Physical examination teaching is a generally well-perceived experience from the patient perspective. Participants hold a positive impression of medical student education and the patient-student interaction has many potential benefits. Physical examination teaching can have several distinct, non-mutually exclusive meanings for patients: Tolerance, Helping, Social, and Learning (Fig. ). We have seen the potential to move from a meaning with less patient value (Tolerance) to meanings with possible higher benefit (Social, Learning, Helping), opening the door to more meaningful patient-student-teacher interactions. We can see no reason why a patient could not “enter” with one meaning and “exit” benefiting from others. Past patient experiences, personal values, the nature of the current illness, and health literacy might determine where the patient starts out18,19
and where they have the potential to move. Of course, if conducted in the wrong manner, patients starting out with positive attitudes might end up deriving little to no benefit.
Figure 1 Potential model of patient meanings from physical examination teaching. Individual factors contribute to where a patient starts on the model (H = Helping, T = Tolerance, S = Social, L = Learning), and also mediate potential movement from one meaning to (more ...)
This model could be easily applied whenever educators facilitate physical examination teaching. Observation and appraisal of patients before and during sessions might classify patients into one of these four meanings. This could direct educators (and students) to employ strategies to give patients more value, for example, guiding a Tolerant patient to greater learning, social, or helping meanings. Explaining things in layman terms and directly to the patient; asking patients about their histories or hobbies; and emphasizing how helpful their participation has been, are some ways to incorporate these other dimensions.
Patients gave various suggestions for improving physical examination teaching, including logistical (avoiding meal time, giving patient lead times) and procedural considerations (asking the patient more questions, checking for patient comfort during sessions). From our experience, the suggestion to have students introduce themselves and say where they are from, has been an easy, quick, and rapport-building addition to the sessions.
The finding that physical examination teaching can lead to patients learning about their own illnesses may merit special consideration given the growing body of literature linking health literacy to self-efficacy, health behaviors, and participation in medical decision-making.19–21
These encounters could represent important educational opportunities for patients (learning about their own disease processes and symptoms) as well as learners (learning how to communicate and teach patients effectively). Participant 12 described two separate teaching session encounters, one in which the group used medical jargon and excluded him from the discussion (Tolerance) and the other where the group took the time to explain things in layman’s terms to him, causing him to feel actively engaged and empowered (Learning). Thus, the meaning of these teaching sessions for patients may vary depending upon how the session is conducted. Pivotal to improving health literacy is teaching effective patient communication techniques to learners;22
teaching rounds could serve this purpose. This could be an area of future study.
Our study findings are consistent with prior work showing that patients perceive bedside teaching involving patients and physician teams to be a positive experience.12
The majority enjoy having medical students involved in their care.12,13
This study adds to existing literature by providing a focus on the component of bedside teaching that may be the most uncomfortable for patients: physical examination teaching. When Fletcher et al. surveyed Veteran patients on their bedside interactions with physician teams, they found 13% were made uncomfortable when several people examined them at once.12
Physical examination teaching often occurs in the small-group setting, involving multiple student examiners; yet, even the “Tolerant” patients in our study did not describe significant discomfort with the examination process. This may be because examinations during daily bedside rounds are often performed without asking the patient’s permission first; asking for permission in any physical examination teaching setting could improve patient comfort. A prior model on bedside interactions found that information exchange, evidence of caring, involvement in teaching, knowing the team, and bedside manner were important to patients.13
The four possible meanings we identified overlap these themes previously identified; not only are these themes important to patients, but they create meaning
This study has several limitations. Patients were Veterans who were mostly male and of older age. While the Veteran population, in of itself, is an important population to study given the large role the Veterans Affairs medical system plays in medical education, there may be unique characteristics of Veterans that limit the ability to generalize findings more broadly. Yet, there are likely universal meanings that exist for patients who voluntarily participate in physical examination teaching. Also, as in any qualitative interview study, it is possible that if we had done more interviews, we might have heard new things. However, we believed that there was limited utility of additional interviews based on the variation of physical examination foci of participants (cardiac, abdominal, etc), concurrent data analysis, and consistency with numbers of participants recommended for phenomenological studies (8–15).16
Finally, all of the patients in our study, by definition, agreed to participate in the physical examination teaching sessions in the first place. Thus, our model may only apply to those who voluntarily agree to physical examination teaching and those who are offered a choice.
Future studies should evaluate how attending to this four-meaning model impacts patient, student, and teacher satisfaction with physical examination teaching, as well as how it applies to other patient populations. Encouragingly, student bedside physical examination teaching, which may appear to only benefit students, can also benefit patients in significant ways. Perhaps “patient-centered teaching” should be the ultimate goal, with student learning as an important, but not exclusive, endpoint.