Engaging patient-centredness in an undergraduate medical curriculum

Archer, Elize (2016-12)

Thesis (DPhil)--Stellenbosch University, 2016.

Thesis

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-centeredness in 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-centeredness are 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-centeredness on 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-centeredness in 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-centeredness in 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-centeredness in modern medical practice.

AFRIKAANSE OPSOMMING : Daar is vele bewyse dat mediese studente se empatie met hul pasiënte en geneentheid tot pasiënt-gesentreerdheid afneem vandat hulle met hul mediese onderrig begin totdat hulle dit voltooi. Pasiënt-gesentreerdheid, ʼn benadering wat die pasiënt in die middelpunt van die konsultasie plaas en op die pasiënt fokus in plaas van op sy/haar siekte, word deesdae deur die meeste mediese skole ter wêreld geïdentifiseer as ʼn gewenste kernvaardigheid van hul graduandi. Dit is dus baie belangrik dat mediese skole pasiënt-gesentreerde waardes en gedrag in hul graduandi koester. Daar blyk egter nog steeds ʼn fokus te wees op die biomediese aspekte van pasiënte in die voorgraadse mediese kurrikula se leer- en onderrigpraktyke en teorie en dit het tot gevolg dat studente geneig is om sinies te raak en op die siektes van ‘n pasiënt te konsentreer, eerder as op ʼn volwaardige mens. Die verwagting dat dokters pasiënt-gesentreerd moet wees, het veroorsaak dat mediese kurrikula regoor die wêreld aandag begin gee het aan aspekte soos opleiding in kommunikasievaardighede, die insluiting van vakke van die humaniora, en plasings in longitudinale kliniese rotasies. Relevante literatuur dui aan dat, ten spyte van sekere van hierdie inisiatiewe, daar steeds ʼn tekort is aan pasiënt-gesentreerdheid in voorgraadse mediese studente teen die tyd wat hul gradueer. Hierdie situasie is kommerwekkend; daarom was dit belangrik om uit te vind wat die faktore is wat die leer en onderrig van pasiëntgesentreerdheid in voorgraadse kurrikula aanhelp of inhibeer. Die studie was dus daarop gemik om beter te verstaan wat die faktore is wat die leer en onderrig van voorgraadse mediese studente beïnvloed wat betref pasiënt-gesentreerdheid in ten minste een voorgraadse mediese studieprogram. ʼn Eksploratiewe programmatiese gevallestudie-ontwerp, gegrond in ʼn interpretatiewe kennisparadigma, is aanvaar as die toepaslikste vir die studie waaraan finalejaar mediese studente en hul dosente deelgeneem het. Observasies van kliniese leeraktiwiteite is gedoen tesame met die analise van die kurrikulumdokumente van die voorgraadse mediese (MB, ChB) program van die Universiteit Stellenbosch. Temas van betekenis is afgelei van die data deurdat komponente van Fishbein se Geïntegreerde Gedragsmodel (IM) gebruik is. Die bevindinge van die studie het aangetoon dat die volgende faktore ʼn rol speel in die student se leer van pasiënt-gesentreerdheid: agtergrond-eienskappe van studente en hul dosente, faktore ten opsigte van hul houding, aangeleerde vaardighede en kennis, subjektiewe norms (die verskuilde kurrikulum), studente se selfwerksaamheid, assessering van leer, en die omgewing of konteks waar pasiënt-gesentreerdheid geleer word. Daar is bevind dat twee faktore ʼn groot invloed op die leer van pasiënt-gesentreerdheid het, naamlik subjektiewe norms en assessering. Subjektiewe norms verwys na die kliniese leeromgewing waar die studente blootgestel word aan rolmodelle sowel as aan geleenthede waar hul pasiënt-gesentreerdheid op pasiënte kan beoefen. Laasgenoemde is baie belangrik in die proses waartydens student selfwerksaamheid ontwikkel, veral as dit gevolg word deur terugvoergeleenthede van kliniese dosente sowel as kanse om te reflekteer op die terugvoer in ʼn poging om nuwe begrippe en nuwe praktyke aan te leer. Assessering is ook uitgewys as ʼn belangrike faktor wat studente se leer rig, aangesien die nie-assessering van pasiënt-gesentreerdheid in baie departemente ʼn boodskap uitstuur dat die biomediese komponent van pasiëntesorg die belangrikste is. Die studie verskaf nuwe insigte in die leer en onderrig van pasiënt-gesentreerdheid in ʼn voorgraadse kurrikulum en stel ʼn aangepaste weergawe van die IM-model voor. Dit dra ook daartoe by dat die faktore wat die leer van pasiënt-gesentreerdheid aanhelp of inhibeer beter verstaan word. Die studie wys verder op die behoefte van ʼn gesamentlik beplande, goed gekoördineerde benadering tot die formele, informele en verskuilde kurrikulumruimtes in een MB,ChB-program saam met goed opgeleide kliniese dosente wat die belangrikheid van die toepassing van pasiënt-gesentreerdheid in moderne mediese praktyk verstaan.

Please refer to this item in SUNScholar by using the following persistent URL: http://hdl.handle.net/10019.1/100338
This item appears in the following collections: