Candid insights and overlooked facets: what medical students write about patient-centeredness in diaries on longitudinal patient contacts.

Despite students' exposure to patient-centered care principles, their dedication to patient-centeredness often experiences a wane throughout their academic journey. The process of learning patient-centeredness is complex and not yet fully understood. Therefore, in our study, we sought to explore what aspects of patient-centeredness students spontaneously document in their diaries during interactions with actual patients. This investigation will help to identify gaps in the current educational practices and better prepare future clinicians to deliver patient-centered healthcare. We analyzed 92 diaries of 28 third-year undergraduate medical students at UMC Utrecht in the Netherlands who participated in an educational intervention, following four patients each as companions over a two-year period early in their clerkships. We conducted thematic analysis, using inductive and deductive coding, within a social-constructionist paradigm. We identified four key themes: communication, the person behind the patient, collaboration and organization in healthcare, and students' professional development. Within these themes, we observed that students spontaneously documented 9 of 15 dimensions of patient-centeredness as outlined in the model of Scholl : 'clinician-patient communication', 'patient as unique person', 'biopsychological perspective', 'essential characteristics of the clinician', 'clinician-patient relationship', 'involvement of family and friends', 'patient-information', 'emotional support' and 'coordination and continuity of care' (mainly principles of patient-centeredness). Conversely, we noted that students underreported six other dimensions (enablers and activities): 'access to care', 'integration of medical and non-medical care', 'teamwork and teambuilding', 'patient involvement in care', 'patient empowerment' and 'physical support'. Throughout their longitudinal journey of following patients as non-medical companions, students spontaneously documented some aspects of patient-centeredness in their diaries. Additionally, students reflected on their own professional development. Our findings suggest that incorporating education on the broadness of the concept of patient-centeredness coupled with enhanced guidance, could potentially enable students to learn about the complete spectrum of patient-centeredness within their medical education.

Learning patient-centredness with simulated/standardized patients: A realist review: BEME Guide No. 68.

BACKGROUND: Given the positive outcomes of patient-centred care on health outcomes, future doctors should learn how to deliver patient-centred care. The literature describes a wide variety of educational interventions with standardized patients (SPs) that focus on learning patient-centredness. However, it is unclear which mechanisms are responsible for learning patient-centredness when applying educational interventions with SPs. OBJECTIVE: This study aims to clarify how healthcare learners and professionals learn patient-centredness through interventions involving SPs in different healthcare educational contexts. METHODS: A realist approach was used to focus on what works, for whom, in what circumstances, in what respect and why. Databases were searched through 2019. Nineteen papers were included for analysis. Through inductive and deductive coding, CIC'MO configurations were identified to build partial program theories. These CIC'MOs describe how Interventions with SPs change the Context (C→C') such that Mechanisms (M) are triggered that are expected to foster patient-centredness as Outcome. RESULTS: Interventions with SPs create three contexts which are 'a safe learning environment,' 'reflective practice,' and 'enabling people to learn together.' These contexts trigger the following seven mechanisms: feeling confident, feeling a sense of comfort, feeling safe, self-reflection, awareness, comparing & contrasting perspectives, combining and broadening perspectives. A tentative final program theory with mechanisms belonging to three main learning components (cognitive, regulative metacognitive and affective) is proposed: Interventions with SPs create a safe learning environment (C') in which learners gain feelings of confidence, comfort and safety (affective M). This safe learning environment enables two other mutual related contexts in which learners learn together (C'), through comparing & contrasting, combining and broadening their perspectives (cognitive M) and in which reflective practice (C') facilitates self-reflection and awareness (metacognitive M) in order to learn patient-centeredness. CONCLUSION: These insights offer educators ways to deliberately use interventions with SPs that trigger the described mechanisms for learning patient-centredness.

Fostering patient-centredness by following patients outside the clinical setting: an interview study.

BACKGROUND: Patient-centredness is considered a core competency for health professionals. To support faculty in designing courses focused on patient-centredness, an understanding of how educational interventions lead to patient-centredness is required. This study aims to show how learning mechanisms, which potentially contribute to patient-centredness, are triggered. METHODS: Thirty-five third-year medical students at the UMC Utrecht followed four different patients for two years. The intervention took place in an out-of-hospital setting. Students visited patients in their home circumstances and accompanied them to clinical events. Twelve students were interviewed. The realist approach was used to construct configurations which relate components of the intervention to the context and learning mechanisms. RESULTS: Following patients in their home circumstances for a prolonged period supported the development of meaningful relationships between students and patients and provided continuity. In the context of a meaningful relationship and continuity, mechanisms contributing to learning patient-centredness were triggered. The most important learning mechanisms found in this study were: reflecting, contextualising disease in a real persons' life, broadening perspectives and engaging with the patients. CONCLUSIONS: Learning mechanisms are triggered by continuity and by meaningful student-patient relationships. These can be enhanced by an out-of-hospital setting and longitudinal contact. Thus, a relationship between students and patients is an important enabler for the development of patient-centredness.

Learning from patients about patient-centredness: A realist review: BEME Guide No. 60.

Background: Patient-centred work is an essential part of contemporary medicine. Literature shows that educational interventions contribute to developing patient-centredness, but there is a lack of insight into the associated learning processes.Objective: Through reviewing articles about educational interventions involving patients, we aspire to develop a program theory that describes the processes through which the educational interventions are expected to result in change. The processes will clarify contextual elements (called contexts) and mechanisms connected to learning patient-centredness.Methods: In our realist review, an initial, rough program theory was generated during the scoping phase, we searched for relevant articles in PubMed, PsycINFO, ERIC, CINAHL and Embase for all years before and through 2016. We included observational studies, case reports, interviews, and experimental studies in which the participants were students, residents, doctors, nurses or dentists. The relevance and rigour of the studies were taken into account during analysis. With deductive as well as inductive coding, we extended the rough program theory.Results: In our review, we classified five different contexts which affect how upcoming professionals learn patient-centredness. These aspects are influenced through components in the intervention(s) related to the learner, the teacher, and the patient. We placed the mechanisms together in four clusters - comparing and combining as well as broadening perspectives, developing narratives and engagement with patients, self-actualisation, and socialisation - to show how the development of (dimensions of) patient-centredness occurs. Three partial-program-theories (that together constituting a whole program theory) were developed, which show how different components of interventions within certain contexts will evoke mechanisms that contribute to patient-centredness.Translation into daily practice: These theories may help us better understand how the roles of patients, learners and teachers interact with contexts such as the kind of knowledge that is considered legitimate or insight in the whole illness trajectory. Our partial program theories open up potential areas for future research and interventions that may benefit learners, teachers, and patients.