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Adopting learner-centred strategies has major implications for faculty and individual students. This issue of CDTL Brief on Learner-centred Teaching/Learning explores how certain learner-centred approaches may be adapted to improve student learning in various contexts.

April 2006, Vol. 9, No. 1 Print Ready ArticlePrint-Ready
Teaching Patient-centred Care in the Community
 
Dr Jeannette Lee, Dr Lee Kheng Hock & Associate Professor Adeline Seow
Department of Community, Occupational and Family Medicine
 
A physician is obligated to consider more than a diseased organ, more even than the whole man—he must view the man in his world.
Harvey Cushing

Rapid advances in technology and increasing specialisation in medicine are changing the way healthcare is delivered. Increasingly, there is a danger of an over-emphasis on the biomedical aspect of illness. This depersonalisation of health care has been recognised as a threat to the quality of healthcare systems throughout the world. A report from the Institute of Medicine points out that patients often must adapt to the customs and procedures of health care organisations that provide services with little regard to the patient's needs and preferences. In its recommendation on a framework for the National Health Care Quality Report, the Institute included patient-centredness as an essential component of quality care.1

Patient-centred care is a characteristic of the relationship between the doctor and the patient. It includes the patient's experience of care and the presence of an effective partnership between the doctor and patient. A prerequisite that the doctor needs to have is an understanding of the individual patient's social and physical environment and their effects on the patient's illness. Based on such an understanding, treatment plans should take into account and maximise the resources available in the patient's community. Figure 1 shows the characteristics of patient-centred care adapted from Bauman, Fardy & Harris (2003).

Learning to Appreciate the Patient's Context

Teaching the paradigm of patient-centred care to undergraduate medical students is a challenging undertaking. It is an area that is generally lacking in undergraduate medical education.2 Patient-centred care teaches more context than content. It requires real life experience in patient management. However, the traditional learning environment of medical students is the lecture theatres and teaching hospitals. These places offer little opportunities for students to observe and learn about the 'real' environment a patient returns to when he/she leaves the hospital. In this article, we briefly describe a module which attempts to provide opportunities for students to learn about patient-centred care, examine its pedagogical basis and reflect on some possibilities for enhancing its effectiveness.

Community Medicine Case Studies

“Community Medicine Case Studies” (CMCS) is an inter-disciplinary module which involves tutors from the Department of COFM and the medical departments in all the teaching hospitals students are posted to. Medical students spend most of their third year in fullday clinical rotations, which includes 8-week rotations through medical wards where a significant proportion of the patients they encounter have chronic conditions which require long-term care after discharge.

Patient-centred care

  • Explores the patient’s ‘cognitions’ (their knowledge, beliefs and expectations with respect to their disease and its management).

  • Explores social supports, family influences and physical environment in which the patient lives, which may influence his/her health and illness.

  • Involves the patient in the disease management plan, including behaviour change, and individualises patient education.

  • Works with teams of healthcare providers, community agencies and support groups.

Figure 1. Characteristics of patient-centred care

During their rotation to these units, each clinical group (of eight or nine students) will select one patient each. In addition to learning about the patient's medical condition and treatment, students conduct a detailed study of the patient's knowledge about the disease, family and home environment, as well as social and occupational backgrounds. The objective of the study is help students understand that the outcome of medical care does not only depend on what medication the doctor prescribes. When a patient leaves the hospital, there are many other factors that will eventually have an impact on how well the patient fares (see a hypothetical case study in Figure 2).

Experience-Reflect-Conceptualise

Experiential learning has been used to describe the acquisition of knowledge, skills and feelings in an immediate and relevant setting through a "direct encounter with the phenomena being studied rather than merely thinking...or considering the possibility of doing something about it."3 Kolb's (1984) model on experiential learning suggests that acquisition and internalisation of knowledge is aided by a cycle of experience-reflection-conceptualisation- experimentation/application. In keeping with this, a critical feature in CMCS is the home visit. The students and their tutors arrange for a convenient time to speak to the patient and his family members in their home environment. For some students, this may be their first time stepping into a 1-room HDB apartment in a disadvantaged neighbourhood. For others, it can be the first time students 'test' the route from the patient's flat to the MRT station to see if their wheelchair-bound patient has any chance of moving about independently. Yet for other students, it may be their sitting down with a patient's son, trying to understand why his mother has difficulties keeping to her follow-up appointments at the polyclinic, or how the family is helping her comply with special dietary requirements. By immersing themselves in the patient's world, even for just a short span of time, students experience something they cannot experience in the hospital wards.

At various stages in the module, each group of students prepares a presentation which is then critiqued by their classmates and tutors. At the end of four months, after students have carried out their own home visits, applied the principles learnt, and observed the progress of their patient, each student submits a write-up on his/her own patient. The most important function of the write-up is to allow the student to reflect on what he or she has learnt about patient management in the community.

The patient

Mr Chew, a 58 year-old Chinese man, turned up at the Emergency Department with a large, infected ulcer on his right foot. The patient is a bachelor who lives alone in an old two-room HDB flat. He works as a drinks stall assistant at a coffee shop in a housing estate. Although he regularly meets up with friends at the coffee shop he does not have any relatives or close friends he can rely on. He seldom cooks, and often buys his meals from the hawker stalls at the coffee shop where he works. He has a preference for fried foods. He drinks about three to four bottles of stout and smokes 15 cigarettes a day. He does not have the financial means to pay for his hospitalisation and medicines.

A worst-case scenario

One week and several blood tests later, the infection subsided and Mr Chew was discharged with follow-up visits scheduled at a polyclinic near his home. He was told briefly by the doctor that he had diabetes and was given medication. He was also advised to control his diet, reduce his alcohol intake and quit smoking. After just two visits to the polyclinic, Mr Chew's boss complained that these absences were disrupting his work. So, Mr Chew defaulted on his follow-up. After two weeks the ulcer got worse and he returned to the EMD. It was recommended that Mr Chew undergo a forefoot amputation.

A better scenario

During the admission the doctor spoke to Mr Chew about diabetes, its complications and management. The doctor also counselled him about quitting smoking. Mr Chew expressed concern that his boss would not give him time-off to visit the polyclinic for review and dressing of his ulcer. The doctor offered to call his boss to explain his condition and the need for follow-up. Luckily the boss agreed and even encouraged Mr Chew to attend the follow-up sessions.

The doctor also referred Mr Chew to a diabetes educator, social worker and dietician. The diabetes educator spent several sessions educating him about diabetes, its management and prevention of complications. She also asked another diabetic patient who recently had a foot amputated because of a non-healing and infected ulcer to talk to him about diabetes. The social worker assessed his financial status and referred him to the relevant authorities for financial assistance. The dietician spent time with him to assess his dietary habits and showed him the healthy food he can buy from the hawker stalls. She also advised him to reduce his alcohol intake.

His ulcer healed and during the subsequent visits to the polyclinic, the importance of regular follow-up and checks for complications of diabetes was reinforced by the doctors and nurses who reviewed him.

Mr Chew remains compliant in taking his medication and going for regular checkups. His diet has also since improved although he does indulge in char kuay teow once a week. Although he is still trying to gradually cut down the number of cigarettes he smokes, he has managed to reduce his alcohol intake to one bottle of stout a day.


Figure 2: Illustrative (hypothetical) case study: a patient with a foot ulcer due to diabetes mellitus

Reflecting: Can We Do More?

If patient-centredness is indeed an essential component of quality care, then the CMCS approach needs to be incorporated as an important part of medical education. For the approach to be effective, CMCS must extend beyond a single module to become an intrinsic part of medical students' approach to all patients they encounter in the hospital wards. However, before one can recommend that the CMCS approach is the way to go, a more rigorous evaluation is needed. To see if the module has achieved its objectives, we plan to adapt or develop valid instruments that can measure changes in attitudes and perspectives, such as the degree of patient-centred orientation. However, this is a challenging task that requires careful planning.

Meanwhile, we are encouraged by students' own reflections on their learning, some examples are quoted below:

  • "This case study has made me realise the importance of treating the patient and not his disease. It is indeed easy to prescribe a certain medication to treat a patient's problem but is this really enough? One must understand his financial difficulties, social concerns and family support. One must also adequately educate the patient.this task involves not only the doctor but other members of the healthcare profession as well. This case study has broadened my horizons, helped me to see beyond the clinic and hospital setting and allowed me to have a better and more complete understanding about patient management."

  • "I have learnt that it takes more than a patient's own efforts for recovery to take place effectively. The support of people around her and every little thing they do for her contribute to her well-being."

  • "It is immensely rewarding to speak to family members who are every bit as concerned about the patient's condition and discover that they are eager to help, and at the end of it, appreciate that their involvement has had a positive effect on the patient's outcome."

  • "Much has been learnt from this enriching experience of following-up a patient after his/her discharge from the hospital. The study shows me that patient management does not end at the hospital. In fact the most important part of long-term management is right in the patient's home."

References

Bauman, A.E.; Fardy, H.J. & Harris, P.G. (2003). 'Getting It Right: Why Bother With Patient-centred Care?' Medical Journal of Australia, Vol. 179, pp. 253-256.

Kolb, D.A. (1984). Experiential Learning: Experience as the Source of Learning and Development. New Jersey: Prentice-Hall.


1 Institute Of Medicine (2001). Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C.: The National Academies Press.

Back to the article

2 Institute Of Medicine (2003). Health Professions Education: A Bridge to Quality. Washington, D.C.: The National Academies Press The National Academies Press.

Back to the article

3 Smith, M.K. (2001). 'David A. Kolb on Experiential Learning'. The Encyclopaedia of Informal Education, http://www.infed.org/biblio/ b-explrn.htm (Last accessed: 29 November 2005).

 
 
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Inside this issue
‘Divide and Conquer’: Breaking a Big Class into Small Teams for Tutorials
   
Teaching Patient-centred Care in the Community
   
Case-based Tutorials
   
Learner-centred Practices and the Necessary Changes
   
The Philetics of Teaching
   
Teaching Students with Different Learning Styles
   
Student-led Tutorials