Teaching to the Test: Patient-Centered Care

By Kimberly Hoffman, PhD, and Josh Geltman

Successful educational organizations explicitly state their values, develop policies and educational experiences in support of those values, and design measurement tools to evaluate whether those values are routinely and systematically incorporated into daily work. At University of Missouri-Columbia (MU) School of Medicine, our values are expressed in the key characteristics we expect of our graduates. The first of these is the ability to deliver effective patient-centered care (PCC), a value and commitment shared by our major teaching hospital. We felt that to achieve routine delivery of PCC, we needed to understand it through the eyes of our patients. We wanted to legitimize and incorporate patients’ voices, and engage them in creating and assessing a more complete understanding of competence.

To meet those goals, we engaged patients to create a Patient-Centered Care Objective Structured Exam (PCC-OSCE) for third-year medical students. Successful completion of the PCC-OSCE is a graduation requirement and is an example of our school’s commitment to its values.

Clearly, medical students must have the knowledge necessary to diagnose and treat medical conditions but, increasingly,  effective care requires providers to move beyond those skills to respect individual patient beliefs, values, and culture; to provide timely, understandable information; and to partner in decision making. There is increasing evidence that patients who are actively engaged in their own health care have better outcomes. Patient-centered approaches to care have a positive impact on adherence to treatment, self-management of chronic disease, improved patient satisfaction, and lower costs.

We realized we needed to understand what patient-centered care really looked like when done well. What were the specific behaviors we were looking for as we designed MU’s educational experiences? To answer this question, our research team searched the literature, conducted focus groups of patients and families, conducted focus groups of faculty and students, and triangulated the data starting with the patient perspective. We found strong agreement among the groups, which gave us a rich description of effective PCC.

Engaging patients as they prefer, understanding that care choices belong to the individual, and partnering in decision making are important elements of PCC. These are complex tasks that require abundant practice and feedback. Beginning in the first year and continuing through third-year clerkships, students engage in role-plays with standardized patients in our Clinical Simulation Center. Students get practice and detailed feedback on behaviors that support PCC and work to refine their behaviors; then the performance improvement cycle starts again. These experiences are coupled with a robust interprofessional patient safety and quality improvement curriculum where students learn to communicate and collaborate with other members of the health care team.

Creation of the PCC-OSCE was arguably the most important use of our knowledge on the specific behaviors that support PCC.  Here faculty members assess students as they engage standardized patients (adolescent to geriatric), standardized family members, and standardized health care providers. The PCC-OSCE forces students to move beyond making a diagnosis and creating a management plan to demonstrate behaviors that play an essential role in the effectiveness of care. For example, students are assessed on their ability to pause to allow patients to contribute to information exchange; and to make learning about unique characteristics and circumstances of patients a priority in a patient encounter, then discuss treatment and medication options with sensitivity to patient’s preferences and concerns. Students receive abundant written feedback on their performance. They also review video of their standardized patient encounters, helping them see the specific behaviors that should be changed or reinforced. [Creation of the PCC-OSCEis described in Medical Teacher, Early Online DOI # 103.3109/0142159X.2014.947931.]

Like most of us, medical students pay close attention to what they are tested on. Effective organizations measure what they value. If we do not have credible assessments of PCC, we send a mixed message to MU students and run the risk of devaluing the very skills that will make our graduates successful in the health care systems of the future.

Creating assessments of student performance is a long and often arduous task, involving multiple and sometimes competing voices, multiple cycles of improvement, and adjustments for logistical and practical limitations. After all the inputs, how can one be confident that the assessment is measuring what was intended? In our case, we once again turned to patients. We recruited patients who were not a part of the original focus groups and asked them to review students’ PCC-OSCE videos. The behaviors in the student videos that these patients identified as promoting PCC were the same as the behaviors described in the original patient focus groups. The patients told us we got it right!

We believe that engaging our patients in describing PCC and seeking their confirmation that we got it right was critical to our efforts to educate the next generation of physicians to routinely deliver effective patient-centered care. The PCC-OSCE provided new and important information on our medical students’ performance in an area that is critical to our mission. This work illustrates how educational programs can engage patients to better understand complex professional competencies and to develop credible assessments. Through this process we have designed educational experiences and assessments that will help students become the type of physicians they seek to become: skilled physicians who know that patient centered care is the way to practice medicine.

Josh Geltman, MS3 class president, sums it up: “During the medical school application process, MU clearly conveyed that teaching and measuring the values of patient-centered care were important. That is why I made the decision to come to MU three years ago.”

Kimberly Hofman, PhD, Associate Dean for Learning StrategiesKimberly Hoffman, PhD, is Associate Dean for Curriculum & Assessment at the University of Missouri-Columbia School of Medicine. She can be reached at hoffmank@health.missouri.edu.