Family medicine residents’ perspectives about patient partners in teaching participation in their training: A retrospective case study using a mixed-method explanatory sequential design

doi:10.21203/rs.3.rs-3515949/v1

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Research Article

Family medicine residents’ perspectives about patient partners in teaching participation in their training: A retrospective case study using a mixed-method explanatory sequential design

https://doi.org/10.21203/rs.3.rs-3515949/v1

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Objective: To explore the perspective of family medicine residents (FMRs) about patient partners in teaching participation in the practice-based learning program (PBLP) offered in university family medicine groups (U-FMG).

Participants and methods: The study was carried out among first- and second-year FMRs who completed their doctorate/externship in Quebec and attended the PBLP workshop involving a patient partner in teaching from U-FMG Notre-Dame. FMRs completed a questionnaire at the end of the PBLP workshop, and quantitative data were analyzed descriptively. Then, a focus group was conducted with some of these FRMs. The results were analyzed by two co-coders using DedooseÒ software.

Results: All FRMs (n=16) completed the questionnaire, and 4 FRMs participated in the focus group. The majority of FRMs mentioned having improved their knowledge of care offered in partnership with patients after the workshop but not their understanding of patients' rights. Two major themes emerged from the analysis: 1) knowledge and skills sought and 2) factors influencing the partnership with the patient partner in teaching.

Conclusion: The contribution of patient partners in teaching to the training of FRMs is promising and could be evaluated more extensively to improve the quality of training. The FRMs raised several avenues for improvement.

Patient partner in teaching

University-family medicine groups

Quality improvement initiative

Medical education

Mixed-method study

The mission of University Family Medicine Groups (U-FMG) is to train family medicine residents (FRMs) to provide exemplary integrated health care and primary care services in interprofessional collaboration.¹ Involving patients as members of the teaching team is an educational innovation that is increasingly seen as essential for the education of future healthcare providers and has greatly evolved since the 1970s.^2–5 Some programs now involve patients as teachers/trainers to train future physicians.^6,7 The University of Montreal has implemented a training continuum on partnerships in care and services involving patients as trainers since 2011.⁷ Anchored in the Montreal Model,⁸ this training continuum brings together students from 13 health and social sciences programs, including medical students. It is spread over the first three years of professional training, totaling 45 hours of training. Early exposure to the concept of partnership during students' initial training will help them apply the concepts during their clinical training and become future agents of change in the health and social services network.⁹

Context of the U-FMG Notre-Dame and the practice-based learning program workshop

The U-FMG Notre-Dame welcomes between 10 and 12 FRMs each year. As part of their clinical training, FRMs participate in practice-based learning program (PBLP) workshops. PBLP workshops enable FMRs to learn in small groups, facilitated by a team of professional teachers.^10,11 The U-FMG Notre-Dame already involves patient partners in teaching in co-facilitating weekly mental health workshops with a professional from the U-FMG and a psychiatric physician, as well as workshops on care relationships and medical communication. Although these workshops are currently being evaluated, the FMRs' perspective has never been explored, and patient partners in teaching have never been involved in PBLP workshops.

In August 2022, the U-FMG Notre-Dame attempted to innovate its teaching method by involving a patient partner in teaching in a PBLP workshop to improve the quality of FMRs' training in chronic obstructive pulmonary disease (COPD). The teaching team consisted of two teaching professionals (a family physician and a clinical nurse) practicing at the U-FMG Notre-Dame, two guest professionals practicing in the community (a pharmacist and a nutritionist) and the patient partner in teaching. The pharmacist was responsible for presenting a capsule during the workshop, and the nutritionist was invited as an observer. The patient partner in teaching was recruited by the family medicine teacher based on his life experience with COPD. The patient partner in teaching and the two guest professionals contributed voluntarily to this PBLP workshop. The patient partner in teaching was remunerated according to the terms described by the Center of Excellence on Partnership with Patients and the Public.

Preworkshop preparation

Six months before the workshop, the FMRs received the program of the PBLP workshop offered at the U-FMG, presenting the themes established and the documents needed to prepare for the workshops. One to two FMRs were notified 4 to 8 weeks before the workshop of their responsibility to present a synthesis of the theme studied at the PBLP workshop.

The patient partner was trained for his role as teacher in three stages. First, the family medicine teacher organized a one-hour virtual meeting with the patient partner in teaching to explain the initiative to involve a patient partner in the PBLP workshop, to clarify his role in the PBLP workshop and the guidelines for his involvement and to validate his interest in getting involved. Second, the patient partner in teaching was asked to write a 500-word reflective document on his experience living with COPD and his partnership with the doctors he met in his care trajectory. In the third stage, the two teaching professionals organized a second two-hour virtual meeting with the patient partner in teaching to 1) present the objectives of the PBLP workshop and the characteristics of the target audience (FMRs), 2) go over his personal journey, 3) co-construct the PBLP workshop program, 4) plan the cofacilitation of the workshop and 5) answer his questions.

PBLP workshop proceedings

The 3-hour PBLP workshop had one main theme: COPD. At the start of the workshop, a round table discussion and an ice-breaker activity were carried out. The agenda and clinical objectives of the workshop were presented: to diagnose COPD, to use spirometry effectively and interpret its results and to use the best evidence on pharmacological and nonpharmacological management of stable COPD and its acute exacerbations. The initiative to involve a patient partner in teaching in the PBLP workshop was also presented to the FMRs. Afterwards, the patient partner in teaching shared his experience with COPD. A vignette was presented by the pharmacist, along with the two vignettes prepared by the FMRs. The presentations were interspersed with discussion periods and theoretical lectures.

Throughout the workshop, the patient partner in teaching had the opportunity to provide feedback to the FMRs, for example, on the vignettes prepared by the FMRs and during the comments made by the participants (FMRs, professionals). These remarks addressed, among other things, his perspective on the patient-professional relationship, the recognition of the patient's experiential knowledge, the physician's referral to available resources, and the importance of patient education and communication between professionals.

Research objective

The overall aim of this research is to explore the perspective of FMRs on the participation of a patient partner in teaching as part of their training in family medicine.

Quote

To meet this research objective, we carried out a retrospective case study using a mixed-method explanatory sequential design.¹² This approach consists of carrying out a quantitative phase followed by a qualitative phase to deepen the results previously obtained. Data integration occurs during the development of the qualitative phase, since this phase is linked to and dependent on the quantitative phase.¹²

Data collection and procedure

Data collection took place in two phases. The quantitative phase took place directly after the PBLP workshop with FMRs who attended the workshop, and the qualitative phase took place 7 weeks after the PBLP workshop with FMRs who volunteered.

Participants and recruitment

The study involved first- and second-year FMRs who completed their doctorate/externship at the University of Montréal (n = 9), the University of Laval (n = 4) and the University of Sherbrooke (n = 3). To participate in the study, FMRs had to have attended the PBLP workshop engaging a patient partner in teaching from the U-FMG Notre-Dame.

At the start of the PBLP workshop, teaching professionals provided information on the initiative, how their collected data could be used and anonymized in the study, and the voluntary nature of participation. FMRs then verbally confirmed their consent to participate. At the end of the PBLP workshop, a verbal invitation to participate in a focus group was extended to all FMRs who attended the PBLP workshop. FMRs with an interest in contributing to the focus group sent an e-mail to the coordinating FMR, who then forwarded the names of the FMRs to the teacher who co-facilitated the PBLP workshop.

Quantitative phase – FMRs questionnaire

The experience of FMRs was explored using a questionnaire developed and validated by Aires and colleagues (2019).⁴ The 11 questions selected from the questionnaire refer to section 2 of the questionnaire asking the FMRs’ perspective of the perceived usefulness of patient partners in teaching and 4 open-ended questions. All responses to the closed-ended questions were measured using a four-point Likert scale (strongly agree - agree - disagree - strongly disagree).

Qualitative phase - Focus group

To deepen the results obtained in the quantitative phase, a focus group was conducted. The interview guide (Additional file 1) was developed based on the results obtained from the questionnaire to explore certain answers that needed further explanation by the family medicine teacher (GL) and was improved by an expert patient partner (GR). The focus group was led by the family medicine teacher (GL). It was digitally recorded. The focus group was transcribed, and the verbatim data were anonymized.

Data analysis

Quantitative phase

Quantitative data from the FMRs questionnaire were analyzed using descriptive statistics by a member of the research team (HB) using Excel software.® The percentage of respondents was calculated for each statement using a four-point Likert scale (strongly agree - agree - disagree - strongly disagree).

Qualitative phase

The focus group data and the data from the open-ended questions of the questionnaire were analyzed using a combined deductive-inductive content analysis inspired by the topics of the FMRs questionnaire and the literature.¹³ To this end, a coding grid was co-constructed by two members of the research team (AT and TD) to extract the data.¹³ The data were analyzed using Dedoose® by the same two members.¹⁴ Finally, the identified themes were reviewed by the research team (TD, GL, AT, HB, GR, M-PC, ML, TR and ML), who validated the data analysis process and the results. No changes to the identified themes were recommended by the research team.

Quantitative phase

All FMRs who completed the PBLP workshop (n = 16) responded to the questionnaire on the perceived usefulness of the patient partner in teaching participation in the training. Figure 1 presents the percentage of responses obtained using a four-point Likert scale (strongly agree - agree - disagree - strongly disagree). The majority of FMRs mentioned having improved their knowledge of care offered in partnership with patients after the workshop but not their understanding of patients' rights (56.3% disagree). Three topics brought different opinions that were explored during the focus group: knowledge of the patient's living and organizational environment, knowledge of the care ethics, and the change in FMRs’ perspective on the patient's role in the healthcare system.

Qualitative phase

Four FMRs agreed to participate in the 55-minute focus group. Two major themes emerged from the analysis: 1) the knowledge and skills sought and 2) the factors influencing the partnership with the patient partner in teaching.

Knowledge and skills sought

Understanding patients' experiences

For all the FMRs who participated in the PBLP workshop, the presence of the patient partner in teaching allowed a better understanding of the patients' experiences. The FMRs’ comments during the focus group were centered on the experience of living with the disease and the trajectory of care and services. The patient partner in teaching made it possible to conceptualize learning in a realistic way and to offer another perspective on the healthcare system.

"[...] patient partners can guide us through the healthcare system, the care system, the patient experience, I think [...] they are very relevant." (H1)

"I think a patient's experience can help put treatments into perspective, the things we discuss, and the care trajectory too. When we were talking about examinations and so on, [...] it is having a realistic conceptualization of what we're learning, [...]. (F2)

Acquiring professional skills

The PBLP workshop covered clinical and technical procedures related to COPD (clinical picture, pump use, etc.). The FMRs reported that they appreciated this more practical part of the training, where patient partners in teaching shared their experience with pump use. A better understanding of the difficulties involved has enabled FMRs to acquire therapeutic teaching skills to better prevent issues related to the use of pumps by patients. Finally, some FMRs believe that the presence of a patient partner in teaching can help less experienced FMRs make better diagnoses.

"It was super relevant when he [the patient partner in teaching] explained a little bit for him, what's involved taking the pumps." (F1)

"[...] I think it can help us make a better diagnosis, because we can see a bit of a patient, not just a disease in books." (H2)

Understanding the reasons for nonadherence to treatment

Sharing the patient partner in teaching's experience was particularly helpful in providing a better understanding of the reasons for patients refusing treatment and being more aware of the importance of offering different treatment options. Therefore, a better understanding of nonadherence to treatment fostered the development of FMRs empathy.

"[...] when we offer two treatments, to understand what the repercussions are, to have a better understanding of why a patient might refuse a test, [...] what makes them stop taking their medication, [...] we are there with more compassion, empathy for patients" (F1)

Understanding the ethics of care

The data collected showed different perspectives from the FMRs regarding the perceived usefulness of the patient partner in teaching to better understand the ethics of care. The ethical situations reported helped to raise awareness among certain FMRs for their future practice, while other FMRs were unsure of the role the patient partner in teaching could play in their understanding of care ethics, as they felt it was difficult to transfer this to another situation.

"[...] to have people who have experienced these situations, [...] I find that it can be extremely rich, if we are also talking about major medical ethical dilemmas." (F2)

"[...] In ethics, I think that each situation is unique. [...] and ethical situations, we have guides to refer to, phone numbers to call for specific situations. " (F1)

Understanding patients' rights

During the focus group, the FMRs confirmed that the PBLP workshop did not provide a better understanding of patients' rights. Although all the FMRs were able to mention examples such as the right to autonomy, confidentiality, access to care and respect for the person, this knowledge was acquired as part of their previous training. Nevertheless, they felt that the presence of a patient partner in teaching could help improve their understanding of patients' rights.

"I think that in the context of this activity, I felt it less. However, I think, yes, it can make us more aware of choices." (F2)

Understanding the role of patient partners in teaching

Although the question of the patient's role in the healthcare system was posed in a broad sense, the discussions focused on the patient's role as a trainer, as it was not clear for all FMRs. Some comments from the FMRs indicated that to improve future workshops, the role of the patient partner in teaching should be better clarified and defined.

"[...] his role could have been better established, or more targeted questions could have been put to him to avoid him [the patient partner in teaching] from interacting at times when it was perhaps less addressed to him [...]." (F2)

Factors influencing the partnership with the patient partner in teaching

Previous FMRs’ experiences

Following the announcement of the patient partner in teaching's presence at the PBLP workshop, some FMRs reported their apprehension due to their previous experience during their medical training. According to them, the presence of the patient partner in teaching altered the learning objectives of the training.

"I think that, when there are patient-partners, it is often meetings that I'm a little apprehensive about. [...] in fact, the objective of the meetings is completely different." (F2)

The importance of advance preparation

FMRs emphasized their perspective on the importance of preparing the patient partner in teaching as well as themselves. According to them, the teaching team should pay particular attention to the preparation of patient partners in teaching so that they are able to detach themselves from their personal situation, to generalize what they are saying to all patients living with COPD and to give constructive feedback at the appropriate time. For the FMRs, the unpredictability of meeting a patient partner in teaching generated emotions of discomfort and destabilization among them.

"[...] It is interesting that they are perhaps a little better trained to understand what the purpose of their input is." (F1)

"[...] we are not prepared, and we do not know what we are going to discuss, I think that adds to the discomfort." (F2)

Difficulty communicating with the patient partner in teaching

As part of the PBLP workshop, the FMRs raised the issue of their difficulty in communicating with the patient partner in teaching. Having to adapt their medical vocabulary to better establish a dialog with the patient partner in teaching was perceived as a barrier to discussions between the FMRs.

"[...] Of course, we adapt our vocabulary differently, but we cannot speak to each other in colloquial language when we are talking about medicine, because we have studied a lot in this area, and we speak further afield." (F1)

Difficulty in recognizing experiential knowledge

The FMRs’ comments in the focus group showed that recognition of the patient partner in teaching experiential knowledge remained a more difficult element to grasp. The patient partner in teaching's testimony might not be understood for its value and for what it said about the trajectory of patient care and their experience of the disease but was instead referred to the patient's personal experience, which could be linked to their character or individual perspective/belief of the situation:

"[...] the patient-partner remains a person, a personality. [...] at the same time, he [patient trainer] brings things, but maybe he was not the best personality for this type of encounter." (F1)

This study shows that FMRs have a generally positive perspective on the participation of patient partners in teaching in their family medicine training. They found it useful for developing certain medical knowledge and skills that can contribute to improving their partnership with patients, but they also named certain concerns to involve them in medical training. This study supports the literature presenting positive perceptions of general medical students on the involvement of patients in medical training⁵ and complements the current literature by identifying the concerns perceived by FMRs.

Perceived benefits and barriers of involving a patient partner in teaching in training

The presence of the patient partner in teaching led to a better understanding of the patient's experience, provided a different perspective on the healthcare system and a realistic conceptualization of learning. These results are consistent with the literature reporting that the involvement of patient partners in teaching has the effect of narrowing the gap between theory and practice.^15,16 Patient partners in teaching involvement humanize students’ training by showing that behind an interesting medical case lies a person with a story.^17,18 It provides a broader and more complete view of the experience of illness and how patients feel.⁴ In addition to demonstrating the relevance of learning, such involvement has also been shown to have the capacity to encourage the development of essential professional skills, such as empathy, communication, collaboration,^5,19–21 and procedures related to the use of pumps and therapeutic teaching. Plus, a better understanding of the reasons for nonadherence to care enabled FMRs to develop empathy toward patients.

However, communication with the patient partner in teaching proved to be a point of tension for the FMRs because he was perceived as a barrier to discussion. Moreover, in contrast to other studies in which the participation of patient partners in teaching in medical training helped to create egalitarian relationships between patients, students and healthcare professionals,^16,17 the FMRs did not mention this benefit. The absence of these benefits could be explained by the lack of clarification of the patient partner in teaching's role, the participation of the patient partner in teaching to a single PBLP workshop not allowing for the long-term development of a partnership, and the difficulty FMRs had in recognizing the patient partner in teaching experiential knowledge. Indeed, better knowledge of patients' experiences does not necessarily lead to better recognition of patients' experiential knowledge.⁶ Finally, it has been reported that patient participation in medical education promotes greater recognition of patients' rights and dignity among students.⁶ However, the PBLP workshop did not enable this knowledge to be acquired, as some rights were named implicitly through the patient partner in teaching's life experiences, and FMRs were unable to identify them. Nevertheless, FMRs believe that the presence of a patient partner in teaching can contribute to this.

The importance of clarifying the role of the patient partner in teaching

During the focus group, FMRs repeatedly mentioned their uncertainty about the role of the patient partner in teaching in the PBLP workshop. Indeed, they were previously exposed to the patient partner in teaching on several occasions during their initial training, and his role was not explicitly redefined prior to the workshop. Thus, it may have contributed to these uncertainties regarding the added value of the patient partner in teaching presence at the workshop. According to the Djik, Dujizer and Wienold (2020) systematic review, patient partners in teaching can have a variety of implications in the training of medical residents: teachers, assessors of student skills, curriculum development, and selection of students in medical schools.²² Therefore, it is essential to clarify the role of the patient partner in teaching with FMRs prior to training. Moreover, the study by Guary and colleagues (2023) argues that the role of the patient partner in teaching must involve a profound cultural change and that integration with FMRs must be aimed at over the long term.²³

Preparation of the patient partner in teaching and the teaching team are essential to the success of the initiative.

Although the patient was trained for his role in three different stages, this study demonstrates the importance of preparing the patient partner in teaching and the teaching professionals to co-train a PBLP workshop. During the focus group, FMRs repeatedly raised the recommendation to better train patient partners in teaching, for them to detach themselves from their personal situation and give constructive feedback at the appropriate time. To become an educational resource, patient partners in teaching must be able to generalize the experience of living with the disease and choose the appropriate time to transmit their experience.²⁴ In this study, the patient partner in teaching was recruited for his experiential knowledge and not for his teaching skills, which may explain this recommendation. However, it was not expressed in a similar study published by Guary and colleagues (2023) in which FMRs were more critical of the generalization of knowledge to the detriment of experiential knowledge.²³ Nevertheless, the importance of preparing and supporting patient partners in teaching throughout their participation in training is supported by other studies to ensure that feedback is well received by FMRs.^4,6,25 Furthermore, training all teachers to involve patient partners in teaching is an important asset to training, as it ensures an optimal and safe learning environment, where everyone is comfortable with this new teaching method.²⁶ Finally, recognition of the patient partner in teaching’s contribution is also essential. For this study, the patient partner in teaching was paid an honorarium for his training and participation in the PBLP workshop. Wykurz and Kelly's (2002) systematic review concluded that when patients are supported, trained and remunerated, they can become colleagues of the teaching team rather than simply representing a teaching resource.²⁷

Study limitations

First, one of the main limitations of this project was the small number of participants, allowing only descriptive statistics. Second, residents may have chosen to participate voluntarily in the focus group because they were interested in patient partners’ teaching involvement, potentially causing self-selection bias. Unfortunately, the anonymity of FMRs in the quantitative phase does not allow us to confirm this hypothesis. Third, the short duration of the patient partner in teaching participation also represents a limitation that may alter the results and explain points of tension that emerged during the workshop. Indeed, experiencing and practicing a long-term partnership is essential for better involvement of the patient partner in teaching the training of FMRs. Last, although the patient partner in teaching was involved in the preparation and throughout the PBLP workshop, he did not contribute to the completion of this study.

This study explored the FMRs' perspective on the perceived usefulness of the participation of a patient partner in teaching in their family medicine training. The contribution of patient partners in teaching to the training of FMRs is promising and could be evaluated more extensively to improve quality. Their presence can contribute to the acquisition of knowledge and professional skills by FMRs, complementary to those taught theoretically during their training, and the recognition of patients' experiential knowledge. The FMRs raised several suggestions for improving the contribution of patient partners in teaching to training.

U-FMG

University-Family Medicine Group

COPD

Chronic Obstructive Pulmonary Disease

PBLP

Practice-Based Learning Program

FMRs

Family Medicine Residents

Ethics approval and consent to participate

This study was approved by the Health and Science Research Ethics Board of the University of Montreal (2023-4322). Informed consent was obtained from all participants during the study. Participants were informed that identifying information would remain confidential to protect individual anonymity.

Consent for publication

Not applicable.

Availability of data and materials

The dataset(s) supporting the conclusions of this article is(are) included within the article (and its additional file(s)).

Competing interest

The authors declare that they have no competing interests.

Funding

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

Authors’ contribution

TD and GL designed the study, with contributions from AT, HB, GR and M-PC. The patient/co-researcher, GR, helped determine research relevance and design the interview guide. GL led the data collection. HB led the quantitative analysis. TD and AT led the qualitative analysis. The entire research team and three collaborators, ML, ML and TR, helped interpretation of the results. TD led the protocol development and is the first author. TD wrote the manuscript under the direction of GL. SMY provided editorial assistance in the preparation of this article. GL is the guarantor and nominal principal researcher. All authors read and approved the final manuscript.

Acknowledgments

The authors thank the teaching team and the patient partners in teaching who co-animated the PBLP workshops. The authors thank Mylène Leclerc for contributing to this work.

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No competing interests reported.

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Family medicine residents’ perspectives about patient partners in teaching participation in their training: A retrospective case study using a mixed-method explanatory sequential design

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Abstract

Figures

BACKGROUND

Context of the U-FMG Notre-Dame and the practice-based learning program workshop

Preworkshop preparation

PBLP workshop proceedings

Research objective

METHODS

Quote

Data collection and procedure

Participants and recruitment

Quantitative phase – FMRs questionnaire

Qualitative phase - Focus group

Data analysis

Quantitative phase

Qualitative phase

RESULTS

Quantitative phase

Qualitative phase

Knowledge and skills sought

Understanding patients' experiences

Acquiring professional skills

Understanding the reasons for nonadherence to treatment

Understanding the ethics of care

Understanding patients' rights

Understanding the role of patient partners in teaching

Factors influencing the partnership with the patient partner in teaching

Previous FMRs’ experiences

The importance of advance preparation

Difficulty communicating with the patient partner in teaching

Difficulty in recognizing experiential knowledge

DISCUSSION

Perceived benefits and barriers of involving a patient partner in teaching in training

The importance of clarifying the role of the patient partner in teaching

Study limitations

CONCLUSION

Abbreviations

Declarations

References

Additional Declarations

Supplementary Files

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