What sort of patient? Lay clinical educators and expert patients
In terms of clinical education, these terms refer to ‘real patients’ who are trained to deliver teaching sessions, acting as both patient and teacher. The idea of the expert patient is also enshrined in the wider patient involvement agenda: the ‘expert patient initiative was … part of the government’s commitment to place patients at the heart of healthcare’ (Hardy, 2004, p. 2). It was primarily targeted at patients with long-term conditions to help them ‘become key decision-makers in their own care’ (Hardy, 2004, p. 2). Expert patients are now widely used in health professions education. Their role is that of a patient (usually with a long-term condition with stable clinical signs, such as a heart murmur or stroke signs) who agrees to participate in teaching and learning. As well as having ‘signs’ they are also seen as ‘experts’ in their own condition and are often briefed or trained so as to facilitate student or learner learning. In other health professions, patients or service users are involved in a wide range of activities such as speaking with learners about their condition and experience, for example mental health service users.
There are a number of advantages in not involving patients who are primarily being treated in the clinical setting for clinical care in teaching. Patient educators have the benefits of being:
- motivated individuals with an interest in health professions training – patients are commonly recruited from local populations
- real patients with real clinical histories and signs
- able to give structured feedback to learners and teachers from the patient’s perspective, such as the pressure of the hands, manipulation or the way in which a history was taken.
Involving real patients need not be as formal as classroom-based activities. ‘Lunch and learn’ was set up where patients with long-term neurological conditions are invited to a lunchtime session with students to simply talk about living with their condition on a day-to-day basis. This informal approach has raised students’ awareness about stroke, multiple sclerosis and other conditions, helped them talk more openly and informally with patients and see them in a non-clinical setting; and patients enjoy coming to the university for an interesting lunchtime experience.
Expert patients are also helpful in overcoming educational challenges involving intimate examinations. For example, female patient educators (e.g. Gynaecology Teaching Associates – GTAs) are commonly used to teach gynaecological or breast examination. They can also help to free up clinical tutors as, once trained, patient educators need little assistance in running sessions. If they are well-trained they can also be used in clinical assessments (standardised and objective). In North America for example, patient educators are commonly used in Objective Structured Clinical Examinations (OSCEs) with no other examiner.
Expert patients or patient educators can be drawn from many settings, even where concerns might be expressed about the potential risk to patients, such as those who are terminally ill or with mental health problems. Lefroy (2008, p. 14) describes how she worked with Ken (a patient educator), who was terminally ill, and identifies the following ‘hints’ for clinical teachers:
- Suitable patients are those whose eyes light up when you ask them to talk to students
- Do some lesson planning with the patient (so that they own the session)
- Prepare the patient to feel challenged
- Prepare the students to meet a person with cancer (something like: ‘be open but be sensitive’)
- Be ready to deal with student reactions – this can be a powerful experience
- Debrief your patient to see whether there is anything that he or she needs to discuss
Sometimes, however, it is neither possible nor appropriate to involve real patients in learning. Next we describe some alternative strategies.