In recent years, the term “patient-centered” has become very popular. “Patient-centered medical home”, “patient-centered medical care”, “patient-centered medical interviewing”, and “patient-centered communication” are several examples of concepts that explicitly recognize patients as the primary focus and/or customer in the provision of healthcare.
There will be increasing emphasis on “patient-centeredness” in the practice and training of healthcare professionals, as national healthcare programs such as the Patient Protection and Affordable Care Act move forward. Similarly, with increasing emphasis on interprofessional education, “patient-centeredness” will likely prove to be a unifying educational requirement that is shared across multiple healthcare professions, leading to more interdisciplinary training activities.
At the level of national medical school accreditation, the Liaison Committee on Medical Education (LCME) is also encouraging medical student curricula to include patient-centered care. As an example, accreditation standard ED-19 states, “the curriculum of a medical education program must include specific instruction in communication skills as they relate to physician responsibilities, including communication with patients and their families, colleagues, and other health professionals.” Also accreditation standards ED-20-22 include specific references to related patient-centered concepts such as, “the medical consequences of common societal problems”, “an understanding of the manner in which people of diverse cultures and belief systems perceive health and illness”, and “address(ing) gender and cultural biases”1.
For years, the medical student curriculum at the University of Hawaii John A. Burns School of Medicine (JABSOM) highlighted and promoted patients as the centerpiece of the educational process. The JABSOM Objectives for Graduation, which serve as the foundation for all medical student educational experiences at JABSOM, include requirements such as, “approaching each patient with an awareness and sensitivity to the impact their age, gender, culture, spiritual beliefs, socioeconomic background, family support, sexuality, and healthcare beliefs may have on the development, diagnosis, and treatment of their illness”, “incorporating patient-centered and shared decision-making principles into their practice”, and “stating the important non-biological determinants of poor health and the economic, psychological, social, and cultural factors that contribute to the development and/or continuation of illness”2. These examples of JABSOM’s Objectives for Graduation reflect the value placed on patient-centeredness throughout the curriculum. The JABSOM medical student curriculum further highlights patient-centered medical education through the following educational experiences:
Problem-Based Learning
Problem-based learning is a form of case-based teaching first developed by Dr. Howard Barrows3 that incorporates the following six characteristics4:
Use of problems as the starting point for learning.
While the majority of medical schools today utilize some form of case-based teaching, JABSOM remains relatively unique in the use of classic PBL methodologies, and the degree of emphasis placed on small-group, faculty-facilitated, student-directed learning focused around the study of PBL cases about patients, their families, and their communities. Rather than reading like traditional medical case reports, JABSOM PBL cases are about people who live in Hawaii and are patients in the health care system. To provide a rich opportunity for patient-centered learning, the biological, clinical, populational, and behavioral issues that impact their health are woven into the case to create an engaging narrative and characters that students care about. Dialogue in the cases model the principles of patient-centeredness. Student learning about relevant biological sciences, clinical sciences, patient communication, and professionalism are contextualized by, and applied to, the patients in their PBL cases.
Patient-Centered Panels and Presentations
With greater emphasis on small-group PBL, there is less lecture time available in the JABSOM curriculum than most medical schools in the United States. Still some of this lecture time is used to reinforce the concepts of patient-centeredness. Panel presentations that include both physicians and patients are among the most highly-rated learning sessions, and patient-centered communication skills and professional behavior are also stressed prominently throughout the curriculum.
Early Clinical Experiences
Clinical learning experiences begin early in the JABSOM curriculum. Exposure to patients helps students see the connections between their responsibilities as physicians and the material they are learning in the classroom. Students are exposed to both hospitalized and ambulatory patients near the start of their first year of medical school. Patient-centered medical interviewing, communication skills, patient safety, and team-based care models are prominent components of the curriculum.
Standardized Patients
At JABSOM a large number of patient simulation learning experiences are provided. Standardized patients are used for face-to-face, personal interactions and each student’s ability to respect the culture and beliefs of their patients is assessed.
Manikin-Based Simulations
Manikin-based simulations begin within the first two months of medical school, and occur in virtually every required course and clerkship at JABSOM. The manikins are able to respond to questions by medical students in real-time and can simulate a variety of physical findings that allow students to apply what they have learned to specific patient scenarios. Both standardized patients and manikin simulations are integrated with the PBL curriculum so that characters from the cases are “brought to life”.
Community Health Experiences
Another unique component of the JABSOM curriculum is a Community Health requirement that spans the first-year of the MD curriculum. Within this weekly course, students work with community organizations and learn the importance of patient advocacy and service.
Diverse Learning Environments
While learning in tertiary care centers within urban settings is strongly valued in the curriculum, JABSOM believes that students should have opportunities to learn within and across a wide range of communities and practice settings. JABSOM provides opportunities for preclerkship students to complete portions of their first year of medical school on the Island of Hawaii. In this option, students live in Hilo for three months and complete their coursework, including clinical skills training, within this community. Similarly, in their third-year of training, students can opt to complete a six-month longitudinal clerkship option in rural areas within the state including clinical sites on the islands of Hawaii, Kauai and Maui. Currently JABSOM is exploring expanding its education into North Hawaii. By living in the same community as their patients, students have a unique opportunity to learn about the different cultures within their state and better appreciate their patient’s perspective on health care.
Patient-Based Evaluations
Exam questions generated by JABSOM faculty in the preclerkship curriculum include patient names and a clinical scenario that requires students to apply the health sciences to the patient described in the question. This practice reinforces important physician decisions, even those rooted within the traditional basic sciences, are still made with the best interest of the patient in mind. In addition, Objective Structured Clinical Examinations (OSCE) and manikin simulations are also used for formative and summative student assessments.
In total, JABSOM’s medical student curriculum and educational environment demonstrate a strong commitment to patient-centeredness in terms of content, philosophical approaches, methodologies and evaluation system.
Current national movements have used the term “patient-centered” to describe new models, paradigms, or ideals. Similarly, at the John A. Burns School of Medicine, we propose that over the past decade our educational program has purposefully evolved to what is best described as “Patient-Centered Medical Education”. The following definition for this educational approach is offered by JABSOM:
Patient-Centered Medical Education is an approach to medical education that places the patient at the center of the learning experience, and requires students to consider the patient in all aspects of learning. Curricular goals and objectives should explicitly reflect these values and expectations. Content included in the curriculum should reflect knowledge, skills and attitudes of greatest need by patients, including areas such as physician-patient communication; ethics and professional behavior; and patient safety. Methods that encourage Patient-Centered Medical Education include problem-based learning or other case-based learning strategies that explicitly include personal and/or social issues relevant to their care; clinical experiences – whether they be with actual patients or simulations – that require students to learn or apply knowledge or skills in the context of specific patient circumstances; or other educational experiences that meld the biomedical, clinical, populational and/or behavioral aspects of the patient experience. Finally, both learner evaluation and curriculum evaluation should regularly review outcomes related to patient-centered learning objectives across the curriculum.
JABSOM believes that for a medical school to define their own curriculum as “patient-centered”, they would need to meet the criteria outlined above related to goals, objectives, content, methods and evaluation. This approach would not be suitable for all medical schools, but may be an organizing structure that would appeal to some.
As the potential of a newly-named paradigm for medical student education is realized, there are a number of exciting opportunities ahead of us. Curricular areas that may have previously sat on the outskirts of a more biomedical model for medical education are now more clearly front-and-center in a patient-centered medical education model. These include topics like patient safety, quality improvement, cultural competency and appreciation of diversity, communication, counseling skills, and professional behavior.
Further exploration of these content areas will also necessitate revisiting JABSOM’s curricular goals, objectives, methods and evaluation processes, which in turn will lead to additional opportunities for educational scholarship and research.
The ultimate goal of realizing the potential of Patient-Centered Medical Education will be to graduate outstanding physicians who truly appreciate the importance of the patient in medical practice, they will become leaders and champions of patient-centeredness in the larger healthcare system.