Exploring patient involvement in obstetrics and gynaecology education for medical students: a scoping review protocol

Abstract

Introduction

It is important to incorporate the patient perspective into healthcare education, as we know that patients are experts in their own conditions. The expertise gained through lived experience serves to complement the theoretical knowledge that healthcare educators can provide. This scoping review aims to explore patient involvement in medical education within obstetrics and gynaecology, a specialty that can provide unique challenges and complexities to patient involvement due to its potentially highly sensitive and intimate nature. The goal of this study is to map the available literature on this topic which will allow for the identification of potential gaps in the provision of training for medical students in this field. The research also aims to highlight challenges that may be associated with patient involvement in this specialty in order to guide future initiatives.

Methods and analysis

The Joanna Briggs Institute scoping review framework and methodology will be used to guide and conduct this scoping review. A systematic search of electronic databases MEDLINE, CINAHL, Embase, Scopus, PsycINFO, ERIC, Google Scholar, Web of Science, African Journals Online, Cochrane Library and SciVerse will be carried out. Articles will be limited to the English language. No geographical limitations will be placed on the search. Literature from 1960 to 2023 will be considered for inclusion which corresponds with the first reports of patient educators used to assist with the demonstration of clinical skills in obstetrics and gynaecology. Relevant academic journals will be hand-searched for the previous 5 years. Identified studies will be screened by two independent reviewers and data extraction carried out by the primary researcher. Key findings will be presented in tables and summarised in narrative form. Findings from the review will be reported according to the PRISMA Extension for Scoping Reviews reporting checklist.

Ethics and dissemination

Ethical approval is not required for this study. The findings from the study will be submitted for publication in peer-reviewed journals and at medical education conferences.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• A comprehensive exploration of the literature will be carried out, including eleven electronic databases, grey literature and academic journals with no limitations placed on study design or evidence type included.

• The well-established Joanna Briggs Institute framework for the conduct of scoping reviews will be strictly adhered to, allowing for rigorous and reproducible methodology.

• Given the language limitations placed on the literature, it is possible articles not published in the English language may be missed.

• The reason for choosing to carry out a scoping review is to provide a broad and comprehensive map of the existing literature; therefore the quality of evidence in the included studies is not assessed.

Introduction

Healthcare systems worldwide have evolved to take on a more patient-centred approach to the delivery of care.¹ In contrast to an older, perhaps more paternalistic style of medicine, the person receiving care is no longer seen as a passive participant in decisions related to their health but rather an active contributor to their care pathway. Patients are encouraged to form collaborative partnerships with their caring physician, one which actively considers the complexities of the lived experience and the unique needs and challenges faced by each individual.

In adopting this more holistic approach to healthcare provision, it is imperative that medical students are provided with an education that places value on the importance of patient participation in their medical journey. Our responsibility as medical educators is to develop doctors who have an appreciation for the patient story on a level that extends beyond the clinical diagnosis and acknowledges the complexities associated with the lived experience. Students who understand the individuality of each patient and the importance of their story will be better be placed to provide care that is both collaborative and patient centred.^{2 3}

The contributions patients can make to medical education are wide and varied.^{4 5} A proposed timeline for patient participation in medical education highlights the diversity of patient involvement.⁶ The concept of the programmed patient (a person trained to demonstrate specific physical signs) was first described in the 1970s,⁷ followed by arthritis educator programmes which involves people with arthritis trained to provide feedback to students in musculoskeletal examinations.⁸ These types of programmes are still in widespread use internationally today. Within the field of obstetrics and gynaecology, Gynaecology teaching associate programmes were first introduced in the 1960s.⁹ This was a concept designed to help students to develop their competence and confidence in the pelvic examination and involves a trained person who provides instruction and feedback on the pelvic examination using their own body for instruction.

Of course, the value of the expert patient extends far beyond the demonstration of physical examination alone. Patients have a wealth of experiential knowledge that can be harnessed to deepen student understanding. The concept of active patient involvement refers to the patient who is engaged in a collaborative way, using the insight gained through personal experience to guide and influence medical student learning.⁴ The value of the patient story has been highlighted in recent years by the introduction of the concept of ‘narrative medicine’. The core principles of this branch of medicine are centred on the idea that every patient can provide their own intricate chronicle of their experience which is as rich and complex as a novel and places value on the fact that every patient has a very personal story to tell. The founder of narrative medicine, Dr. Rita Charon, has said that ‘Doctors need the expertise to listen to their patients, to understand as best they can the ordeals of illness, to honour the meanings of their patients’ narrative of illness and to be moved by what they behold so that they can act on their patients’ behalf’.¹⁰

Individuals seeking care in obstetrics and gynaecology are often doing so at pivotal stages in their lives, whether this be through childbirth, experiencing pregnancy loss or facing challenges of menopause. Clinicians in this specialty often come into contact with individuals who are experiencing a period of great transition in their lives. There are times of profound joy, deep sadness and huge change. For this reason, there is an intimate and deeply personal nature to the practice of obstetrics and gynaecology and a sensitivity that is required to provide a high standard of care to these patients. It is hard to imagine that this full spectrum of engagement can be taught through didactic methods or textbooks alone. In order to provide a future for women’s healthcare that is driven by empathy, understanding and compassion, there is a need to amplify the patient story.

Our research aims to provide an up to date analysis on patient involvement in obstetrics and gynaecology medical education while also examining what challenges are highlighted for patient-student engagement and partnership in this specialty in particular.

Language and terminology

The authors acknowledge the complex and emotive nature surrounding the language used in healthcare to describe individuals engaged with the medical system and in particular with regard to the term ‘patient’. This term can be perceived as paternalistic as it may be seen to imply a passive role for the individual in their relationship with their care provider. This term may at times be rejected by some individuals in favour of terms such as ‘service user’ or ‘client’ or ‘consumer’. While recognising the concerns associated with this term, this protocol opts to use the term ‘patient’ for the sake of clarity and consistency throughout the study. It is challenging to find a universally accepted alternative term that provides a clear and concise definition for those individuals engaged with healthcare services. The choice to include the term ‘patient’ is not intended to dismiss alternative terms, rather to provide a coherent and consistent approach to the reporting of this study.

Scoping review objectives

The importance of incorporating the patient voice into the provision of training for medical students cannot be underestimated. As highlighted, care in obstetrics and gynaecology traverses life stages and therefore lends itself to diverse patient experiences. If harnessed, these patient narratives present opportunities for students to learn about the importance of empathy, sensitivity, communication, and the unique joys and challenges associated with this specialty.

A preliminary review of the literature highlights the lack of emphasis on the patient story within obstetrics and gynaecology education for medical students. The objective of this review is to map the available literature to explore the extent of patient involvement to date within this field so that we may identify gaps in current delivery of training to medical students in obstetrics and gynaecology. The objective of the review is also to explore outcomes from existing patient-student interactions in this specialty and how these outcomes are evaluated.

Establishing a clear picture of the current landscape and highlighting the potential challenges faced will aid in expanding future training for medical students that places the individual at the heart of the care we provide.

Methods and analysis

This scoping review will adhere to the framework provided by the Joanna Briggs Institute (JBI) methodology for scoping reviews,¹¹ and findings will be reported according to the PRISMA Extension for Scoping Reviews (PRISMA-ScR) guideline and checklist provided.¹² In order to measure the extent of patient involvement, the ‘Ladder of Involvement’ conceptualised by Tew et al¹³ will be used to assign the ‘level’ of involvement to each patient encounter identified. Included studies will also be further categorised according to the taxonomy for patient involvement developed by Towle et al.⁴

A scoping review allows for a broad and comprehensive exploration of the available literature. A preliminary search of MEDLINE confirmed that there are no existing systematic or scoping reviews examining the extent of patient involvement in medical education within the specialty of obstetrics and gynaecology specifically.

Identification of the research questions

In line with the JBI framework, core review questions have been established. These research questions have been refined and focused through author discussion. While our primary goal is to establish what involvement patients have had to date, it is also necessary to investigate the outcomes of patient involvement in this specialty and how potential outcomes have been assessed or evaluated. To do this, we will describe at which level of the Kirkpatrick model the authors evaluated their intervention.¹⁴

There is an important factor that needs to be considered in relation to student-patient interactions in obstetrics and gynaecology. This pertains to ethical considerations surrounding patient participation in the education of students in a branch of medicine which is particularly sensitive and personal in nature. For this reason, a portion of our review will aim to establish how the safety and well-being of patient educators is being protected in this context. The primary research question is as follows:

1. What published research is available on the extent of patient involvement in undergraduate medical education within the field of obstetrics and gynaecology?

Secondary research questions are:

• 2 1Are there benefits to patient contact for both the student and the participant, and how is this assessed?
• 2 2What are the ethical issues highlighted in the literature surrounding patient involvement in this specialty, and how is the safety and well-being of the patient educator cared for?

Inclusion criteria

Inclusion criteria have been defined which will aim to identify all the relevant literature pertaining to the research questions above. These criteria have been assigned using the population, concept and context mnemonic as a framework.¹⁵ This is displayed in table 1.

Table 1. Population, concept and context framework.

Population	Medical students: undergraduate or graduate entry
Concept	Active patient involvement in medical student education
Context	Specialty of obstetrics and gynaecology

Population

This study is focused on the education of undergraduate and graduate-entry medical students only. We will exclude qualified doctors and other health professional students from the scoping review. We want to specifically analyse patient contact levels for students before they enter clinical practice and embark on their clinical journeys.

Concept

As the goal of this study is to broadly map patient involvement in medical student education, all forms of patient involvement will be considered aside from simulated or acting roles.

Context

While previous studies have mapped patient involvement within medication education more broadly,¹⁶ there is a lack of published evidence exploring this concept with a spotlight on the field of obstetrics and gynaecology in particular. An early adjustment was made to the inclusion criteria when establishing this protocol as preliminary searches were found to retrieve too many irrelevant articles when women’s health was considered in a broad context, for example, articles related to breast disease/breast examination were being retrieved. The goal is to focus the research within the specialty of obstetrics and gynaecology specifically; therefore, the inclusion criteria has been adjusted and refined accordingly.

A full list of eligibility criteria is included in online supplemental table 1.

Search strategy

In accordance with the recommendations from the JBI Manual for Evidence Synthesis,¹¹ a three-step process will be carried out to develop a comprehensive search strategy. An initial limited search has been carried out to identify relevant articles in this subject area. This has been carried out through the MEDLINE database. Secondly, keywords and terms used in these titles and abstracts will been extracted and relevant synonyms and concepts identified to build on the search strategy. Terms will then be crosschecked using Medical Subject Headings in MEDLINE, Excerpta Medica Thesaurus (EMTREE terms) in EMBASE and CINAHL Subject Headings in CINAHL. Finally, the reference list of identified articles will be searched for additional literature sources. This search strategy has been developed with the assistance of an expert academic librarian (see online supplemental file 1 for sample MEDLINE search strategy). The final search strategy will be adapted accordingly for all other included databases. Databases will be searched from the 1 January 1960 to 31 December 2023. This timeframe was chosen to correspond with the first reported introduction of patient educators to obstetrics and gynaecology. Medical education journals including Medical Education, Medical Teacher and The Clinical Teacher will be hand-searched for relevant articles. A timeframe of 5 years will be placed on the hand-searched academic journals due to timeframe constraints.

It has been noted in previous systematic reviews on patient involvement in medical education that devising a search strategy for this topic can be a challenge as there is a lack of standardised language in use for the concept of ‘patient involvement’ in medical education.⁶ The initial findings from the authors of this paper would corroborate this view. For example, the terms ‘patient educator’, ‘patient tutor and ‘teaching associate’ are some of the many descriptive terms used. A further challenge in formulating a search strategy was the decision to include studies involving ‘gynaecology teaching associates’; however, it was felt necessary to include this concept in order to gain a broad understanding of the role patients play in educating medical students within the specialty of obstetrics and gynaecology.

Source of evidence selection

All studies identified will first be uploaded onto EndNote (V.20; Clarivate, PA, USA), and duplicates will be removed. The results will then be transferred to Rayyan QCRI¹⁷ for review and screening by authors. Three researchers (CK, SAT, KAB) will review each title and abstract independently to determine its suitability for inclusion based on previously agreed eligibility criteria. Online supplemental table 1 outlines inclusion and exclusion criteria. This will be carried out blindly to reduce bias. Following title and abstract screening, full-text review will be carried out on articles deemed to have satisfied the inclusion criteria. Disagreements on inclusion of articles will be discussed and referred to a fourth researcher (MH) with a final agreement reached among the authors. Reasons for exclusion will be noted and reported in the final scoping review. The final search results will be reported using the PRISMA-ScR flow diagram.¹²

Data extraction and management

A pilot standardised data extraction table will be developed through discussion with team members (online supplemental table 2). This extraction table will be piloted initially with two papers allowing for amendments to be made to the table as required. This will be formulated based on the information required to answer the core research questions as well as including basic details pertaining to study characteristics, author, source of study, the year of publication, location and key findings. Relevant data will be extracted and collated primarily by the lead author (CK).

The data form will be revised as required throughout the process of data extraction. Any modifications will be detailed in the final scoping review. Regular team meetings will be carried out throughout this process to ensure the data charting remains in line with research goals.

Data analysis and presentation

According to JBI recommendations, the results of the search and eligibility screening will be presented in accordance with the PRISMA-ScR flow diagram. The data extracted from included papers will be presented in table format. For studies with qualitative data, thematic analysis will be carried out on the qualitative data extracted to analyse findings and answer the proposed research questions. The final results will be presented in tables and diagrams in addition to a narrative summary of findings.

Patient and public involvement

Representatives from the Irish Neonatal Health Alliance, a body which represents families of preterm infants and who are instrumental in providing education to healthcare professionals and families on this topic, were consulted early in the development of the scoping review protocol. This was with a view to gaining an insight into the unique perspective and experience patients can bring to advancing overall education and understanding on any given topic. In addition, author NC is a founding member of Placenta Accreta Ireland, a foundation set up to represent the interests of patients with this complex obstetric condition and their families. NC was instrumental in providing an insight into the service user perspective throughout the development of this protocol.

Ethics and dissemination

Ethical approval was not required for this scoping review. The protocol has been developed with a view to achieving publication of the full scoping review in a peer-reviewed journal once completed. The primary goal of this research is to first establish current levels of patient involvement in obstetrics and gynaecology education for medical students and therefore identify gaps where this can be improved. An aim of this review is to identify any challenges to patient participation so that these can be overcome to allow for a more collaborative approach between future doctors and their patient’s in women’s health. The intended plan for dissemination of the final scoping review will be through presentation at medical education and obstetrics and gynaecology conferences both nationally and internationally. The hope is to generate conversation around the importance of the medical student’s appreciation of the patient perspective and how this can be best achieved.