Abstract
The aim of this study was to examine patients' motivation to participate in the Royal College of Physicians Practical Assessment of Clinical Examination Skills (PACES). An exploratory cross-sectional study was performed with data collected via telephone interviews. All patients aged 18+ who participated in PACES at University Hospitals Coventry and Warwickshire in the last two years were invited to take part; 28 patients were interviewed. Data were analysed using thematic content analysis. Motivational factors identified included the opportunity to give something back for the care received, contributing to doctors' learning processes, altruism and being able to learn more about one's own condition. Patients believed that they offered real-life experiences that cannot be provided by actors. The social environment during PACES played a large part in volunteer retention. Recruitment of patient volunteers needs to emphasise the altruistic nature of the role in assisting the learning process for doctors and the subsequent benefit for future patients.
Introduction
Medical trainees need to learn how to interview and examine patients. In an examination setting, demonstration of competence in history-taking and clinical examination is achieved by using actors or real patients. Patients provide an element of unpredictability and reality that is difficult to achieve with actors. However, recruiting suitable real patients has become increasingly difficult.1 During Royal College of Physicians (RCP) Practical Assessment of Clinical Examination Skills (PACES) (Part 2), candidates rotate around five examination stations while being observed by two examiners. Each station presents one or two patients for assessment and includes history-taking, communication skills and a range of clinical examination scenarios based on the major organ systems. Each assessment lasts 20 minutes and candidates are required to interview, examine and discuss management options with the patient. Patient volunteers attend for either a three- or four-hour session, and at University Hospitals Coventry and Warwickshire (UHCW) they receive a £10 voucher and free transportation. Recruiting sufficient patient volunteers for clinical examinations can be difficult, leading many institutions to opt for methods of assessing clinical skills that do not involve real patients.
The demand for PACES examination places continues to increase and the RCP is keen to establish additional examination centres. Each host centre must recruit and retain patient volunteers. However, there is little guidance for new host examiners on how to undertake this process successfully. Indeed, there is little published research on patient participation in examinations and the available literature has focused on methods for improving patients' satisfaction,2 ensuring assessment criteria are met3 and the ethical and legal implications.4 The motivation for patients to volunteer for participation in PACES has received little research attention. This exploratory study addresses this omission by exploring the motivation of patients to take part in PACES in order to inform continued recruitment in assessments of clinical competence.
Methods
Ethics approval was obtained from the University Ethics Committee and the NHS Research Ethics Committee. Recruitment procedures were based on those used by the UHCW Postgraduate Centre when inviting patients to take part in PACES (ie a written invitation followed by a courtesy phone call). An information pack was issued to all patients on the database (n=44) who had taken part in PACES in the last two years: 28 patients provided written consent and were interviewed (15 male, 13 female; age range 42–82). Participants had taken part in PACES between one and six times (mean = 3).
Following written informed consent, participants were contacted to arrange a time for the telephone interviews. Interviews were audio-recorded with the permission of each participant at the time of interview. The content of the tapes was transcribed verbatim. Data were analysed using thematic content analysis, an inductive approach whereby a list of common themes are distilled from the data, not imposed upon it by the researcher. Themes are grouped to give voice to the participants and to reflect the texts as a whole. Transcripts were read and points of interest noted. A second reading produced emerging themes that were then grouped and checked with the original transcripts to validate the data. The first author independently analysed the transcripts, a second researcher checked the analysis and a random sample of transcripts was analysed by a third researcher. The themes and quotes are presented in Table 1.
Themes and quotes.
Results
Satisfaction of giving something back
The primary motivation for taking part in PACES was to ‘give something back’ to the NHS for the care received in the past. This form of repayment engendered feelings of satisfaction, which alleviated patients' sense of indebtedness (see Table 1 for illustrative quotes).
Contributing to doctors' learning process
Patients believed that their participation helped the doctors in a way that books and teaching could not by providing ‘hands-on experience’. Equally, patients felt that they were contributing to the training and supply of future doctors. In addition, they felt that they were appreciated by doctors for their role in the examinations. One patient volunteered for PACES because of previous errors in treatment and felt that ‘being a proper patient’ and making his illnesses available would contribute to doctors' learning process.
Several patient volunteers reported that they had quite rare and complex health conditions and felt that participation in PACES enhanced doctors' understanding. Similarly, a number of patient volunteers had experienced difficulties and frustration in obtaining a diagnosis and delays before a suitable treatment could be found, and this influenced their decision to take part in PACES. Speed of diagnosis was of great importance; patients considered that their participation in the examinations would reduce diagnosis time for future patients (ie altruism). They believed that their conditions were inadequately described in textbooks and thus doctors would not have sufficient information to help with diagnosis or treatment. Equally, improved training increases knowledge and standards that will personally benefit the study participants themselves.
A learning opportunity for patient volunteers
Patients regarded their involvement in PACES as an opportunity to learn more about their illnesses both through listening to the discussions going on around them and being able to ask questions of the candidates and examiners. Several patients reported that they had volunteered in order to obtain a second opinion from the examiners. One patient felt that PACES was an opportunity for any symptoms or problems to be ‘picked up’ because she was no longer ‘under the system’. Through participation in PACES she felt that she was still being looked after and could ask questions regarding any current concerns. One patient suggested, ‘It's a free MOT’.
Patient volunteers valued the opportunity to meet people with illnesses that they would not otherwise encounter, thus adding to their own knowledge. Some patients regard themselves as experts in their own conditions and used PACES as an opportunity to test doctors' knowledge. This does cause some concern for patients if the candidates do not reach the correct diagnosis and then go on to become consultants. This expert knowledge contributes to patients' professional attitude toward their role in the examinations. They are keen to present the same picture to each of the candidates and to answer questions thoroughly and concisely without volunteering information in order to remain fair to each candidate. Patients are nervous for the candidates and recognise the importance of the event for their future careers.
Actors versus patients
Patients considered their presence as ‘real-life patients' with ‘real-life’ ailments to be preferable to actors, representing something akin to the hospital clinic situation. They suggested that, as people with real illnesses, they were able to present a ‘whole experience’ thus doctors had to consider not only clinical aspects but also patients' emotional state as well as being polite (eg introducing themselves) during a clinical examination. There was a desire to inform doctors of the ‘trauma’ associated with their illnesses that only real patients would know about.
The social experience of participation
There was a consensus that taking part in PACES was both a privilege and an honour. Being involved in a well organised event, combined with the friendly and personal treatment received from the staff involved, led to patients feeling quite special and appreciated. Patients valued being provided with a taxi and highly rate the quality and quantity of the refreshments. One patient suggested, ‘It's just a lazy day out for me’ and another was happy to take part because, ‘it has not really been inconvenient for me at all’. Several patients valued taking part because it is an opportunity to talk to other people from different age groups and exchange experiences. The receipt of a token or voucher was regarded as a nice gesture. However, some patients felt that this form of reward was not necessary and one felt the token was ‘patronising’.
Altruism: doctors and other patients
Altruism was an underlying motivating factor. Not only did patient volunteers wish to help doctors gain knowledge and understanding of their conditions, but they were also aware that this increased knowledge would be of value to future patients.
Conclusions
Results show that motivational factors influencing the decision to participate in PACES include patients' desire to give something back for the care received in the past, the opportunity to contribute to doctors' knowledge and understanding as well as being able to learn more about one's own condition, and altruism. Recruitment of patient volunteers may be enhanced by emphasising the altruistic nature of the patient volunteer role in doctors' learning process as well as the subsequent benefits such increased knowledge and understanding may have for future patients. In addition, potential patient volunteers could be informed that existing volunteers view their role as rewarding, enjoyable and useful in offering a real-life experience of their conditions that cannot be provided by actors. Production of a leaflet describing the patient volunteer role including comments from past participants may aid recruitment. Results highlight the need to ensure that the social environment (eg refreshments) and transport arrangements are satisfactory in order to encourage volunteer retention.
The most commonly reported motivational factor in studies, which have examined motivation to volunteer, is altruism; this is described as comprising the desire to help others, to feel useful and to have a sense of responsibility.5 In accord with studies of volunteerism in other health-related contexts,6–8 the results reported here found that altruism was an important motivating factor offering patient volunteers the opportunity to help others by taking on a useful and responsible role in the PACES examination process. Some patients acknowledged the benefit of learning more about their own condition through having a ‘free MOT’ or obtaining a second opinion. Regarding the last of these, Dearlove found that over half of the respondents to a questionnaire concerning child patients in medical examinations had wanted a second opinion on their child's condition.9
A number of caveats to the study need mentioning. The study was exploratory and based on qualitative data generated through interviews with patient volunteers who were on the database of one hospital where PACES is organised. Future studies would benefit from considering the views of patients who decline to participate as well as those patient volunteers who take part in only one PACES examination. A more comprehensive picture of the advantages and disadvantages of patient participation in PACES may be obtained by examining the views of the organisers, examiners and candidates themselves, including those who had experience of both patient volunteers and actors.
Acknowledgements
The authors wish to extend their thanks to all the patients who agreed to take part in this study. Contributors: CN had the original idea for the study, JB and LM designed the study. LM designed the interview schedule, collected and analysed the data and wrote the full report with contribution from JB. All the authors contributed jointly to the final writing of the article.
Ethical approval was obtained from the Coventry University Research Ethics Committee, Coventry NHS Research Ethics Committee and the University Hospitals Coventry and Warwickshire NHS Trust R & D Department. Patients gave written informed consent.
- © 2012 Royal College of Physicians
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