Richard Smith: Teaching medical students online consultation with patients

Richard SmithA first year medical student of today may well still be practising in 2070. We can’t know how medicine will look then, but we can see some clear trends. The relationship between doctors and patients will surely be much more equal; indeed, health will be the business primarily of patients, with doctors as advisers, guides, and facilitators. Much of medical practice will be conducted online, with online consultations routine. Indeed, in some parts of medicine online consultations are routine now, reminding us that the future is already here but not evenly distributed. Recognising these trends, Leicester Medical School has introduced medical students to online interaction with patients at the very beginning of their course. I went to Leicester to meet with patients, students, and teachers who are participating in the programme.

As in many medical schools, students in Leicester work a lot in groups, but Leicester may be the first medical school in the world to use psychometric testing to balance the groups. The impression of the teachers is that the groups now work better and are less likely to run into serious problems. In the first year there are 24 groups of eight students. Each group is allocated a patient to communicate with online using software developed by Patients Know Best. (I am the chair of the board of Patients Know Best, see detailed conflict of interest statement at the end if the blog.)

The patients are actually avatars, meaning that they are given identities other than their own. The only requirement of the patients is that they are neither academics nor clinicians. They are “ordinary people.” Their identities were created by Dr Ron Hsu, head of innovation in the school, who has had the vision, tenacity, guile, and energy that are essential for introducing something new into a crowded curriculum. Hsu is particularly interested to use the online interaction to help students to learn to be comfortable with cultural diversity, so many of the identities are from ethnic minorities. (Leicester is the first city in Britain where “white British” are the minority.)

Each identity comprises age, gender, income, ethnicity, religion, and a brief biography that says something about their family, occupation, and other things like having a history of depression. At a meeting the 12 “patients” chose their identities, a process that took only five minutes. People seemed happy, even excited, to adopt identities very different from their real ones.

The interaction between the patients and the students begins with a question. Most of the questions relate to what the students are being taught, which at this stage is mostly basic science. But the questions need to be ones that patients would ask, so a process has been developed to create such questions. The basic science teachers pose a question that is passed to a clinician, who may completely transform the question—so a question on Krebs Cycle becomes a question on ketones or even peardrops. Hsu looks at the questions from the scientist and clinician and combines them into a question that a patient might ask. He then passes the question to the patient, who puts it into his or her words. Some of the patients are adopting poor English, reflecting the real world.

The patient then sends the question to the students using the secure software. The students are encouraged to act as the patients’ clinicians and so must preserve confidentiality. They must answer the patients’ questions within two working days.

The students told me that they begin by discussing the question together and framing an answer. Sometimes they have to go back to the patient to clarify the question. These students are all “digital natives” and are entirely comfortable with the software; one group discovered a discussion board within the software that the teachers didn’t know existed. One of the students then drafts an answer, and once all the students are comfortable they send the answer to the patient.

One of the educational aims is for the students to become proficient at working in groups, and the students said that having to answer the questions together provided good learning. Another aim is for the students to be able to communicate clearly with patients, and the patients are encouraged to come back to the students when they don’t understand. Some do this repeatedly. The onus is on the patients not the teachers to say when language is too complex and they don’t understand.

Every fourth week the patients are encouraged to come up with their own question on anything. Some pick subjects in the media, but one patient inspired by talking to her neighbour said that because her culture stigmatised left handedness she wanted to know how she could turn her daughter right handed. In the questioning she mentioned that she had tried tying her daughter’s left hand behind her back. This rightly created consternation among the students, who raised child protection issue with their teachers. But at the same time the students were excited and challenged by this interaction.

So far (this began only in September 2013) the questions have been fairly simple. The students have noticed that the questions relate to what they are being taught, which makes them suspicious about who the patients are. They had been told that the patients would be informed about what the students were being taught, but lots of the students think that the patients are all Hsu. They were reminded that the patients are real people, ordinary people, but one student said it would feel more real if the patients were patients they had met. The students have now met with a patient with a long term condition to whom they have been allocated, and I pointed out that they could suggest to those patients that they joined Patients Know Best.  It might also be in the future that the medical school might use real patients, but using avatars provides a safe place for students who have just started to learn. Another educational aim is to provide students with access to patients, albeit “ordinary people,” as early on as possible.

I was surprised that the students hadn’t asked the patients questions about them and their lives. So, it turned out, were the patients. It seemed not to have occurred to the students, but they also felt that it would be somehow intrusive. Their job, they felt, was to answer the questions, no more.

The patients liked it all very much, saying “It’s so much fun,” “really interesting,” and “I missed it over Christmas.” The students weren’t so enthusiastic and looked forward to having more complex, perhaps ethical, questions.

As with any innovation like this, it needed a visionary and a champion to make it happen. Hsu is that person. He heard Mohammad Al-Ubyadli, the founder of Patients Know Best, talk about the software four years ago—and immediately conceived how it could be used in teaching. He tried the idea out on various colleagues, and they weren’t actively against but it didn’t seem a priority to them. But Hsu kept plugging away, persuading the teachers that it could be educationally useful, and telling the school leaders that it could be done without extra resources.

I met Nick London, an associate dean, who told me that he was keen on anything that gave students early exposure to patients, and he didn’t see much risk in the experiment. The worst that could happen would be that the students simply wouldn’t engage. As far as he could tell, the experiment was going well.

Once he had the all clear, Hsu contacted Al-Ubaydli, three years after the original contact, and did a deal whereby Patients Know Best would provide the software and do everything for free on the condition that all materials produced to make the programme work would be open source and that Leicester would help any other medical school that might want to use the software. Hsu then persuaded Jane Bethea, a lecturer in public health and epidemiology, and Mary Hall, a specialty registrar in public health working for Leicester City Council, to help. They told me that they liked the idea and that it’s hard to say no to Hsu. They did the hard work of setting it all up, and Hall has produced a guide that she thinks should make it much easier for anybody who wants to follow. Hsu also managed to find 12 volunteers as patients in a very short time.

I was struck that Hsu needed almost exactly the same skills that Al-Ubaydli has needed to start up Patients Know Best: vision, tenacity, commitment, and a boundless sense that you can find a way to get it done.

Bethea is working with Robert Golding, a foundation year two doctor, to evaluate the programme. They are using mixed methods, and they will need to convince themselves that “the pain is worth the gain” and that the programme is sustainable. As with any experiment they can already see ways to make it better, but from my biased point of view (see below) I think that they are introducing developments that will make it more likely that the students will still be practising good medicine in 2070.

The team from Leicester, including the students and the patients, will be describing their experiences at a free meeting at the Royal Society of Medicine in London on 20 March in the evening. If you’d like to go, sign up here.

If you would like to volunteer as a patient in the programme, then contact Ron Hsu at You can be anywhere in the world but cannot be an academic or a clinician.

Richard Smith was the editor of the BMJ until 2004 and is director of the United Health Group’s chronic disease initiative.

Competing interest: I am the chair of Patients Know Best. I’m not paid, but I have equity in the company. I paid my own fare to Leicester, which even with my Senior Rail Card was horribly expensive (about £90). Patients Know Best, as I describe in the blog, has provided the software, set up, and back up for free. All material produced by Leicester Medical School is open source, and the school has undertaken to advise any other school that would like to experiment with the programme.