Patients teach students: partners in arthritis education

Graham D Hendry,1 Leslie Schrieber2 & Deborah Bryce3

Context A large metropolitan teaching hospital within

The Northern Clinical School, University of Sydney.

Objective To assess whether students taught by trained

patients (Patient Partners) acquire the same levels of

competence in musculoskeletal examination skills for

arthritis as students taught by Consultant Rheum-

atologists.

Subjects Year four medical students in a six-year

Undergraduate Medical Programme.

Method Students randomized to eight tutorial groups

were taught musculoskeletal examination skills in a

75±90 minute tutorial. Four groups were taught by

Consultants with an untrained patient present and four

groups were taught by Patient Partners.

Results Students' mean self-ratings of skill before and

after their tutorial were summed. For both groups, self-

ratings before the tutorial were similar. After the tuto-

rial both groups showed substantial gains in levels of

skill. Patient Partners' ratings of students' taught by

either Consultants or Partners were comparable.

Conclusions Patient Partners are at least equal to

Consultant Rheumatologists in the teaching of

musculoskeletal examination techniques for arthritis.

Keywords Rheumatology, *education; undergraduate

medical education*; Australia, *physician±patient

relations; rheumatoid arthritis; self-concept; teaching,

methods; physical examination, methods; *patient

participation.

Medical Education 1999;33:674±677

Introduction

The acquisition of speci®c skills is an important part of

students' overall experience in the clinical years of the

six-year Undergraduate Medical Programme at the

University of Sydney. During the fourth year, students

complete several specialty `rotations' or terms. In their

Rheumatology rotation students are traditionally taught

musculoskeletal examination skills by Consultant

Rheumatologists. A typical tutorial involves the con-

sultant introducing the patient to students, explaining

aspects of the patient's disease and demonstrating how

to perform a musculoskeletal examination. The tutor

then encourages students to conduct a physical exam-

ination. Students often receive feedback about their

performance from the doctor and no feedback from the

patient. Patients are not `active' during the tutorial in

terms of guiding students in their learning. In one

sense, a patient is like a `teaching aid'.

In 1997 a programme involving patients in the teach-

ing of upper limb musculoskeletal examination skills was

tried for the ®rst time in the Rheumatology rotation at the

University of Sydney's Northern Clinical School. The

Patient Partner programme, originally developed at the

University of Texas,1 involves patients with rheumatoid

arthritis or osteoarthritis who want to use their experi-

ence of the disease to teach doctors and medical students.

Attributes of Patient Partners include intelligence, good

interpersonal skills and a positive self-concept. Partners

also possess `classic' symptoms of their particular type of

rheumatic disease and are willing to learn more about

their disease through structured training.

The Partners in this trial attended a three day

intensive workshop in 1997 conducted by a panel of

trained Texan Patient Partners who were taught by

Rheumatologists at the University of Texas, Dallas.

Areas covered in the workshop included surface anat-

omy, recognition of rheumatoid and osteoarthritic

deformities, physical examination skills and techniques

of assessment.2 The Australian Partners were also

Departments in which work was carried out: 1Dept of Educational

Development and Evaluation, A27, Faculty of Medicine, University of

Sydney, NSW, 2006, Australia; 2Dept of Rheumatology, Royal North

Shore Hospital, St. Leonards, NSW, 2065, Australia; and 3Dept of

Anatomy & Histology, F13, Faculty of Medicine, University of Syd-

ney, NSW, 2006, Australia

Correspondence: Dr Graham Hendry, Dept of Educational Develop-

ment and Evaluation A27, Faculty of Medicine, University of Sydney,

NSW 2006, Australia

The patient in medical education

674 Ó Blackwell Science Ltd MEDICAL EDUCATION 1999;33:674±677

experienced in giving feedback and detailed information

about their disease process to health care professionals.

A Patient Partner tutorial differs from a traditional

tutorial in that the doctor is not present; the patient

describes aspects of his or her disease and encourages

students to conduct an examination. The Patient

Partner provides guidance and feedback to students

about their performance and plays an active role in

students' learning.

In a previous evaluation of the Patient Partner

programme,2 statistically signi®cant gains were found in

students' knowledge of rheumatoid arthritis, their con-

®dence in performing an examination, their ability to

recognize relevant clinical signs and their attitudes

regarding psychosocial aspects of arthritis. However, the

study did not have a control group of students. In a

study involving internal medicine residents in a six-week

rheumatology rotation, residents taught by a Patient

Partner made highly signi®cant gains in competence

compared to residents who received standard instruc-

tion.3 In the current evaluation, we aimed to assess

whether students taught by Patient Partners acquired

the same levels of competence in musculoskeletal

examination skills for arthritis as students taught by

Consultants. We also sought to measure students' and

Partners' perceptions of their experience in tutorials.

Method

Year four Undergraduate students in their Rheumato-

logy rotation at the Northern Clinical School were

randomized by lot to eight tutorial groups, each com-

prising 7±8 students. Groups were taught musculo-

skeletal examination skills in small group tutorials. Four

groups were taught by Consultants with an untrained

patient present and four groups were taught by Patient

Partners. All tutorials lasted approximately 80 min.

Students (N � 41) completed a 34 item self-rating

form on their level of competence in examination skills

for arthritis immediately prior to the tutorial. Students

(N � 36) completed the same form 11 days after the

tutorial. Items consisted of standard skills to be taught

by Patient Partners and Consultants and were grouped

under the following headings: Wrist, Hand, Knee,

Ankle and Foot. Students rated their level of compe-

tence on a four point scale that comprised `Have never

seen', `Have observed only', `Have attempted' and

`Could perform alone''.

In addition, samples of students were randomly

selected by lot from the tutorial groups taught by either

Consultants or Partners. These students (N � 24)

were invited to participate in an individual 20 minute

`formative assessment' (a practice assessment that does

not have any affect on students' progress through a

course4) for wrist and hand examination conducted by

Patient Partners 13 days after the tutorial. One student

subsequently did not attend. The size of this sample

was restricted by the availability of Patient Partners and

number of assessments that they could conduct during

a morning period as well as students' timetable com-

mitments. Partners were blinded as to whether students

had been taught by Consultants or Patient Partners. At

the end of the formative assessment Partners rated

students on their level of competence using a form

containing items 1 through 14 from the self-rating form

described above and a three point scale that consisted

of `Did not attempt', `Attempted but needs further

development' and `Satisfactory'.

Students (N � 12) from the tutorial groups taught by

Consultants and Partners volunteered to participate in

focus groups following the formative assessment. Patient

Partners (N � 4) also participated in a focus group at

the end of the trial. A focus group is an open discussion

of participant's perceptions concerning a certain issue or

area of interest, guided by a moderator or group facili-

tator. The key feature of focus groups is that the mod-

erator uses participants' responses to focus the group's

discussion on issues that emerge. Emphasis is placed on

creating a relaxed atmosphere so that all participants feel

comfortable about sharing their views.5,6

We used the Statistical Package for the Social Sci-

ences (SPSS) for Windows, Release 7á5.1, to calculate

means and perform independent samples Mann±

Whitney U-tests. Focus groups were audiotape

recorded using a Walkman-type cassette recorder and

powered microphone and recordings were later tran-

scribed. Two of us (DB and GH) repeatedly read

through each transcript and independently identi®ed

common issues. These issues are reported below.

Results

Students' mean self-ratings of level of examination skill

before and after their tutorial were summed. The

summed means (from a possible total of 136) for the

Partner group and the Consultant group before and

after the tutorial are shown in Table 1.

Both groups showed substantial gains in self-rated

levels of competence. An independent groups Mann±

Whitney U-test revealed that the Partner group rated

themselves signi®cantly higher than the Consultant

group after their tutorial for one skill only: (Knee)

Palpate: Suprapatellar pouch, Infrapatellar bursa, Pre-

patellar bursa, Anserine bursa (P < 0á013).

Patient Partners' mean ratings for students' levels of

competence in wrist and hand examination at the end

Ó Blackwell Science Ltd MEDICAL EDUCATION 1999;33:674±677

Patients teach students · G D Hendry, L Schrieber & D Bryce 675

of the formative assessment were also summed. The

summed means (from a possible total of 42) for the

Patient Partner sample (N � 11) and the Consultant

sample (N � 12) were 36á18 and 32á40, respectively.

These data are consistent with the trend in students'

self-ratings. However, as rated by Patient Partners,

students taught by Partners showed no signi®cantly

higher levels of skill than those taught by Consultants.

Feedback collected in focus groups was that students

valued the Patient Partner tutorials because the Partner

could describe what students should be perceiving. The

students felt less `intimidated' than in a traditional

tutorial and thought they had more time to develop

con®dence in their sense of touch. The tutorial was

more `personal' and interactive in that students had

greater responsibility for establishing a rapport with the

patient.

Students thought that Partners were systematic and

thorough in the way that they led students through each

examination of the wrist, hand, etc. Students appreciat-

ed the fact that Partners' descriptions and demonstra-

tions began at a basic level and covered surface

anatomy; they thought that some doctors often pitched

their teaching too high. They felt that the Partners were

motivated ± `they were all really keen to teach us' ± and

were comfortable with being examined by several stu-

dents and with students taking their time to practise a

skill. Partners could give students immediate and spe-

ci®c feedback about their performance, for example,

they could say `you need to press harder' or `you're

pressing too hard'. Partners also made every effort to

allow each person to conduct each joint examination.

Some students felt that Partners asked them fewer

questions about the importance of certain signs than

doctors; these questions help students to improve their

learning. Some students also thought that doctors gave

more explanations of the theory underlying examina-

tion skills. Other students, however, felt that the main

purpose of the Partner tutorial was to develop their

clinical skills; they suggested that underlying theory

could be acquired in lectures and/or through textbooks.

For example, one student commented:

`The point [of the tutorial] is to learn how to examine . . .

to actually be able to feel a nodule, feel a subluxation, and

not to learn the theory behind the subluxation which you

[can] get from a lecture'

Students were concerned about the size of Partner

tutorials and suggested that a group size of six or less

would be optimal. It was suggested that a mix of tra-

ditional and Partner tutorials in students' Rheumato-

logy rotation would be most useful for their learning. In

particular, in traditional tutorials doctors are able to

highlight important and unusual features of a disease.

Overall, students valued the Partner tutorials highly

and thought they were an effective learning experience

particularly in terms of learning examination skills.

The focus group feedback from Patient Partners was

that medical students were very willing to learn. Part-

ners felt more con®dent and enjoyed teaching students.

They thought their training had prepared them well. It

was suggested that the size of tutorial groups should be

reduced from eight to six so that Partners could give

each student more time to perform an examination.

Partners felt useful and that they had greater control

over the examination and could give feedback to stu-

dents about a procedure. As a patient in a traditional

tutorial they often did not feel that they could

intervene.

Discussion

Our results show a trend in overall level of examination

skill in favour of students taught by Patient Partners, as

measured by both self- and Partners' ratings. This

suggests that Patient Partners are at least equal to

Consultant Rheumatologists in the teaching of

musculoskeletal examination techniques for arthritis.

Student feedback stated that Patient Partner tutorials

were an effective learning experience particularly in

terms of enhancing examination skills. The small

number of tutors and students involved in this trial

limits the extent to which our results can be generali-

zed. One of the limitations of this study was that,

because of logistic reasons, students were not assessed

by Consultants as well as by Patient Partners, which

may have introduced a possible source of bias.

The advantages of Patient Partner tutorials are that

tutorials begin at an introductory level and include

surface anatomy; Partners are more systematic in the

way that they lead students through each examination;

Partners provide immediate feedback and tutorials are

more interactive and relaxed. The advantages of Con-

sultant-led tutorials are that Consultants ask more

questions about the signi®cance of certain signs,

Table 1 Summed mean students' self-ratings of level of

examination skill before and after their tutorial

Before tutorial After tutorial

N Summed mean N Summed mean

Partner group 19 83á6 18 117á5Consultant group 22 81á44 18 111á33

Patients teach students · G D Hendry, L Schrieber & D Bryce676

Ó Blackwell Science Ltd MEDICAL EDUCATION 1999;33:674±677

provide more explanations of the theory underlying

examination skills and highlight important and unusual

features of the disease.

This trial also suggests that trained Patient Partners

are effective as both teachers and assessors of students'

examination skills. Participating students commented

on the usefulness for their learning of the individual

formative assessment during the trial. They did not feel

as pressured as they often do in traditional tutorials

making other students wait and with a doctor looking on.

Feedback from focus groups in this trial suggests that

the educational bene®t of Patient Partner tutorials

decreases with large group sizes. We believe that a

programme involving tutorials of six students or less

with up to six trained Patient Partners and 200 students

is logistically possible. A second Patient Partner pro-

gramme is planned for implementation in the problem-

based Graduate Medical Programme that replaced the

Undergraduate Medical programme at the University

of Sydney in 1997. The promise of patient teaching in

arthritis education may also extend to patients as edu-

cators in relation to knowledge, skills and/or attitudes in

other areas of medical education.

Acknowledgements

We are especially grateful to the Patient Partners,

Therese Stewart, Lyn Kearnes, Lynette Denman and

Angela Thompson, Consultant Rheumatologists and

Staff at The Northern Clinical School for their contri-

bution. We thank SEARLE for their ongoing support of

the Patient Partner programme.

References

1 Gruppen LD, Branch VK, Laing TJ. The use of trained patient

educators with rheumatoid arthritis to teach medical students.

Arthritis Care Res 1996;9:302±8.

2 Lipsky PE, Branch VK, Wortham H, Powell L, Caldwell B,

Casper D. Arthritis Educator Training Manual for the Musculo-

skeletal Exam. Dallas: The University of Texas Southwestern

Medical Centre at Dallas, 1994.

3 Graves G, Hanczyc M, Klusas Branch V, Lipsky PE. Positive

impact of an intervention by arthritis educators on musculo-

skeletal examination skills of internal medicine residents.

Arthritis Res 1997;40:S70.

4 Sadler DR. Formative assessment and the design of instruc-

tional systems. Instructional Sci 1989;18:119±44.

5 Folch-Lyon E, Trost JF. Conducting focus group sessions.

Studies Family Planning 1981;12:443±9.

6 Lockyer J, Simpson E, Toews J, Becker WJ. Use of focus

groups from different disciplines to identify clinical manage-

ment and educational issues. Teaching Learning Med

1996;8:223±6.

Received 24 June 1998; editorial comments to authors 28 August

1998; accepted for publication 10 December 1998

Patients teach students · G D Hendry, L Schrieber & D Bryce 677

Ó Blackwell Science Ltd MEDICAL EDUCATION 1999;33:674±677