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