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: [email protected]
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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