Engaging patient-centredness in an undergraduate medical curriculum

[摘要] ENGLISH SUMMARY : There is ample evidence that medical students' empathy with their patients and their inclination towards patient-centeredness decline from the time they enter medical school until they complete their medical education. Patient-centeredness , an approach that puts the patient at the center of the consultation, thus focusing on patients instead of on their disease, has been identified by most medical schools worldwide as a desired core competence of their graduates. It thus seems vital that medical schools foster patient-centered values and behaviour in their graduates. However, there seems to be a focus on the biomedical aspects of patients in the practice and theory of teaching and learning in undergraduate medical curricula; therefore, students tend to become cynical and soon tend to focus on the disease of their patients. The expectation that doctors should be patient-centered has thus caused medical curriculum planners worldwide to pay attention to aspects such as communication skills training, the inclusion of subjects from the humanities and placements of students in longitudinal clerkships. Relevant literature reports that despite some of these initiatives, undergraduate medical students often still display a lack of patient- centeredness by the time they graduate. This state of affairs is reason for concern and it was thus deemed important to explore the possible factors that enable or inhibit the teaching and learning of patient-centerednessin undergraduate medical curricula. The aim of this study was therefore to gain a better understanding of the factors that influence the learning of patient- centeredness in at least one undergraduate medical programme. An explorative programmatic case study design, rooted in an interpretive knowledge paradigm, was considered most appropriate for the study in which final-year medical students and their lecturers participated. Observations of clinical teaching activities were also conducted and curriculum documents of the undergraduate medical (MB, ChB) curriculum at Stellenbosch University were analyzed. Themes of meaning were deduced from the data by employing components of an integrated behaviour model (IM). The findings of the study revealed that the following factors play a role in students' learning about patient-centeredness : background characteristics of students and their lecturers, attitudinal factors, acquired skills and knowledge, subjective norms (the hidden curriculum), student self-efficacy, assessment of learning, and the environment or context within which patient- centeredness is taught and learnt. Two factors that have proved to have a highly significant effect on the learning of patient-centerednessare subjective norms and assessment. Subjective norms refer to the clinical learning environment where the students are exposed to role models, as well as opportunities to practice patient-centerednesson real patients. The latter is highly important in the process by which students develop self-efficacy, especially if followed by opportunities for feedback from a clinician teacher as well as opportunities for reflection on such feedback in order to discover new meanings and learn new practices. Assessment is recognized as an important factor that drives student learning, and the lack of assessment of patient-centerednessin many departments renders a message strongly favouring the biomedical component of patient care. The study provides new insights into the teaching and learning of patient-centerednessin an undergraduate medical curriculum by suggesting an adapted version of Fischbein's IM and an improved understanding of enablers and disablers in the teaching and learning of patient-centeredness . This study further points to a need for a jointly planned and well-coordinated approach to the formal, informal and hidden curriculum spaces within one MB, ChB programme with well-trained clinician teachers/faculty members who understand the importance and application of patient-centerednessin modern medical practice.

[发布机构] Stellenbosch University