Patient Advocacy for Healthcare Quality Earp, French, Gilkey

1. Patient Advocacy for Healthcare QualityEarp, French, Gilkey Chapter 12 Confronting the Hidden Curriculum in Medical Education

2. Recent Efforts to Support Patient-centered Care in Medical Education • The National Board of Medical Examiners (NBME) requires that students be graded on their clinical skills, including taking medical histories, writing chart notes, communicating clearly with patients, and performing physical exams. • The Accreditation Council on Graduate Medical Education (ACGME/ABMS) requires all training programs to demonstrate that graduates are competent in communicating and developing relationships with patients and families. • Many specialty groups now include clinical skills examinations in their board recertification programs.

3. Persisting Barriers to Teaching Patient-centered Care • Most new curricula are classroom-based and limited to the first two years of medical education • Trained standardized patients are reliable and valid evaluators of medical student interviewing and physical examination skills, but do not perfectly mimic the dynamics in a typical patient encounter • The “hidden curriculum” overshadows classroom class room teaching

4. What is the hidden curriculum? “The commonly held understandings, customs, rituals, and taken-for-granted assets of what goes on in the life-space we call medical education” (Hafferty, 1998)

5. The Hidden Curriculum • Includes all the teachings students imbibe “on the job” during their clinical rotations under the guidance of senior medical faculty • Exists because teachers at the bedside often provide more powerful guidance to students about “the way it’s really done” than does the overt curriculum espoused by classroom professors • Means that medical curricula reform requires more than simply changing classroom lessons

6. Factors Contributing to the Influence of the Hidden Curriculum • Time-pressure of clinical rotations which leaves little room for reflection, innovation • Students’ need to master technical medical knowledge and skills • Hierarchical-style of teamwork based on a command and control structure

7. Confronting the Hidden Curriculum • Acknowledging the importance of observational, on-the-job learning • Creating ongoing, seamless training in the delivery of patient-centered care • Changing organizational culture to support new teaching practices

8. Case Study: The Medical College of Georgia’s Children’s Medical Center • In the early 1990s, hospital administrators commissioned a team of parents to work as partners on an extensive facilities design project • More than 20 parents and children worked with architects and hospital staff to ensure that the new space provided a healing environment • Many features important to parents, such as sleeping accommodations in their children’s rooms, were easily and inexpensively achieved to create an award-winning design

9. Case Study: The Medical College of Georgia’s Children’s Medical Center (con’t) The success of MCG’s participatory approach spurred continued partnership among patients and staff: • 130 patients and family members currently serve as advisors on hospital committees, including the Family Advisory Council and the Children’s Advisory Council • MCG’s Neurosciences Center opened in 2003 with an open visitation policy, a family resource area, and organized patient advisors who interview all staff before they began working on the unit • A Family Faculty was developed in 2002 to co-teach alongside the professional faculty in all five MCG schools (medicine, nursing, allied health, dentistry, and graduate studies)

10. Examples of Teaching Points from Patients’ Perspectives • It is often small things that are most important---“If you are going to put windows in the waiting room of the Cancer Clinic make sure there is a heat source nearby….we are all cold from our chemotherapy treatments.” • “Women getting mammograms don’t want a test on Friday and lose sleep all weekend waiting for results.” • “Cardiology patients want a sense of competence, confidence, and security in receiving heart care. There are no generic spaces and no generic patients.” • “We want to know what medications we are taking in the hospital; we want to know, if any error touches us, whether harm occurred or not; we want a list of medications that follows us wherever we go in the hospital.”

11. Conclusions • Changing classroom curricula is not enough • Medical centers must commit to organization-wide change if they truly intend to support the teaching of patient-centered clinical practices • Reforms need to extend to all levels of the learning environment, from the classroom to mentoring relationships to the culture of teaching hospitals themselves