Richard Smith: Giving medical students patient contact through online consultation

richard_smith_2014Medical students arrive at medical school hungry to have contact with patients, but it can be unfair to unleash on patients students who know nothing of medicine and until yesterday were school children. Leicester Medical School has an innovative solution to this conundrum that has the added benefit of familiarising students with consulting online, something that the government wants to happen in the NHS and surely will happen during their 50 years of practice.

Leicester’s solution to the conundrum is to connect students in groups to patients through the software of Patients Know Best (see competing interest statement below), which gives patients control of all their medical and social records and allows confidential text communication between the students and the patients. Potentially the platform can offer much more—including audio and visual consultation, real time sharing of results of investigations, access to reliable health information, and computer history taking—but for now the Leicester programme is restricted to communication by text.

When the medical school first started using Patients Know Best the patients were “virtual patients,” and the students were all convinced that Ron Hsu, the teacher who’d led the innovation, was all of them. He wasn’t, but the programme has developed to include real patients, all of them volunteers. The medical school has around 30 patients keen to participate in the programme. The students in groups of eight have an initial meeting with the patients, and thereafter the communication is electronic. The patients all have long term conditions, and one of the main aims of the programme is to help medical students understand what it is like to live with a long term condition. This is clearly important as most of modern healthcare is concerned with patients with long term conditions, usually more than one.

The students have all had to make posters and presentations on what they have learnt, and on a Monday night in June the three finalists had to make their presentations to five judges—a patient, a medical student, the head of the medical school, a professor who supports patient-centred learning, and me—and their patients and fellow students. We scored the finalists using the method of Strictly Come Dancing with the judges giving half the score and the audience the other half.

The first group, three women and a man, described their interactions with Carol, a patient with several long term conditions herself who also had to care for a son with long term conditions. The students had learnt a lot about the social and emotional aspects, including the isolation of living with a long term condition and being a carer at the same time. They’d learnt too about her positive and negative experiences with health professionals, sensitising them to how patients will react to them. One simple lesson was the importance of being punctual. Like all the students they had been given pieces of information about the patient before they met them—and they had made assumptions about the patients based on those pieces of information. Their assumptions were usually wrong, not least in that they expected the patients to be severely ill, but they weren’t.

The students also reflected on the pros and cons of Patients Know Best. They liked that they had time together to reflect on what to ask the patients and how to interpret what the patients sent back. They regretted the absence of immediate responses and the impossibility of interpreting body language. They thought that in the “real world” Patients Know Best would be good for communicating with patients with long term conditions but not so good for patients with acute problems.

The second group, four women, introduced and thanked their patient, Annie, who has a son with a chromosomal disorder. They came to understand deeply what it’s like to be a carer, and the electronic communication had begun to teach them how to ask questions that seem intrusive to new students. They were a little surprised that none of Annie’s family had wanted any genetic testing, but Annie leapt up and said how her family were Christians and it was very complicated.

Anthony, the patient of the third group, two men, had challenged them to find out what was wrong with him, and they had become detectives. It took them a long time to work out that he had amyloidosis, and the challenge of the diagnosis had meant they spent less time exploring Anthony’s social and emotional side—but then he was a fiercely independent 80 year old involved in all sorts of activities, including advising NHS England and being a subject in the 100 000 Genome Project.

The judging was difficult in that we all had selected a different winner, and the audience too was divided with 20 votes for two groups and 22 for one. But we all agreed on the final result which made the second group first and the other two second equal.

Andy Ward, the GP who directs the compassionate, holistic, diagnostic detective course, of which the online consulting is part, reported on the programme in a brief presentation, and described how the students had developed empathy, felt empowered, and had grown in confidence as the programme developed. But they still had to learn to ask deeper questions. The time delay of the electronic communication was seen as positive, but the students regretted the loss of body language and spontaneity.

Patients were asked: “What impact do you think the electronic nature of the communications had on the interactions compared with traditional face-to-face communication?”

One patient answered: “It is rare that I as a patient have had time to reflect on my condition and the thinking time that this structure allows provides me with a better understanding of my own coping mechanisms and triggers. It also feels like a proper relationship rather than a rushed consultation, which is empowering, as the opportunity to communicate does not disappear after 8 minutes when a door closes.”

Another said: “I think that the electronic nature of the communications has meant that our responses to each other have been more considered than face-to-face communication would be and as we are in touch with each other on a regular basis it feels as though we are having an on-going conversation.”

But patients also had negative comments: “…there wasn’t always the professional relaxed nature on electronic consultations, as body language, and facial expression, tone of voice, can add to that”; “You lose the tone of voice. And facial expression. So, you are left unsure whether the queries include empathy or are merely factual”; and “There’s the obvious lack of spontaneity and access to immediate clarification. However, it worked well, very close to conversation style.”

Overall students, staff, and patients all thought the experience positive, although interestingly only 15% of staff reported that they would like to introduce online consultation into their routine practice. Worries about increased workload seemed to be the main block, but evidence suggests that in the longer term it can reduce workload.

The students will continue consulting with their patients as they move into second year, and Leicester Medical School will continue to develop the programme. So far no other medical schools have adopted the programme, although courses for other health students have; and one teacher observed as staff, patients, and judges enjoyed an Indian meal that it’s easier to be innovative in a relatively new medical school.

Richard Smith was the editor of The BMJ until 2004.

Competing interest: RS is the chair of Patients Know Best and has invested in the company. He is not paid but has equity in the company, which could ultimately prove either valuable or worthless. The former is more likely. He paid his own fare to and from Leicester but didn’t have to pay for his excellent vegetable balti.