|ORIGINAL RESEARCH PAPER
|Year : 2012 | Volume
| Issue : 2 | Page : 87-91
Involving Patients in Medical Education: Ethical Issues Experienced by Syrian Patients
H Bashour1, R Sayed-Hassan2, A Koudsi3
1 Department of Family and Community Medicine, Faculty of Medicine, and Centre for Medical Education Development, Damascus University, Damascus, Syria
2 Department of Internal Medicine, Faculty of Medicine, Damascus University, Damascus, Syria
3 Department of Family & Community Medicine, Faculty of Medicine, Damascus University, Syria
|Date of Submission||25-Jul-2011|
|Date of Decision||12-Apr-2012|
|Date of Acceptance||16-Apr-2012|
|Date of Web Publication||14-Nov-2012|
Faculty of Medicine, Damascus University, P. O. Box: 9241, Damascus
Source of Support: None, Conflict of Interest: None
Introduction: Patients' involvement and their willingness to cooperate in clinical teaching is a vital element of medical education. Clinical teaching at the Faculty of Medicine of Damascus University relies heavily on inpatients at teaching hospitals but also on patients brought to teaching rooms. The purpose of this study was to identify patients' experiences and their attitudes toward the involvement of medical students in clinical consultations within teaching rooms conducted mainly for students' benefit. Methods: In-depth interviews were carried out by a sociologist using an interview guide with 14 patients whose clinical cases were presented to a large group of students in the teaching room at Damascus University teaching hospitals. Data analysis involved content analysis. Findings: Main themes were identified with negative ethical aspects, such as the lack of patient's involvement in decision making and approving to be part of clinical teaching. Risk and benefits were experienced by patients and identified in their experiences. Some felt that they were treated inhumanely and with a lack of dignity. Patients nevertheless felt a responsibility to be part of the teaching process. They expressed their positive attitudes towards involvement in the teaching process to serve medical students as well as the greater community. Discussion: Findings provide perspectives and insights into the current clinical teaching at Damascus University Faculty of Medicine. The findings highlight the need in our institution to carry out medical education involving patients in a more ethical manner. Medical students and their teachers need more training in the ethical involvement of patients in students' learning process, as well as the need to better regulate patients' involvement in education.
Keywords: Clinical teaching, confidentiality, ethical principles, informed consent, medical education, medical ethics, patients′ involvement, Syria
|How to cite this article:|
Bashour H, Sayed-Hassan R, Koudsi A. Involving Patients in Medical Education: Ethical Issues Experienced by Syrian Patients. Educ Health 2012;25:87-91
| Introduction|| |
One of the most well-known and internationally recognized dictums is that of Sir William Osler "it is a safe rule to have no teaching without a patient for a text and the best teaching is that taught by the patient himself0". The importance of learning from the patient has been repeatedly emphasized in the literature. ,,,,
The general principles of bioethics, including respect for individuals, beneficence, non-maleficence and justice extend in their application to patient participation in medical education. Unfortunately, current practice of medical education does not always accord adequate respect to patients and they are not always happy about the students' presence and involvement in their care. ,,,
Patients have always been vital to medical education. Howe and Anderson argued that there is a need for better approaches to involving patients in the training process, including the need for informed consent and the creation of a more equal partnership in shared decision making in clinical practice. ,,,,,,,,,[ 10]0 Patients' concerns towards their participation in medical education include matters of consent and confidentiality, as well as receiving information in advance about student and trainee involvement in their care.  Understanding how patients view community-based and bedside teaching has received a good deal of research, including through the use of patient' surveys, but this has occurred largely within the developed world. ,,,,,,,,[ 10 9] Bodies such as the British Medical Association argued that these concerns can have an impact on patients and on the learning outcomes for medical students and doctors themselves.  As Jagsi and Lehmann put it "an ethical dilemma results from the fact that patients may not benefit from doctors in training and medical students participating in their care, and may even be harmed by it". 
Clinical teaching is an integral component of the curriculum in Damascus University Faculty of Medicine. Teaching occurs mainly in hospital wards and less so in outpatient clinics, operating theatres and other consulting rooms. The clinical skills laboratory is very new and is not yet functioning. The Faculty of Medicine admits over 500 students each year. Clinical teaching starts in the fourth year and continues for three years up to the final year. This clinical training takes the shape of rounds and visits with clinical teachers. In addition, selected cases relevant for teaching are brought to teaching rooms with about 40 students present, for an extensive case presentation in the presence of patient and discussion.
Reviews of student and patient perspectives regarding the teaching environment can be effective tools to inform curriculum development. Curriculum development has been high on the agenda of the Damascus University Faculty of medicine for the past three years. The purpose of this study is to identify patients' experiences and their attitudes towards involving medical students in their clinical consultations in lecture theatre settings conducted principally for students' benefit.
| Methods|| |
This qualitative study included 14 semi-structured, in-depth interviews with patients conducted at two teaching hospitals affiliated with Damascus University. All individuals interviewed were male patients seen at the Internal Medicine and Surgery departments at the two main teaching hospitals in Damascus (al-Mouassat and al-Assad teaching hospitals). Patients were recruited to represent all who served as a "teaching tool" in lecture theatre, where their cases were fully discussed in front of the patient himself, medical students (around 40 in number) and the clinical teacher. These patients came from a larger sample of 400 who were recruited for a quantitative component of this study.  All patients who moved from wards to the teaching room for teaching purposes were recruited. Data collection was done in May 2011 during the 2010-2011 academic year.
The study was approved by the Institutional Review Board at Damascus University. Written informed consent was obtained prior to data collection. For ethical reasons, all names used in the presentation of our findings are pseudonyms. The interviews were conducted in Arabic by an experienced female field worker who has a background in social sciences and is trained in asking probing questions, using the study's interview guide. The interview guide was designed by the researchers based on literature review.  The interview guide included items related to the experience of the patients in the classroom, experience with being interviewed and examined by students, likes and dislikes feelings and expectations about involvement in teaching of students. All interviews were tape-recorded and their length varied according to patients' responses, but generally took between 30 and 90 minutes to complete.
The process of data analysis occurred simultaneously with ongoing data collection. Data saturation was determined when the interview responses of the final participants fit within the emergent coding scheme. The interviews were transcribed verbatim and initially read as narrative accounts in order to gain an overall sense of each patient's experience. Coding was then performed by one of the authors in order to identify general themes. The content analysis method of analysing qualitative data was used.  All quotes and excerpts presented here are translated from Arabic into English to best describe the original meaning.
| Findings|| |
Patients who participated in this study were aged 21-67 years. All were male and all had finished at least elementary level education. Almost all were in clinical condition that allowed them to move from the wards of the internal medicine and surgery departments to the teaching room. Their clinical illnesses fell principally within the fields of endocrinology, nephrology and gastroenterology. The selection of those patients by clinical teachers was based solely on the relevance of the case to students' learning and the appropriateness of their clinical condition as a "teaching tool".
In what follows we present the main themes that emerged from interviews to describe patients' experiences. Many of these themes are not mutually exclusive; rather, they appear simultaneously in many of the interviews.
Involvement in decision making
The most striking theme that emerged in this study was patients' lack of involvement in the decision to be brought to the teaching room for their cases to be presented to the medical students. Many of the interviewed patients explained that they were approached by senior doctors or postgraduate students and moved to the teaching room without knowing where they were going. Some expected that they were going for further investigations or to the radiology department and ended in the classroom in front of numerous students. Patients expressed frustration about this : t0 hey had not consented to be part of the teaching process at these two hospitals. Sami, a 28-year-old, explained his experience:
"At the beginning I did not know, I did not know. I did not expect that they will ask me about my disease. I was not comfortable. I am ok now, but I wish they had told me. Something like saying, 'We need your help, you know.' If one wants any help, he needs to ask, he needs to tell, not taking me like a blind person to the classroom."
Another patient (67 years old) described the following:
"The doctor came and said let's go down. He did not tell me where to. I ended in a teaching hall; there were many people, including young ladies. They put me on the table and asked me about my case. I had to repeat everything I said to doctors up in the ward. They were many, around 50 of them, and I had two who examined me."
Risk and benefit
Another theme that emerged from interviews is related to the concepts of risk and benefit. "Do good" and "do no harm" are important principles in medical ethics. This emerged very clearly in patients' excerpts as they looked into their experiences in various ways.
Sharing information and the opportunity to further discuss their clinical case in front of the medical students was regarded of great value. Patients felt that the thorough discussion of their case for teaching purposes is a good opportunity for them to learn more about their case.
"Having the teacher as well as the students asking is very good, as they might discover things I did not know about" (Issam, 21 years old).
Getting general knowledge was felt by Adham (47 years old) as a beneficial thing that he enjoyed the experience.
"Now I know the location of the spleen. The teacher put his hand on my abdomen and kept repeating the thing to the students. Students then examined me. The teacher's hand was lighter on me. Now I understand more."
As for the potential risks felt and expressed by the patients, they included having to disclose information they wished not to reveal. This was the case of 65-year-old Karim, who was not happy disclosing information about drinking alcohol before a class with many students. Drinking alcohol is forbidden for religious reasons among Muslims.
"Yes, I had to tell them that I drink alcohol. The student asked me; [Karim talking in an ironic way] 'Yes I drink' I had to say."
Another example given by Bassim (65 years old) concerned the lack of comfort by being in the classroom for a long time. He stated:
"The students benefited from me. But I lost the visit of my family. They were coming to see me. The timing was not good. I wish I was there for shorter time."
Many other patients felt that one hour to one hour and a half is a long period for them to be caught in teaching rooms. One patient was worried that this might have negatively affected his health.
Dignity and respect for the patients is undoubtedly one of the main guiding principles in the ethics of medical education. However, there were instances in which patients felt that they were treated inhumanely by the medical students. Ali (38 years old) who is a patient in the chest disease unit described his experience as being the "most inhumane instance" he had ever experienced.
"I wished I had died before they had laughed at me. These two students were laughing. I did not know why. One student was asking me a few questions. I said I was going to give the sputum. Well I was extremely annoyed by their behaviour. They laughed at me. That laugh killed me."
Patients also described instances of embarrassment that annoyed them:
"I had to uncover my chest in front of them."
Another patient said:
"I kept repeating the same story and being examined by many students. Their hands were light on me but definitely the teacher is different. He was telling them how to examine my body."
Evidently, having one's body used as a teaching tool for the students carried a sense of indignity. Houssam said:
"Why should they bring me four times to the classroom. This is too much."
The Role of the patient in serving medical students and the community
In the Syrian culture, serving community is particularly appreciated. Bringing beneficence and good to medical students emerged as a common theme identified in most interviews. Enthusiasm to those young medical students and keenness to bring benefit to them and their future as doctors serving in their community was expressed in the words of many patients interviewed. The following excerpt of an interview with Karim, a 65-year-old patient, reveals this:
"God bless them, I wish them bright future. I came here [to the classroom] for their benefit. Why not? I could also benefit. I liked them and was happy. Their words were really sweet."
Masri (47 years old) was very keen to bring good by educating medical students:
"Let them learn. Why not, they should learn. I was happy that my case was presented to them, the teacher was explaining and they must have benefited from this."
| Discussion|| |
The inclusion of humanities in medical education may offer significant benefits to individual future physicians and to the medical community as a whole. The in-progress work on curriculum transformation at Damascus University's Faculty of Medicine revealed the current focus on biomedicine in the curriculum with little space for humanities and patient-doctor communication. This apparently has had serious implications for the care of patients and the teaching of medical students. The narratives of patients recruited for our study illustrate their lack of proper involvement in consenting to be involved in students' education and the lack of empathy and professionalism on the part of medical students and their supervisors when dealing with them.
The ethical principles of patient autonomy, beneficence, and non-maleficence would argue for fully informing the patient about their involvement in teaching medical students. Bedside or even classroom teaching in the presence of the patient is the dominant practice of medical education at many universities, as it is at ours. The findings from this qualitative study bring clear evidence of the lack of adherence to the ethical principles of autonomy, beneficence and non-maleficence where patients are not informed about being moved to teaching room where they are to be interviewed and examined in front of a crowd of students. As with regard to the ethical principle of justice, we might argue that repeatedly selecting the same patients for classroom instructions, at the expense of their comfort and expectations, is unjust.
Altruism, rather than perceived benefit to self, seems to be the primary motivation for patients' participation in the medical education process. , Many previous studies indicate that patients have, in general, shown positive attitudes towards medical students for different reasons. ,,, In agreement with other literature, our study highlighted this very clearly, as Syrian patients were very keen to serve the community by allowing themselves to be used in the teaching of medical students.
Lack of dignity and respect for the patient have emerged as dominant themes in our study. This can be prevented if a greater focus on humanities teaching is given at our faculty and if codes of ethics were formulated and adhered to. Interestingly, patients who indicated that they were uncomfortable still allowed student involvement for altruistic reasons. There is therefore an additional ethical obligation to make patients as comfortable as possible and to carry out medical education in an ethical manner. Empathy and respect for patients is an integrated part of medical education. ,
This study alerted us to the need to study further the role of senior doctors and postgraduate students, for it was them, not the medical students, who took patients to the teaching room without telling them where and why they are going. Observing this unethical behaviour in their seniors will remain part of a vicious cycle if today's medical students copy this practice when they become postgraduates at these same hospitals and later pass on this behaviour to their juniors.
The main limitation in our study is that it included only male patients, as female patients receive positive discrimination in our setting by not being brought to the teaching room for teaching purposes. Furthermore, this is a qualitative study that aims to give in-depth understanding rather than create generalisable findings. To our knowledge, there have not been previous studies on this topic in our setting, where most clinical teaching is carried out in front of the patient, whether at the bedside or in teaching rooms or in the corridor. Although teachers in other settings may generally avoid bedside teaching out of concern for patient comfort, this type of teaching is still common in Syria, as well as in the region and globally. A recent article by Fischer put it very clearly, that professionalisation in medical education should start with a close look at bedside teaching because it is the core of training medical doctors.  In principle, teaching in the presence of patients, when conducted with sensitivity and respect, can add to rapport and proper communication.
| Conclusion|| |
In conclusion, ethical issues brought out in this study suggest that medical students at Damascus University need to be taught the importance of respecting the patient's autonomy and showing empathy for patients. The gap between biomedicine and the humanities should be bridged. Training and enforcing ethical guidelines, if not legislation, could contribute to more professional and quality medical education in our setting and also in other settings where bedside teaching is still common.
| Acknowledgement|| |
The authors are grateful to Damascus University for funding this study. The authors thank their colleague Dr. Nizar Abazid for kindly reviewing this manuscript.
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