Original Publication
Open Access

Lived Experience and Patient Advocacy Module: Curriculum and Faculty Guide

Published: August 12, 2017 | 10.15766/mep_2374-8265.10617

Appendices

  • Facilitator Guide to Teaching.pdf
  • Supplemental Questions.pdf
  • Reference Links.pdf
  • Lived Experience Video folder

All appendices are peer reviewed as integral parts of the Original Publication.

To view all publication components, extract (i.e., unzip) them from the downloaded .zip file.


Abstract

Introduction: Medical teachers frequently tell learners how some of the greatest challenges in clinical care are not associated with the scientific details of biomedicine but are instead related to patient interactions and the human dimensions of illness and recovery. Beyond providing direct care, physicians sometimes serve as advocates and supporters for their patient as the patient navigates through the health care system. Opportunities to discuss and reflect on these aspects of medical practice may not arise in the course of clinical experiences. Methods: This video module and accompanying lesson plan provide the basis for a structured session on patient-physician communication and patient advocacy. In the video, learners hear from a patient who experienced a life-changing medical condition and who faced challenges both before diagnosis and during a long recovery. The video provides a basis for vital discussions about the patient-physician relationship, highlighting the importance of clear and continuing communication. Results: Students indicated that this module effectively provided a patient perspective. The video format and fast pace of the presentation appealed to them. Discussion: This module is ideally suited for use as a stimulus for a facilitated small-group discussion with medical students. It can be presented within a 1-hour session. It can also be used as a freestanding module for independent study. Though the patient suffered from a specific medical condition—a pituitary tumor and related complications—students do not need to be knowledgeable about those conditions or have in-depth clinical experience to readily comprehend the messages in this lesson.


Educational Objectives

By the end of this module, learners will be able to:

  1. Explain the need to avoid premature closure in medical decision-making.
  2. Recognize how patients may be best served when clinicians can think and collaborate across traditional specialty boundaries.
  3. Explain the importance of empathy and active listening in patient care.

Introduction

It is not unusual to hear medical teachers tell learners how some of the greatest challenges in clinical care are not associated with the scientific details of biomedicine but are instead related to interactions with patients and the human dimensions of illness and recovery. Beyond providing direct care, physicians sometimes serve as advocates and supporters for their patients as the patients navigate through the health care system. Opportunities to discuss and reflect on these aspects of medical practice may not always arise in the course of clinical experiences.

Actual patient encounters provide some of the most powerful learning experiences for medical students. A video presentation by a patient can offer an opportunity for learners to hear directly from the patient, in his or her own words, using a modality that can be deployed within a medical school curriculum. A patient video can be an effective supplement to in-person experiences.

In this video module, medical students hear from a patient about her experience with a life-changing medical condition who faced challenges before diagnosis and during a long recovery. The video provides a basis for vital discussions about the patient-physician relationship, highlighting the importance of clear and continuing communication. This module is ideally suited for use as a stimulus for a faculty-facilitated small-group discussion with medical students. Though the patient suffered from a specific medical condition—a pituitary tumor and related complications—students do not need to be knowledgeable about those conditions or have in-depth clinical experience to readily comprehend the messages in this lesson. The resource can also be used as a freestanding module, though some of the benefit of reflection and discussion will be lost.

The patient’s presentation is accompanied by a faculty narrative and an expert commentary. Accompanying discussion questions and references are provided to help an end user deploy this resource within a curriculum.

This instructional module originally began as a faculty-facilitated small-group discussion session that was offered as a supplement to the core medical student curriculum. The patient presented her case history in person, and a faculty facilitator guided a follow-on discussion with the patient and students. The session provided a forum for discussions on patient-physician communication and relationships, the role of physician as patient advocate, and how physicians can optimally support patients when they are accessing alternative healing approaches.

Students consistently appreciated the opportunity to hear the patient’s perspective directly and to discuss these subjects in the context of an individual patient’s care and recovery. The enthusiastic student response to this session inspired the creation of a video-recorded patient presentation and standardized materials to help faculty use this lesson and video as an instructional resource—anytime, anywhere.

Methods

The educational basis for this resource begins with the premises that students learn well from the study of cases, and that actual patient cases make for the richest learning experience.1 This module builds on this existing, time-tested approach of teaching using patient case presentations. The original version of the module used a live presentation rather than a video recording. We recognized that presenting a live, small-group session requiring the presence of this particular patient would prohibit us from reaching a larger audience. While a live patient presentation would be more engaging for learners, it is not always possible to have an ideal patient at the ready. The desire to be able to reach a larger audience, both at Pittsburgh and at other medical schools, prompted the development of this video-based module.

The discussion format used is one that is common in medical education and in higher education in general.1 The sample topics for discussion (contained within Appendix A, the Facilitator Guide) are items that have been used to prompt student discussion. When we conducted this session at our institution, many students did not need prompting and pursued these types of questions on their own initiative.

The subjects raised in the video and subsequent discussion are well known to practicing physicians and are cited in the literature as problems that need to be addressed. For example, there can be gaps and delays in patient diagnostic workups and treatment if there is no effective communication and coordination among the various clinicians.2 In this patient’s case, “fragmentation—focusing and acting on the parts without adequately appreciating their relation to the evolving whole”—may have played a role in her clinical course.3 This module also focuses attention on how physicians may be supportive and empathetic when their patients turn to alternative or integrative techniques for healing or relief of suffering.4-6 In this area, Dr. Peabody’s message from 1927 is still true today: “The secret of the care of the patient is in caring for the patient.”7

Target Audience
The primary target audience is preclinical medical students. The content readily generalizes to other health professions students, including dental medicine, nursing, and physician assistant students, and to residents. There are no specific prerequisites.

This module was introduced as a supplement to the preclinical Patient, Physician, and Society block at the University of Pittsburgh School of Medicine. This block covers fundamental aspects of the patient-doctor relationship, including ethics, professionalism, behavioral medicine, and other related topics. The nature of the content would permit it to be used for any health science trainees.

Logistics
Implementation of this module is fairly simple. At the University of Pittsburgh School of Medicine, this session was conducted in a small-group classroom that was able to accommodate 10 students and one facilitator. As presented here, the session requires 1 hour of curriculum time. The facilitator should view the video and review the supplemental materials in advance. The Facilitator Guide (Appendix A) includes several items that can be used to prompt discussion. The ideal facilitator is a clinician.

During the classroom session, students watch the video presentation (Appendix D). This 30-minute video is divided into three major segments—the patient presentation in two parts and a follow-up commentary. At the midpoint in the patient presentation, the video moderator poses reflection questions for students to consider individually during the pause and during the second segment. The video is designed to be played on Windows-based computers.

After the patient presentation, there is a reflective commentary by Dr. Phil Gold from McGill University. The facilitator may opt to show this closing commentary immediately or to defer it until after student discussions. A benefit of deferring the commentary is to allow students an opportunity to reflect on their own before hearing how an experienced clinician views this subject.

Preparation
The Facilitator Guide to Teaching (Appendix A) is a concise and practical summary for the small-group facilitator. It assumes that the facilitator will watch the video as part of preparing for the session. The Facilitator Guide’s Video Outline summarizes but does not fully reiterate what is presented in the video.

The Supplemental Questions (Appendix B) are items that students have commonly asked the patient during live sessions. We recommend that these be distributed to students at the conclusion of the session.

The Reference Links (Appendix C) may be given to students at the discretion of the facilitator. The module is entirely self-contained. Students do not need to review any of the additional references to cover the core material, though they may be of interest to students.

This module has been formatted to allow it to be used for independent study. In this application, learners could watch the video on their own, with a self-paced pause for reflection. While this approach is less engaging than using the module in a classroom setting, the primary messages can still be transmitted in this manner.

In our curriculum, students were not specifically evaluated as to whether they had achieved the module learning objectives. Such evaluation could be possible through presentation of an additional case scenario where students would be assessed on the basis of a reflective essay, or using a checklist or global rating scale. However, as used at Pittsburgh, the module is intended to be a formative experience, and it is not viewed as critical to evaluate students on mastery of specific material as a result of this one module.

Results

This lesson was developed in two phases. It was initially conducted with four groups of 10-20 preclinical medical students on an elective basis, using a live presentation of the case. Though there was no specific formal evaluation process, there was a consistent sentiment expressed by each cohort of students that this opportunity was unique, that it provided new insights, and that they wished all students could have the opportunity to experience this lesson. This inspired the creation of the video and sharable materials, as described above.

The video lesson was created in the following manner. Learning objectives were identified. An overall plan for the lesson was developed with the aim of producing a module that was practical and straightforward for use in the medical school learning environment. The outline of the live presentation was reviewed and sectioned for use as the basis for the storyboard for the video. Appropriate images and text were identified to support the spoken messages. The opening, middle, and closing commentaries were developed to complement the patient presentation. The video segments were recorded by a media production company that also performed the postproduction integration of still images and text slides. The closing commentary was recorded at the commentator’s institution.

The video-based lesson was then field-tested with a separate cohort of eight medical students and a naïve facilitator (one who had not been present for the live sessions). The students were debriefed in a focus group that included question-based and free-range discussion. Their comments were transcribed. The focus group results were summarized and analyzed by the focus group facilitator. We used these results to refine the sample topics for discussion suggested in the Facilitator’s Guide. The focus group results were consistent with the experience of the live group. Focus group members felt that this module had an appropriate focus, was level appropriate, and was of an appropriate duration. They felt that the format—having the video in segments with a pause for discussion—was a good one. They appreciated being guided by the midpoint commentator and thought that Dr. Gold’s wrap-up was valuable. Overall, the focus group findings supported the idea that the module would be effective. Specific comments included “powerful message,” “it focused on the patient’s story and not the medical differential—this is good,” and “reflection on alternative medicine use was good.” Students voiced that it would be important for curriculum leaders to place the module appropriately within the context of the local curriculum, ideally at a point where “you would be able to identify with the topic: ‘This could be/will be me’.” Our interpretation of these results is that this lesson can be a useful addition to a curriculum when thoughtfully added at an appropriate point.

One basic goal (beyond the learning objectives) was to have students spend some time reflecting on this subject matter. From the faculty, we learned that this module was effective in provoking students to reflect on and discuss the key issues raised. With so many other subjects competing for students’ attention, it can be challenging to divert them from subjects that will appear on an upcoming examination. This module was able to hold students’ attention and provide a launchpad for engaging discussions.

Discussion

The approach of creating a patient presentation as a video-based module can be used in any subject area. One challenge to this approach is that many patients will not be comfortable having their stories recorded and widely disseminated. Other patients may welcome this opportunity.

A specific benefit of creating this type of recorded presentation is that it can then be deployed as needed in the curriculum, without being constrained by the availability of a suitable patient at the necessary time. This may be the only practical way to provide students with access to patients with less-common conditions or circumstances. This approach could fill a curriculum gap for educators with limited resources, such as those who do not have ready access to a population of willing patients. A related benefit is that using a video permits the instructor to reveal the patient presentation in controlled segments, providing an opportunity for facilitated discussion along the way.

Preparing a patient video, whether in the form of a patient presenting his or her own case history (as in this module) or a patient being interviewed by a clinician, provides medical educators with an opportunity to work with the patient in a behind-the-scenes setting to help focus the presentation, if necessary. In the future, a collection of videos of actual patients could be created in this manner, forming the basis for a series of discussions. This could be far more engaging than simply reading about a patient case as a text-based case history.

Limitations
The video format itself can be a limitation as compared with how compelling it can be to be to have a live, in-person discussion with a patient. Another limitation is that preparing a video of this nature can be resource intensive, requiring a facility and support from a video production staff. A simple recording of a patient presentation could be achieved using a single camera and minimal editing.

Lessons Learned
In the process of developing this module, we gained valuable insights about how students and faculty relate to this type of material. One major learning point was on how to focus the lesson to optimize student engagement while still delivering the content in the desired manner. The lesson was intended to help students concentrate on the patient-physician relationship, communications skills, and patient experiences. Early on during the live versions of this module, some students were more concerned with the details of the disease processes. This was entirely understandable as these preclinical students were most focused on learning pathophysiology and treatment during the majority of their coursework. After seeing how students reacted to the lesson, we revised the presentation to refocus student attention more on the patient’s experience, while preserving enough of the clinical details to bolster that part of their interest.

A second lesson learned was the degree to which this material was relevant to multiple levels of trainees. It was initially presented to first-year students. Later, it was presented to students in years two and three. Students at all levels, including the focus group students, found the module to be relevant and engaging. Reflecting on the reasons for success with various levels of students, we believe that it is mostly due to the fundamental nature of the subject matter. Early preclinical students—perhaps rooted in a perspective more comparable to that of a nonphysician—can relate to this material in spite of not having significant clinical experience. Students in the midst of clerkships have a more substantial clinical experience on which to base their perspectives on this material and can see its importance through an even more mature lens.


Author Information

  • Laurie Gerber: Patient Advocate, Office of Medical Education, University of Pittsburgh School of Medicine
  • John F. Mahoney, MD: Associate Dean for Medical Education, University of Pittsburgh School of Medicine
  • Phil Gold, MD, PhD: Douglas G. Cameron Professor of Medicine, McGill University

Acknowledgments
A project of this magnitude is made successful by the contributions of many individuals beyond the core team. We extend our gratitude to Drs. Kathleen Ryan, Hollis Day, Rosanne Granieri, and Geoffrey Gerber and to the development team at CE City for their support and invaluable feedback throughout this project.

Disclosures
None to report.

Funding/Support
The production of this video module was supported by a grant from the Burroughs Wellcome Fund.

Ethical Approval
Reported as not applicable.


References

  1. Fry H, Ketteridge S, Marshall S, eds. A Handbook for Teaching and Learning in Higher Education: Enhancing Academic Practice. 2nd ed. Sterling VA: Kogan Page; 2003:138.
  2. Shannon D. Effective physician-to-physician communication: an essential ingredient for care coordination. Physician Exec. 2012;38(1):16-21.
  3. Stange KC. The problem of fragmentation and the need for integrative solutions. Ann Fam Med. 2009;7(2):100-103. https://doi.org/10.1370/afm.971
  4. Zinn W. The empathic physician. Arch Intern Med. 1993;153(3):306-312. https://doi.org/10.1001/archinte.1993.00410030022004
  5. Schofield P, Diggens J, Charleson C, Marigliani R, Jefford M. Effectively discussing complementary and alternative medicine in a conventional oncology setting: communication recommendations for clinicians. Patient Educ Couns. 2010;79(2):143-151. https://doi.org/10.1016/j.pec.2009.07.038
  6. Egnew TR. The meaning of healing: transcending suffering. Ann Fam Med. 2005;3(3):255-262. https://doi.org/10.1370/afm.313
  7. Peabody FW. The care of the patient. JAMA. 1927;88(12):877-882. https://doi.org/10.1001/jama.1927.02680380001001


Citation

Gerber L, Mahoney JF, Gold P. Lived experience and patient advocacy module: curriculum and faculty guide. MedEdPORTAL. 2017;13:10617. https://doi.org/10.15766/mep_2374-8265.10617

Received: March 6, 2017

Accepted: July 25, 2017