Patients in general practice are generally well cared for in their encounters with medical students. But what exactly is the patient's role in medical education?
In this edition of the Journal of the Norwegian Medical Association, Skonnord et al. publish the results of an extensive survey on patients' experiences with medical students in general practice (1). The feedback is largely reassuring: most patients enjoyed meeting the students. They reported feeling safe during the consultation and well cared for.
Patients with previous experience of students were more positive than those without, suggesting that positive encounters reinforce the willingness to participate in student training at a later date. Many felt they were listened to more attentively and examined more thoroughly when students were involved.
The survey was conducted in the waiting rooms of general practices affiliated with the medical schools at the University of Oslo and the University of Bergen. Over half of the invited patients declined to participate or did not respond for other reasons. The generally positive results should therefore be interpreted in light of the possibility that non-respondents may have had a more negative attitude than those who responded.
Some patients felt more uneasy about consultations with students than others. This was particularly the case for patients with mental health issues and those from countries outside the Nordic region. A small proportion reported negative experiences when students were present during a consultation, and general practitioners (GPs) supervising students should therefore be mindful of vulnerable patients and sensitive situations.
About a quarter of the patients found it difficult to decline a student's participation, both when the GP was present and when the student conducted the consultation alone. This challenge represents a fundamental dilemma associated with students in clinical practice: while it is important for medical education to be a natural and integral part of health care, it is also essential that patients feel they have genuine autonomy in their encounters with students and in relation to the healthcare institutions' educational responsibilities.
Patients are inherently vulnerable. They come seeking health care, not to serve as a 'case' for medical education
At the same time, we must have zero tolerance if patients refuse students on the basis of racist or other discriminatory attitudes. We live in a diverse society, and everyone has a responsibility to help create an inclusive learning environment (2). Different considerations must be weighed and balanced, and education in general practice is more complex than simply 'placing' students in a GP's office (3).
Patients are inherently vulnerable. They come seeking health care, not to serve as a 'case' for medical education. They can therefore be uncertain or caught off guard when the purpose of the consultation is changed or expanded.
Students, for their part, are inexperienced in the doctor role and can be overwhelmed by the level of trust and authority that comes with the white coat and introducing themselves as a medical student. Many are understandably uncertain during their first patient encounters. Medical education is an ongoing process of encountering new people, situations and information, where a key objective is learning to manage uncertainty (4, 5).
Clinical supervisors have to manage a challenging learning environment while simultaneously ensuring that patients receive safe and appropriate care. They typically combine the role of educator with a busy clinical workload and rarely have time for pedagogical development. As someone who regularly debriefs medical students after their first placement in general practice, I wish to commend the many clinical supervisors who impressively master this delicate balancing act.
It is a privilege to teach students who excitedly describe their first encounters with patients and professional role models. However, students' feedback varies considerably. This can partly be attributed to the diverse nature of general practice, but it also reflects limitations in terms of time, dedication and expertise. While most students have engaging patient encounters and welcoming supervisors, some are relegated to the role of passive observer without even being introduced to the patient. Others describe clinical supervisors who appear more concerned with billing systems than with supporting patients and students. This highlights the need for a more robust quality assurance system for clinical placements.
With an increasing number of students, pressure on the health service and national requirements for professional relevance (6), it is particularly important to evaluate and further develop clinical placement models for medical students. Skonnord et al.'s article is an important contribution to the evidence base as it maps the patient perspective, with valuable assistance from students in clinical placement (1).
Many students report transformative patient encounters – not when they are trying to be efficient GPs, but when they have the time and space to listen and allow patients to share their thoughts and experiences
An interesting question is whether we can make greater use of the opportunities offered by this unique learning environment. Many students report transformative patient encounters – not when they are trying to be efficient GPs, but when they have the time and space to listen and allow patients to share their thoughts and experiences. In doing so, patients take on an active role in the learning situation. They are no longer merely a 'case', but conveyors of experiential knowledge to the country's future doctors. This gives substance and meaning to a situation that might otherwise feel uncertain or intrusive.
Medical students have time to listen to patients, which adds value to busy general practices. I therefore encourage general practice and other clinical disciplines to systematically explore, evaluate and, above all, share methods for the active involvement of patients in clinical practice (7).