Patient ‘ follow up ’ as a pedagogical technique for medical students

Medicine is a career that requires lifelong learning, and finding an effective way of doing this is a valuable skill to have acquired as a medical student. ‘Follow up’ is a normal part of the treatment process for patients where most doctors see their patients in clinic post-discharge. This is beneficial for the patient, who receives a high quality continuum of care, and for the doctor, who can further their knowledge of pathological progression and individual responses to treatment. Medical students do not seem to regularly chase patient results or seek to find out clinical outcomes, despite students at some hospitals having access to electronic patient records systems. Pedagogy is the science of teaching and education. There is little evidence of the use of ‘follow up’ as a pedagogical technique, but there are some obvious gains to be made from doing so, including acquiring skills in using specific hospital computer systems, appreciating the holistic nature of medical care and laying down strong foundations of clinical experiences, which can be built on with personal study. There are ethical issues surrounding patient confidentiality where students have access to personal records, but as long as governance guidelines are followed the benefits of the ‘follow up’ process outweigh any potential risk to patient confidentiality. There are multiple benefits to following up a patient, and it is a practice that more medical students should embark upon. Copyright Royal Medical Society. All rights reserved. The copyright is retained by the author and the Royal Medical Society, except where explicitly otherwise stated. Scans have been produced by the Digital Imaging Unit at Edinburgh University Library. Res Medica is supported by the University of Edinburgh’s Journal Hosting Service: http://journals.ed.ac.uk ISSN: 2051-7580 (Online) ISSN: 0482-3206 (Print) Res Medica is published by the Royal Medical Society, 5/5 Bristo Square, Edinburgh, EH8 9AL Res Medica, 2013, 21(1):82-84 doi: 10.2218/resmedica.v21i1.173 Williams LR. http://journals.ed.ac.uk/resmedica Volume 21, Issue 1 Res Medica ‘L ost to follow up’ is a phrase frequently used in medicine, meaning once a patient is discharged from hospital, they are not encountered again by that team of clinicians. It is a less than ideal outcome for both the patient and the clinician. The patient, for whatever reason (e.g. change of address, poor engagement or compliance with the treatment process), may suffer suboptimal recovery due to the lack of medical input, leading to comorbidity or even death. There is plenty of data supporting the importance of medical follow up for patients, be it with a consultant, a general practitioner (GP) or in occupational or physical therapy. It seems obvious that patient follow up is also important for clinicians, providing excellent opportunities to learn from previous experience. Every patient outcome should influence the way a doctor views the next patient they treat with the same condition. Being unaware of the outcome means that clinicians cannot use the experience to their advantage. Pedagogy is the science of education; the theory of how to improve learning and the use of ‘follow up’ as an educational technique. This should be very useful to medical students. However, it seems that at the moment, for reasons explored in this article, medical students do not maximize the potential opportunities available to them to follow patients up and, therefore, are missing out on crucial learning opportunities. Considered in this article are some of the possible barriers to doing so and finally some suggestions to help overcome these issues. Medical students, as a result of limited ward time (and also, to a degree, laziness), do not tend to see patient outcomes or see only part of the clinical picture. This is a less than ideal way of learning about holistic medicine. We are encouraged to take and present histories and even to look at the images taken of a patient to enrich our learning experiences. But off the ward, few people think to look up the outstanding imaging report or blood results on Patient X, despite this being best practice and an excellent way to prepare for foundation jobs. Apart from student motivation, obstacles in the way of regularly following up patients are more bureaucratic. The sheer numbers of medical students in each year, sometimes as many as 400, means that it would be difficult to arrange for students to see patients at their GP practice or on a home visit. GP practices often struggle to allow extra time to accommodate students allocated to them, let alone additional ones enquiring after specific patients. Medical students have a high workload, especially during clinical years, and this may mean that they allocate more time to book work and less time on the wards. It is important to realize that with little experience on the sheer amount of pathology out there, follow up would be an effective revision or a primary learning experience, where each patient could become a personal case study or PBL case and, therefore, as effective as personal study. Another issue that may prevent students from pursuing patient results is a lack of access to the computer systems holding patient data. If the medical school is not inclined towards students having their own login information, it would be difficult to keep on top of a patient’s progress. On the contrary, if students are provided with this, issues can arise in terms of patient confidentiality. It is important to remember that any time a student accesses patient notes there is the opportunity for a breach in the patient’s right to confidentiality. For example, on placement, I have access to both IT systems and paper notes and can therefore see most data available for a single patient at any one time, but I am not required, except out of common courtesy, to speak to that patient to ask permission to do this. On reflection, it might be helpful for patients to receive information from the Trust, P E R S P E C T IV E

'L ost to follow up' is a phrase frequently used in medicine, meaning once a patient is discharged from hospital, they are not encountered again by that team of clinicians.It is a less than ideal outcome for both the patient and the clinician.The patient, for whatever reason (e.g.change of address, poor engagement or compliance with the treatment process), may suffer suboptimal recovery due to the lack of medical input, leading to comorbidity or even death.There is plenty of data supporting the importance of medical follow up for patients, be it with a consultant, a general practitioner (GP) or in occupational or physical therapy. 1 It seems obvious that patient follow up is also important for clinicians, providing excellent opportunities to learn from previous experience.Every patient outcome should influence the way a doctor views the next patient they treat with the same condition.Being unaware of the outcome means that clinicians cannot use the experience to their advantage.
Pedagogy is the science of education; the theory of how to improve learning and the use of 'follow up' as an educational technique.This should be very useful to medical students.However, it seems that at the moment, for reasons explored in this article, medical students do not maximize the potential opportunities available to them to follow patients up and, therefore, are missing out on crucial learning opportunities.Considered in this article are some of the possible barriers to doing so and finally some suggestions to help overcome these issues.
Medical students, as a result of limited ward time (and also, to a degree, laziness), do not tend to see patient outcomes or see only part of the clinical picture.This is a less than ideal way of learning about holistic medicine.We are encouraged to take and present histories and even to look at the images taken of a patient to enrich our learning experiences.But off the ward, few people think to look up the outstanding imaging report or blood results on Patient X, despite this being best practice and an excellent way to prepare for foundation jobs.
Apart from student motivation, obstacles in the way of regularly following up patients are more bureaucratic.The sheer numbers of medical students in each year, sometimes as many as 400, means that it would be difficult to arrange for students to see patients at their GP practice or on a home visit.GP practices often struggle to allow extra time to accommodate students allocated to them, let alone additional ones enquiring after specific patients.
Medical students have a high workload, especially during clinical years, and this may mean that they allocate more time to book work and less time on the wards.It is important to realize that with little experience on the sheer amount of pathology out there, follow up would be an effective revision or a primary learning experience, where each patient could become a personal case study or PBL case and, therefore, as effective as personal study.
Another issue that may prevent students from pursuing patient results is a lack of access to the computer systems holding patient data.If the medical school is not inclined towards students having their own login information, it would be difficult to keep on top of a patient's progress.On the contrary, if students are provided with this, issues can arise in terms of patient confidentiality.It is important to remember that any time a student accesses patient notes there is the opportunity for a breach in the patient's right to confidentiality.For example, on placement, I have access to both IT systems and paper notes and can therefore see most data available for a single patient at any one time, but I am not required, except out of common courtesy, to speak to that patient to ask permission to do this.On reflection, it might be helpful for patients to receive information from the Trust,

Patient follow up as a pedagogical technique for medical students
Volume 21, Issue 1 Res Medica potentially in leaflet form, outlining the fact that they will be encountering students who may want to speak to them, and know more about their progress in hospital.Medical students do need access to patient information; it is important for us to be involved in ward life and, hence, the ability to see images and results gives us a role in the medical team that justifies our IT logins, if used correctly and safely.
We must remember however, that the access privileges we have must not be taken lightly; Misuse bears heavy consequences.Even accidental misuse, such as unintentional loss of patient identifiable information, can be punishable if not to the student, then to the hospital.
There have been several studies where by patients have been discharged and visited in the community by the same students who encountered them in hospital, with the aim of demonstrating multidisciplinary team management in the community and to give the students a better understanding of the nature of some chronic diseases.These studies came following new guidance from the Carnegie Foundation for the Advancement of Teaching in United States of America, calling for an increase in opportunities available to medical students "to foster lifelong learning through habits of inquiry". 2,3A Singaporean study, responding to this guidance, allowed students multiple follow-ups to the patients' homes and to their outpatient appointments.The students felt the process supplemented knowledge from the course as to the natural history of various diseases, but also demonstrated to them allocation of community resources and the importance of holistic care in patient management. 3,4 the UK, our medical schools follow advice from the GMC's Tomorrow's Doctors to develop curriculum.Under The doctor as a Professional it encourages students to "establish the foundations for lifelong learning and continuing professional development". 5There would be benefits to maximizing our clinical time and our interactions with patients in order to better our knowledge, clinical practices, patient interactions and bedside manner.

Conclusion
Following up a patient is an excellent way of learning about patient management.'Follow up' as a pedagogical technique has a small evidence base but, in doing it, students have the opportunity to increase their knowledge that would be central to becoming patient centered doctors.

Key Learning Points
 Following a patient up, from clerking until discharge, chasing their imaging and bloods and monitoring their medication allows development of multiple skill sets  Some evidence suggests that students found seeing patients post-discharge in the community is beneficial to their learning  It is a GMC requirement to "establish foundations for lifelong learning" and, ideally, we should start this in medical school 83 PERSPECTIVE