2010; 32: 552–557

Can final year medical students significantlycontribute to patient care? A pilot study aboutthe perception of patients and clinical staff

CHRISTIAN SCHEFFER1, FRIEDRICH EDELHAUSER1, DIETHARD TAUSCHEL1, MERLE RIECHMANN2 &ARA TEKIAN3

1University of Witten/Herdecke, Germany, 2Picker Institute Germany, Germany, 3University of Illinois/Chicago, USA

Abstract

Background: Active participation of medical students in patient care has been shown to be important for professional

development of learners. Not much is known about the impact of active student participation (ASP) to the quality of patient care.

Aims: We established a Clinical Education Ward (CEW) for the final year medical students caring for patients under structured

clinical supervision. This study investigates the views of both patients and clinical staff on the impact of ASP on patient care.

Methods: The Picker Inpatient Questionnaire (PIQ) was used to survey all the patients admitted to the CEW during the pilot

phase. Results concerning the general quality of health care and the patient–physician relationship (PPR) were compared to two

matched pair control groups: patients of the same department (CG1) and of internal wards in Germany (CG2). In addition,

quantitative and qualitative data were collected from patients and clinical staff members to specify the impact of students on

patient care.

Results: Out of 111 patients, 64 responded. The PIQ results revealed very minor problems in the assessment of the overall general

quality of care and in PPR at the CEW, while significant improvements existed when compared to CG2. Furthermore, 79% of the

patients and 95% of the staff members recorded a positive impact of ASP. Qualitative data illustrated and complemented these

results. Chances and challenges in programs with high participation of students in clinical care are discussed.

Conclusion: ASP may not only be useful for learners but also offers chances and benefits for patient care.

Introduction

Clinical education as a vital component of the medical

curriculum has to meet a wide range of educational goals.

During clinical clerkships, students extend their medical

knowledge, practice procedural and communication skills,

and develop clinical thinking. Moreover, they acquire organi-

zational abilities, competencies in interprofessional communi-

cation, and learn to act in their professional role as a physician.

Usually, the latter aspects are not explicitly taught but are a

part of the ‘‘hidden curriculum’’.

Since the study by Lave and Wenger (1991) on situated

learning, we know that active participation is essential for the

development of expertise and professional identity. The tacit

skills of every profession are within the ‘‘community of

practice’’ and are learned from there. According to Lave and

Wenger, who studied the learning process in apprenticeships

of midwives, tailors, and butchers, even novices start by being

involved and absorbed in the ‘‘culture of practice’’ and not by

merely passive observations. Adapting this concept of ‘‘legit-

imate peripheral participation’’ in the field of medical educa-

tion means that students are not only instructed and taught in

clinical settings but have to be integrated in the health care

team and to play an active role in the daily task of good patient

care. Using the words of Ludmerer (1985), students have to

become an ‘‘active part of the hospital machinery,’’ not only in

an observing role, but experiencing the conditions of medical

practice. The concept of ‘‘legitimate peripheral participation’’

provides the conceptual framework for our research.

Some programs with active student participation (ASP) in

patient care have shown good educational effects. In various

universities in Sweden and Great Britain, Clinical Education

Practice points

. ASP in patient care has been shown to be important for

professional development of learners. Not much is

known about the impact of ASP to patient care.

. The majority of patients accept and value ASP. Specific

qualities like high motivation of students, more time

spent with patients, and reflection of clinical activities

may lead to benefits for patients in particular concerning

communication with the physician team and the expe-

rience of individual and comprehensive care.

. In concepts with ASP, structured supervision becomes

vital for learning as well as for patient care. Facilitators

are challenged to find the right balance between

autonomy of students and the needs of patient care.

Correspondence: C. Scheffer, Integrated Curriculum for Anthroposophic Medicine, University of Witten/Herdecke, Alfred-Herrhausenstr. 50, 58448

Witten, Germany. Tel: 49 2330 623468; fax: 49 2330 62 4061; email: cscheffer@web.de

552 ISSN 0142–159X print/ISSN 1466–187X online/10/070552–6 � 2010 Informa Healthcare Ltd.

DOI: 10.3109/01421590903437170

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Wards (CEW) were established with students of different

health care professions taking care of patient under supervi-

sion (Fallsberg & Wijma 1999; Reeves & Freeth 2002; Hylin

et al. 2007). Competencies in interprofessional teamwork, role

development, real-life practice, and patient care were devel-

oped specifically. A program for interns in general practice

demonstrated higher learning motivation due to greater

autonomy and responsibility of students under good supervi-

sion (Cantillon & Macdermott 2008).

In realizing programs with active participation, medical

education has to answer two questions. First, how the

‘‘community of practice’’, the health care team, its collabora-

tion, and its organizational processes are affected by student

participation, and second more importantly, how patient care

itself is influenced by that. There is a growing public interest in

patients’ views on being involved in medical education (Howe

& Anderson 2003). Till now, research has focused on the

attitudes of patients toward the presence of students during

consultations, namely in outpatient settings (Cooke et al. 1996;

Choudhury et al. 2006) or during the practice of smaller

procedures like suturing or intravenous access (Santen et al.

2005). But how are patient care and the relationship between

patients and physicians altered if patients are not only treated

by professionals in the presence of observing students but by

students in the presence of supervising professionals?

In consideration of these issues, we developed a CEW for

the final year medical students who were fully integrated in the

clinical team and acting as ‘‘physicians under supervision’’.

The purpose of our pilot study was to investigate the impact of

that educational concept on patient care. In particular, we

were interested to learn how patients perceived the quality of

care at the CEW. In addition, we were interested to explore the

views of patients and clinical staff on the specific impact of

ASP to patient care.

Methods

Implementation of the CEW

Based on the idea and the concept of the first CEW in Sweden

(Wahlstrom et al. 1997; Fallsberg & Wijma 1999; Ponzer et al.

2004), we implemented a CEW with a maximum of 10 beds in

a ward for Internal Medicine with 36 beds. During the

preparation phase of more than 1 year, educational goals

and a concept to achieve them were developed in collabora-

tion with participating students. In the following process, the

concept was presented to the health care team on the ward

and adapted to the needs of interprofessional cooperation and

organizational aspects. A monthly feedback round was initi-

ated to follow the progress of the project in close contact.

Upon admission to the CEW, patients were informed about

the aims of the CEW, the role and the duties of students, as

well as responsibilities and tasks of supervising clinicians.

During a pilot phase with two rotations, four and five final year

volunteering medical students (five female, four male) spent a

16-week clerkship in internal medicine at the CEW. Each

student was in charge of the care of 2–4 patients at a time.

Students had to fulfill all tasks of a junior house officer, from

admission of patients, conducting ward rounds and

communication with patients, to the letter of discharge.

Students were supported and supervised by two experienced

clinicians. Every important decision, like changing medication

or arranging diagnostic interventions (e.g., X-rays), had to be

done after consultation and in agreement with the supervising

physicians. Clinical support was increased in cases with more

complex diseases and was adapted to each student’s individ-

ual abilities. The project is part of the Integrated Curriculum for

Anthroposophic Medicine (ICURAM) at the University of

Witten/Herdecke, Germany, a program to foster self-directed

learning and self-development as well as the practice of

Integrative Medicine (Scheffer et al. 2005).

Quantitative inquiry about general satisfaction withclinical care

We used the German Picker Inpatient Questionnaire (PIQ) to

get feedback from patients on the quality of care received in

the CEW. Originally developed in the United States by Cleary

et al. (1991), the PIQ was accredited in 1997 by the Joint

Commission for Accreditation of Health Care Organizations

(JCAHO 1998) and is now used worldwide. Patients are asked

to report their experience with specific events and processes in

the hospital. It includes six questions about patient–physician

relationship (PPR) as well as two general quality items like

further recommendation to friends and relatives. To include

medical students in the patients’ feedback form, the word

‘physician’ was replaced by ‘the physicians’ team’ in all

relevant questions together with a note that students should be

seen as part of the physicians’ team. Exclusion criteria were

applied similarly to the use of PIQ in other conditions: death

of patient, age 518 years, hospital stay 52 nights, and

re-admission during the period of survey.

Two control groups were selected: patients of the same

department without students (CG1) and patients of internal

medicine wards in Germany (CG2). Since socio-demographic

factors as well as health conditions may have a significant

impact on the results, matched pairs were created according to

five criteria (age, gender, education, patients’ self-assessment

about their health status, and the presence of pain).

As described by Cleary et al. (1991), we calculated a score

for each item by counting all responses indicating the presence

or absence of a problem. The score ranges from 0% (no

problem reported) to 100% (all answers to that item indicate

the presence of a problem). The original data with an ordinal

scale with 3–5 points were used for the Mann–Whitney test. A

p-value50.05 was considered to show significant differences.

SPSS for Mac (16.0) was used for all statistical analyses.

Quantitative and qualitative inquiry about specificinfluence of student involvement

Patients were asked to assess the impact of students on their

care on a five-point scale between very negative and very

positive and to describe the possible impact with free text. All

members of the health care team (n¼ 28/26 during the first/

second rotation) consisting of nurses, therapists (physiother-

apists, art therapists, and masseurs), and physicians were

equally asked about the effects of student’s active participation

Can medical students contribute to patient care?

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on patient care. To sustain anonymity, all answers were sent to

an independent institute for a preliminary analysis.

The free text responses by patients and staff members were

analyzed according to qualitative content analysis by Mayring

(2000). Inductive categories were formulated from the material

by one researcher (CS) and consecutively checked by and

discussed with a second author (FE). After reassignment of

comments to new categories, a consensus was formed about

the summary and presentation.

Results

Quantitative data

During the pilot phase, 127 patients were treated at the CEW

(Table 1). After exclusion, 111 patients remained of whom 58%

returned the questionnaire. Compared to two control groups

(Figure 1), the scores at the CEW showed the lowest problem

score in PPR with significant differences in four out of six items

compared to CG2 (patients of internal wards in Germany).

Concerning the two general items, problem scores in

‘‘no satisfaction with overall treatment’’ were significantly

lower at CEW patients compared to CG2, while there was a

non-significant tendency (p50.1) for ‘‘no further recommen-

dation to friends and relatives’’. Compared to CG1 (same

department without students), the scores at the CEW also

showed lower problem scores in all eight items but only in ‘‘no

physician in charge of care’’ difference was significant. No

significant differences were found between CG1 and CG2.

Most patients (79%) had the impression that the impact of

actively participating students was partly positive or very

positive (Figure 2), 5% saw a partly negative influence. The

same question for staff members resulted in 95% positive and

5% partly negative assessments (Figure 2).

Qualitative data

Free text responses were collected from 22 patients and 38

staff members to the question ‘‘If, and if yes, which differences

did you note compared to patient care without students?’’

Qualitative content analysis emerged in three major

0% 5% 10% 15% 20% 25% 30% 35%

1. No physician in charge of care

2. No understandable answers to important questions

3. No physician to talk about personal concerns

4. No relationship of trust with physicians

5. Not enough empathy on the part of physicians

6. No physician available when needed

Patients–Physician Relationship (1–6)

7. Not satisfied with overall treatment

8. No further recommendation to friends andrelatives

CEWCG1CG2

Figure 1. Problem frequency reported by patients of CEW, of the matched pair control groups of same department without

students (CG1) and of internal wards in Germany (CG2).

Notes: indicates a significant difference between CEW and CG2 and between CEW and CG1 (p50.05; Mann–Whitney test).

Did student participation have anyimpact on patient care?

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

Verypositive

Partlypositive

No impact Partlynegative

Verynegative

PatientsStaff

Figure 2. Answers by patients (n¼ 64) and staff members

(n¼ 44) on the general impact of student participation on

patient care.

Table 1. Characterization of patients.

Number of patients 127

Female/male 75/52

Age (mean) 66.2 years

Exclusion criteria

Died 5

518 years 1

52 nights stay 8

Re-admission 2

Sum of patients excluded 16

Asked patients 111

Questionnaires returned 64 (58%)

C. Scheffer et al.

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categories: quality of care, relationship: patients–physicians’

team, and teamwork and organization.

Quality of care. Most patients (n¼ 17) described care in the

CEW compared to a ward without students as intensive,

comprehensive, and/or consistent. The high amount of time

students spent with patients was noticed frequently as well as

high motivation and commitment on the part of the students.

History taking and physical examinations were characterized

as intensive and elaborate. Care in general was perceived as

being more individualistic and holistic.

Staff members frequently stated that students knew their

patients better, including their social background and that

differential diagnostic considerations as well as therapeutic

plans were extensive and thorough. While one staff member

noticed problems with stringent proceedings in complex

patients, most team members described positive changes

with benefits for the patients.

Relationship: Patient-physicians’ team. Patients normally

described a positive relationship to students: Students devel-

oped a relationship of confidence. I felt perceived as a whole

person (one patient). It was frequently expressed that students

were good and active listeners and that patients felt safe and

had the impression that their conversations and communica-

tions were taken seriously. Two out of the 22 responding

patients made negative comments. One stated that a student

was overextended and not supported enough, one expressed

problems to accept students in the role as the primary contact

person. One staff member made a similar comment, saying

that insecurity in students may produce feelings of insecurity in

patients.

Twenty-two comments by staff members confirmed the

higher amount of attention and mindfulness that patients

received. It was frequently stated that students had closer and

better contact to patients and relatives, that biographic and

psychosocial aspects were recognized better, and that students

had time to respond to patients’ individual wishes. A deeper

and more intense commitment of students to the patient and

his or her illness was noted.

Teamwork and organization. Some patients and several

staff members noted a faster work-up of diagnostic tasks like

completing admission in time or placing IV lines. Some staff

members pointed to the better and continuous medical

presence and to a more intensive interprofessional exchange.

Two mentioned that students contributed new ideas and

suggestions, resulting in improved teamwork.

Discussion

In this pilot project, patients were treated by final year medical

students who were integrated in the health care team and

supervised by experienced physicians. Responses by patients

and staff members confirmed that ASP did not result in lower

satisfaction with patient care. Taking into account that students

have relatively little clinical experience, less practice in

communication skills with patients, and less confidence in

clinical management, the good results of the CEW concerning

further recommendation and overall treatment seem to be

encouraging. The fact that students may have to exercise

technical skills like taking blood and that the presence of four

or five additional persons on ward rounds may be perceived as

stressful, all these possible negative aspects of student

involvement did not result in lower acceptance on the part

of patients.

In our case, the CEW was placed in a hospital practicing

Integrative Medicine. This may be one reason for the better

PIQ results of the department (CEW and CG1) compared to the

national reference group (CG2). The differences in PIQ results

between the CEW and CG1 are not significant except for one

item. Nevertheless, the CEW showed the best results among

the three groups for all the selected items. Furthermore, results

of the qualitative data as well as the inquiry of staff members

support the interpretation that not only the hospital itself

but also the student participation had a specific effect on

patient care.

Our study also reveals some specific chances and chal-

lenges for active participation of students in clinical care that

are summarized in Box 1. First, the majority of patients noticed

a partly positive or very positive impact of student involvement

on patient care. One might criticize that these results were

influenced by a tendency of being generous to learners with

more positive feedback, or that some patients may not have

had much experience with clinical care without students. On

the other hand, patients’ positive impressions were confirmed

by staff members who know the normal situation without

students very well. Furthermore, results of the PIQ compared

to two control groups also indicated a positive impact of

student involvement, in particular on PPR.

Specific chances for clinical care with actively participating

students may not be only seen in the additional time students

can spend with patients. In the PIQ, patients reported that they

Box 1. Chances and challenges for patient care due to ASP.

Possible chances due to ASP in patient care

� More time spent with patients

� High motivation and commitment of students

� Careful history taking and physical examination

� More information about patients’ psychosocial background

� Higher reflection of clinical activities through teaching

� Fast work-up of clinical duties

Possible benefits for patients

� More time for patients and relatives to ask questions

� Better understanding of illness and consequences

� Experience of attentiveness and mindfulness

� Higher consideration of their social needs

� More individual and comprehensive care

Possible problems due to ASP

� Students’ insecurity may produce insecurity in patients

� Confidence in students’ competences

� Acceptance of students’ role

� Stringency in treatment of patients with complex problems

Challenges for facilitators

� How to find the best dose of guidance/level of supervision for

students?

� How to identify patients who are not/less appropriate for student

involvement?

� How to disclose the role of students and of supervisors to patients?

Can medical students contribute to patient care?

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had fewer problems in understanding the answers to impor-

tant problems. Empathy and attentiveness in students was also

rated as high. Taking into account the analysis of qualitative

data, commitment, and motivation in students as well as

interest and active listening seem to be important for the

experience of comprehensive and individual care.

Furthermore, teaching lessons with real patients may lead to

higher levels of reflection of clinical decision making and of

clinical proceedings.

A smaller minority of patients expressed criticism about the

care at the CEW. Obviously, the perception of good supervi-

sion by clinicians is vital for patients. Although various studies

noted a positive attitude of patients in general, a minority of 1–

7% remains skeptical about student involvement in their care

(Cooke et al. 1996; Bentham et al. 1999; Walters et al. 2003;

Choudhury et al. 2006). Further investigation will have to

determine the type of patients who are more likely to benefit

from student involvement.

Our results are in accordance with a first evaluation of

patients’ feedback of a CEW in London (Reeves & Freeth

2002). In a qualitative study with 34 participants, patients were

more satisfied with communications aspects compared to a

normal ward. In addition, patients noted that motivation and

enthusiasm in students were higher than in professionals. A

quantitative analysis with 23 patients came to similar results

(Reeves et al. 2002). Some other studies with lower student

participation also showed that patients might benefit from

interaction with students. Patients appreciated that students

tend to take the history or perform the physical examination

very carefully and extensively (Thomas et al. 1999). It was also

noted that talking with students might help patients to get a

deeper understanding of their illness (Thistlethwaite &

Cockayne 2004). In a study by Walters et al. (2003), patients

valued the experience of being listened to with respect,

growing self-esteem, and empowerment, as well as a strength-

ened doctor–patient relationship.

Strengths and limitations

To our knowledge, this is the first study with a validated

questionnaire and matched pair control groups on the effects

of high student participation in clinical patient care.

Results of the quantitative analysis are specified and comple-

mented by the qualitative analysis. Patients’ views are

complemented by the perspective of clinical staff.

This pilot study has several limitations. First, the CEW was

implemented at only one hospital. Second, we used only

subjective data. For an analysis of the impact of ASP on the

quality of patient care, other aspects might be analyzed, like

complications during or shortly after the hospital stay as well

as medical error rates. Economic aspects like changes in

duration of hospital stay or numbers of performed investiga-

tions are not examined either.

Implications for clinical education

Due to economic changes in the health care systems,

physicians’ time per patient has been reduced during the

past decades with consequences for patients’ outcome and the

PPR (Davidoff 1997). The shortage of personal resources also

leads to conflicts between delivering patient care and clinical

teaching: physicians who are completely occupied with

patient care may not be willing to spend additional time with

teaching. In this situation, ASP in patient care may be a

possible alternative among other traditional models. In our

case, four and five final year medical students replaced one

house officer in his daily duties of patient care. Free resources

of the house officer were used for supervision and teaching.

Student participation resulted in more time for patients and a

closer relationship between patients and the physicians’ team.

Thus, ASP may offer chances of active learning for students

and greater satisfaction for patients.

As shown in different studies about CEWs, a supervised

trainee ward seems to be a useful method of ASP for both final

year rotations and clerkships during earlier clinical education

(Reeves & Freeth 2002; Reeves et al. 2002; Ponzer et al. 2004;

Lindblom et al. 2007; Scheffer et al. 2009). Moreover, ASP is a

very powerful learning concept even in earlier years of

medical education (Dornan et al. 2006). As shown with the

model of task-based learning (Harden et al. 2000), it seems to

be a worthwhile challenge to create clinical settings where

learners are asked to take over responsible activities in patient

care which are adequate for their stage of education through-

out the complete medical curriculum. Longitudinal inte-

grated clerkships may be a very useful tool to realize

such concepts (Norris et al. 2009). Comprehensive clinical

supervision, adequate support of the learners, and enhance-

ment of reflection of practice will play a central role in those

concepts.

Conclusions

Taking the strengths and limitations into account, our study

shows that it is possible to involve the medical students in a

clinical health care team without lowering acceptance on the

part of patients. Furthermore, the potential strengths of such

educational models may result in specific benefits for patients,

in particular with regards to the PPR. Future research will have

to explore in greater depth the impact of teaching and student

involvement in clinical care.

Declaration of interest: There are no conflicts of interest.

Notes on contributors

CHRISTIAN SCHEFFER, FRIEDRICH EDELHAUSER and DIETHARD

TAUSCHEL are physicians and educators at the University of Witten/

Herdecke in Germany. Together they are responsible for a program in

Integrative Medicine, namely the ‘‘ICURAM’’.

MERLE RIECHMANN is working as a study nurse at the German Picker

Institute in Hamburg, Germany.

ARA TEKIAN is an associate professor of Medical Education and director of

International Affairs in the Department of Medical Education, University of

Illinois, Chicago. He teaches and advises graduate students in the masters

in health professions education program.

C. Scheffer et al.

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