Richard Smith: Medical schools move to teaching online consultation with patients

As for everybody and every organisation, the covid-19 pandemic has presented challenges, but also opportunities, to medical schools. One challenge is how the schools can ensure adequate and safe contact with patients, particularly for students in their early years. The answer—as for so much—is to provide contact online, and therein lies the opportunity because these young students will practice in a world where many, even most, consultations will take place online. During the pandemic all general practice consultations with patients have been initially online or by phone, and the president of the Royal College of General Practitioners has suggested that half of all consultations may be by phone or online in the future. Similarly a high proportion of hospital outpatients have been and will be conducted online or by phone.

Patients Know Best (which I chair and in which I have equity) is a company predicated on the idea that patients should control all their medical and social care records, receive results online as soon as they are available, be able to communicate electronically with the health professionals caring for them, and take change of their health and healthcare. We think—and increasingly everybody agrees—that this is the way healthcare will inevitably develop. It thus makes complete sense for medical students, who will be practising until 2070, to be trained in such an environment.

The experience of Leicester Medical School

Leicester Medical School was the first to recognise this, and I wrote about the scheme it developed in 2014. First year students were divided into groups of eight and given fictitious patients to communicate with online using software developed by Patients Know Best. The aims were to give first year students safe contact with a variety of patients (many from ethnic minorities) with a variety of problems, but particularly long-term conditions. By 2017, when I returned to Leicester the medical school had begun to use real patients, and both patients and students enjoyed the experience, although they recognised that there would always be an important role for face-to-face consultations

Pharmacy schools at Aston University and Liverpool Johns Moore’s University, the nursing school at De Montfort University, and the midwifery school at City University have all used the programme in various forms. One benefit has been to encourage multidisciplinary learning, which is much needed but has proved hard to implement. City University used the programme to introduce students to patients with complex health and ethical issues; the students stay with patients long-term and can contribute to their care and notes.

With the pandemic online teaching spreads: three models

Although various medical schools had expressed interest in the programme, which Patients Know Best provides at no cost, no other medical school had started a programme. But then came the covid-19 pandemic and medical schools recognised that online consultation was going to be an essential skill for students to learn and that such consultations could ensure that students could have safe contact with patients. Sarah Wright, a former academic who now works for Patients Know Best, presented on the programme to the UK Council for Clinical Communication, and 12 of the UK’s 36 medical schools have expressed an interest in joining the programme.

Patients Know Best’s software has developed many more features since it was first used for teaching in Leicester, and the experience in Leicester and other schools has taught us much. Plus Patients Know Best now has contacts to provide its services to 12 million people in Britain. We now offer three standard models that can be readily implemented for schools of health professionals. Each school can adapt the models to its own requirements.

In the simplest “simulated” model the school uses fictitious patients with fictitious records. This is the model used initially in Leicester, and the team created a collection of fictitious patients—with different names, demographics, illnesses, medications, and allergies. There is obviously great potential for universities to both enlarge and share collections of fictitious patients. A few volunteers can then interact with the students and the records.

The second “hybrid” model uses real patients but fictitious records. Many patients are only too happy to interact with students, and these interactions can last for years. The Leicester students interacted, for example, with a woman who had multiple long-term conditions who also had a son with long term conditions and another woman with a chromosomal disorder. The students learnt a great deal from the patients about their experiences with professionals, not all of which were positive. Using records that are created for education avoids information governance problems that can otherwise cause difficulties. The medical schools can find patients but so can Patients Know Best, which now has hundreds of thousands of patients controlling their records. (Indeed, if readers of this article would like to volunteer complete the form here:

The third model uses real patients and real records and does mean that information governance problems must be overcome. Most medical schools opt for the first or second model with the expectation of building towards real patients with real records, but Cambridge Medical School is planning a pilot with real patients and real records.

Support to patients

As well as learning from patients, students can offer support to patients. We have all heard the stories of patients with covid-19 sick and even dying in intensive care units without any face to face visits from their family and friends. An intensive care clinician in University Hospital Wales thinks that giving patients access to students via Patients Know Best might provide both rich learning for students and support to patients. The students can also if given consent by the patient communicate with families, providing knowledge and comfort. (Patients decide who has access to their records, and many patients may grant access to others in their family.) This scheme also has to overcome problems with information governance. (It’s worth noting that in some places concerns about information governance were put aside in the need to respond rapidly to the pandemic.)

Bristol Medical School has 270 patients in a year, and usually new students are connected via general practices in a group to a patient. The aim is now to achieve this through Patients Know Best, and the school needs two patients from each of about 50 practices. So far 25 have agreed.

Although Patients Know Best provides all these services for free, there are costs to the company. We have tried to standardise the processes to keep costs to a minimum. Nevertheless, models must be explained, contracts negotiated, software installed and supported, and staff and students trained to use Patients Know Best. Students are, of course, “digital natives,” and find the software easy to use, and need little training. Sarah Wright has devoted a considerable proportion of her time to the project, but enjoys interacting with staff and students and watching the different models emerge. The company plans to appoint a new member of staff to administer the programme, and with luck we might be able to find sponsorship for the post. Patients Know Best does, of course, benefit from having the next generation of health professionals familiar with its software.


The team in Leicester have struggled to find funding for a full evaluation, but they have conducted focus groups with staff, students, and patients and published their results. Their conclusions are that students quickly adapt to the technology and behave professionally when communicating with patients online. The permanent online record of interactions, which Patients Know Best provides, is valuable for providing feedback to students on their consultation skills, and the interactions provide a realistic test of students’ knowledge. 

But, the Leicester team concluded, “more work is needed to identify the key skills required to communicate effectively with patients in this way.” With so many health professional schools beginning to use online consulting for teaching—and so many qualified professionals doing it every day—we should progress rapidly with identifying the skills and how to teach them.

Richard Smith was the editor of The BMJ until 2004.

Competing interest: RS has been the unpaid chair of Patients Know Best since the company began 11 years ago but has equity (about a 1% share) in the company.