As soon as the elevator door closed, the tears gave way, and I walked home with my head down … thoughts of my mistakes running rampant.
So began the reflection of a third-year medical student, who described falling short of his residents’ expectations on a history and physical examination. The crucial flaw? He had taken too long. His reflection continued:
[The next day], an elderly patient, traction stockings covering her small, dark brown legs, shuffled toward me. She stopped directly in front of me, her delicate, slightly stooped frame supported by her thin hand, grasping the IV pole. “Young man,” she said, “I heard you speaking to the patient in the bed next to me [last night]. And I just wanted you to know that I’m just so proud of you.… How you spoke to that patient with such care and intelligence. I’m just so proud.”
She was not my patient, and I never knew her name. Yet, this unexpected observer gave me feedback. Her critique would not be factored into my final grade. But, my encounter with this elderly woman stands out as one of my most profound patient interactions during my third year.
Having taught students for over a decade, I pondered what was suddenly obvious: Why don’t we routinely solicit patient feedback as part of our students’ learning experience? Who better to teach them about humanism, compassion, empathy, and professionalism?
Fast forward to 2010 and the disruptive innovation OpenNotes. About 100 doctors from three U.S. medical centers volunteered to share their visit notes with 20,000 of their patients through a secure online portal.1 When one, an educator, found her student’s clinic performance subpar, rather than again rely on her own feedback, she pivoted. “Write an open note,” she instructed the student, inviting the patient to critique the student’s note. In the end, the student learned far more from the patient than from her, as patient feedback sometimes can motivate behavior change more powerfully than feedback from supervisors.
Today over five million patients across the country have access to their physicians’ notes, and that number is rapidly growing. As experts sound the call to action for patient- and family-centered education, patients and families are at the other end of their notes, ready to help.
Innovations like OpenNotes can connect patients with learners in new ways and bring patient and family voices—now shockingly sparse—into medical education. Sharing notes with patients and inviting their feedback offers a unique and scalable opportunity to incorporate patient perspectives into educational experiences.
Stan, the student above, is now an adolescent medicine fellow. Each year, he gets aggregate data from a handful of anonymous surveys completed by randomly selected patients in his clinic as part of a “360-degree” evaluation. These are important first steps, but he still craves real-time, qualitative feedback from patients, and he is not alone. When I ask my colleagues, very few ever hear from patients about how they are doing, what can be improved, and how they can work better together as a team, all of which are critical components of patient engagement. As one colleague recently reflected: “There’s a lot we can learn from patients. But we don’t ask, and they don’t tell.”
Efficiency matters, and lessons in clinical competency from superiors can never be replaced. But they can be enhanced. Stan was lucky. Had his patient’s neighbor not stopped him in the hall, he would be one step closer to being “more efficient” but perhaps one step farther from recognizing his capacity for compassion. Could such experiences be part of the solution to reversing the empathy degradation that often characterizes the development of young doctors? Could patient input balance and humanize the curriculum? Because of his early experience, Stan knows to seek more from his patients than Likert scale ratings on standardized questions, but such opportunities are rare. Turning to patients—the expert witnesses of our care and our most frequent and invested observers—educators and learners may benefit from patient feedback through formal systems that recognize not only the value of clinical skill but also the power of patient insight.
Acknowledgments: The authors thank this patient and others for sharing their feedback, the Beth Israel Deaconess primary care physician who shared her experience teaching with OpenNotes, and Alison B. Rapoport, MD, for her insights on engaging patients.
Sigall K. Bell, MD, and Stanley R. Vance Jr, MD
S.K. Bell is associate professor of medicine, Department of Medicine, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, Massachusetts; e-mail: Sbell1@bidmc.harvard.edu.
S.R. Vance Jr is clinical fellow, Division of Adolescent and Young Adult Medicine, Benioff Children’s Hospital, University of California, San Francisco, San Francisco, California.
1. Delbanco T, Walker J, Bell SK, Darer JD, Elmore JG, Farag N, et al. Inviting patients to read their doctors’ notes: a quasi-experimental study and a look ahead. Ann Intern Med. 2012;157:461–470