible in medical training would benefit students and allow them to explore how to provide PCC in their own style, so they are able to provide PCC as a matter of urgency. Medical school is challenging, there is a huge amount of information to retain, learn and to then put into practice. This therefore highlights why timing is important. Professional implementation of PCC will mean it will likely become second nature if practiced.
Current undergraduate teaching of problem based learning and person-centred care
One of the many approaches to medical school teaching is problem based learning (PBL). PBL has been described as an “effective teaching and learning approach” and should continue to challenge student’s problem solving skills. PBL is a spiral curriculum that encompasses all aspects of learning including lectures, clinical placement, clinical skills, workshops, anatomy and self-directed learning. At Hull York Medical School (HYMS) this is based on four strands: applied life sciences, health and society, clinical reasoning and professionalism.
Teaching is enhanced by using virtual patients in specific scenarios in which students discuss all problematic elements of a case to create learning outcomes based around the four strands. In PBL, group work is beneficial for sharing ideas, discussing with others and testing one’s own knowledge.
One limitation to PBL is that students are initially only taught about one personal experience of e.g. diabetes; however, this is not always representative of the affected population. Whilst PBL allows for self-directed learning it could be enhanced to offer integration of PCC elements for more than one individual experience (health and society strand) with clinical decision making (clinical reasoning and applied life sciences strands) by exploring discrete features of the individual patient values, contexts, attitudes and preferences in a professional manner.
After consolidating knowledge based on an ‘idealised’ patient, PCC learning could be extended through the PBL model in a 5th strand to explicitly include integrated scenarios to include multiple or differently treated patients. For example, those who are burdened with an overload of treatment and overwhelmed by physical and mental consequences, and those who experience ‘too little medicine’ leading to late diagnosis of disease. An example of this can be read in the appendix.
Although there is opportunity to test knowledge formatively, it is rarely specifically on the PCC aspect. In order to ensure each of the four stands is discussed during every virtual patient case, it is important to recognise that the same disease can manifest in different ways by presenting similarities and differences between the same cases.
A possible solution to enhance teaching of PCC within undergraduate teaching?
To develop a deeper understanding of PCC and manage individuals with complex illness, I have developed an idea to introduce specific, additional PCC teaching within the PBL format which can be reinforced using an interactive mobile application that presents students with multiple scenarios of managing a particular health problem.
Using valuable and reliable information from publicly available resources such as ‘healthtalk’ and ‘Speaking Clinically’ to create additional sessions and self-directed learning using a mobile application could be used to put this into practice. This could challenge students current understanding of an ‘idealised’ patient and allow them to acknowledge, explore and review the implications of inconsistent and unpredictable health of numerous patients. Facilitated reflection will allow students to critically evaluate the similarities, differences, and consequences of being either a ‘good’ or ‘great’ physician, whilst providing examples of different models of care.
An excellent physician is one who not only has the appropriate knowledge to manage patient health but one who can also tailor the skills and expertise they have acquired during training to enhance patient care. Using multiple resources available to select the most appropriate course of action is in the patient’s best interest, whether this be guidelines, consulting with a colleague or through experience of treating other patients. Professionals, family and carers can use facilitated reflection to learn and begin to understand, if different interpretations of illness, affects patient treatment and by reflecting on past experience, this will help to further develop scholarship skills needed for PCC.
I propose that the quicker PCC is implemented within teaching the sooner students begin to benefit and recognise the importance of PCC. My idea complements existing initiatives such as the Longitudinal Integrated Clerkship at HYMS which offers the opportunity to follow the same patient over time, my idea extends this learning opportunity across earlier years of training.
Successful PCC will most likely become a natural part of patient management if students have an early awareness and experience of exposure to individual patients experiencing the same disease in a different way.
Consider this, if you required medical care, would you want to be treated as an individual? Absolutely!
Hannah Louise Watson is a 2nd year medical student at Hull York Medical School. She wrote this blog following her Year 1 SSIP (Scholarship and Special Interest Programme) on Goldilocks Medicine: getting medical care ‘just right’.