‘That's someone's grandma’: Teaching person‐centred care in a frailty context

The ability to provide person‐centred care (PCC) is an essential skill for doctors and requires therapeutic empathy. We sought to evaluate a novel teaching approach to understand how medical students' personal reflections on an older person impact their views about PCC and frailty.

Implications: This flexible teaching technique was an effective stimulus for medical students to consider the person behind the patient.Future work could consider how to promote retention of empathy as medical students make the transition to working as a doctor.

| BACKGROUND
Person-centred care (PCC) means delivering care that is responsive to a patient's unique needs, 1 and to do so requires therapeutic empathy. 2 The importance of PCC has been emphasised in guidance for medical school curricula. 3Within our department, we noticed recurrent instances where medical students failed to consider the person behind the patient, particularly older people living with frailty.Negative attitudes towards older people, and the use of pejorative language, has been identified in medical students previously. 4We contend that sharing authentic life stories about older people can positively influence attitudes and potentially empathy.To implement this teaching initiative, we set it in the context of a Plan, Do, Study, Act (PDSA) cycle to ensure evaluation and continuous improvement at each stage.
We sought to understand how this novel approach, using medical students' personal reflections on an older person, impacted their views about PCC and frailty.
Sharing authentic life stories about older people can positively influence attitudes and potentially empathy.

| APPROACH
The session (Figure 1) was designed for third year medical students at Newcastle University in their first clinical rotation.As pre-work, we asked the students to think of an older person they had a connection with and to bring life stories and an image representing that person to the session.The older person could be a relative, someone they had met on placement or a fictional character.This flexibility enabled students to choose whether or not to discuss personal issues.We asked them to reflect on what would be important to that person if they were making health care decisions.
Students undertook the session in small groups of 10-12; a total of 53 students completed the session in 2019 and 51 in 2020.
During our session, the tutor encouraged students to discuss their stories and facilitated a discussion focussing on PCC.Before and after the 2020 session, students anonymously provided three words they associated with 'frailty'.These were collated into word clouds in real time using Mentimeter.The types of words the group used pre-and post-session were analysed by two researchers using content analysis. 5Following the session, all participants were offered the opportunity to form part of an online focus group; five students volunteered.Using thematic analysis, two researchers independently coded these data before discussion and development of themes. 6

| EVALUATION
The written evaluations and tutor reflections revealed that the 2019 session was feasible and well received by most students.We considered these evaluations, made changes to the session and adapted it for online delivery due to COVID-19 restrictions.
Figure 3 shows the word clouds of the words the students submitted when asked to think about 'frailty' before and after the 2020 session.Figure 4 displays the content analysis results summarising the change in the types of words used.Pre-session, 96% of words were associated with age, illness or vulnerability, compared with 30% post-session.Words relating to a person's character or experience made up 4% of words pre-session and 68% post-session.
Figure 5 summarises the five themes from the focus group analysis.These are discussed below, along with illustrative quotes.Students' perceptions of people living with frailty moved from detached, clinically focussed connotations to more positive, connected, human characteristics.

| The person behind the patient
You go into a clinical setting and you see all these elderly, frail patients, they're just sort of separate and then you don't think about the fact that … if your grandparents or anyone elderly you knew ended up in hospital they would then also be considered under that same umbrella term … after everyone had shared their stories that made me realise that, well if I wouldn't label the people that I'm close to who are older as frail, then I shouldn't do that with them.

| The person behind the medical student
An unexpected finding was that students learnt more about their peers through listening to their personal stories.By doing so, they saw them in a more 'human' sense as opposed to the 'filtered' version that students typically presented.
We only see these people really on clinical placement, so you only really see that side of them, so it's nice to be able to see a different side of people, like a less medical side.
Students expressed apprehension about revealing a personal story, but this was placated by knowing there could be no 'right or wrong' in what they shared.Some students described feeling closer as a group by the end of the session and more comfortable about approaching peers in the future.I think it was a little difficult because I get a bit socially anxious but I think I felt better by the end and I felt like it would be easier to approach a lot of the other people who told stories than it would have been beforehand.

| Pre-work flexibility and personal approach were welcomed
Medical students recognised the session as being 'different' and expressed a preference for it over previous sessions on PCC and empathy they had attended.You can't teach empathy by just telling people to be empathetic.
They valued the creative, flexible and personal nature of the presession task, which provided depth and context to frailty teaching, and they contrasted it to more 'detached' clinical sessions.

| Scaffolding and support aided success
Students felt the session worked because they were empowered to only share as much as they wanted and because there was a supportive session facilitator.I think it was okay cause you kind of decide how much you want to share.
Images and stories appeared to provide a scaffold 7 that enabled students to discuss personal stories.
Images and stories appeared to provide a scaffold that enabled students to discuss personal stories.

| Challenge and sadness of PCC
Medical students identified that seeing 'patients' as 'people' was challenging, as encountering patient suffering could result in difficult emotions, which would make their job as a doctor harder.They suggested that loss of empathy as a health care professional could be a coping mechanism.
… I know it's the point, that you should feel more empathetic but … the reason people lose empathy in medicine is because it does make the job easier.
Students appeared to conceptualise empathy as something that could be dispensed with when time pressures were prominent or when situations were difficult.Their rationale for this position was that maintaining medical care ought to be their overarching priority-empathy was not acknowledged as a core aspect of this care.
Students appeared to conceptualise empathy as something that could be dispensed with when time pressures were prominent.
… It makes it a bit harder because you want to try and remember that they're a person, then but you've also got to focus on delivering care and that is still your main priority.

| IMPLICATIONS
Our data show that this simple and flexible teaching technique was an effective stimulus for medical students to consider the person behind the patient, an essential component of delivering PCC.Students' shift in thinking required them to reveal something of themselves to their peers, and by doing so, an unexpected consequence of the session was enhanced student bonding.This was, in part, driven by the images shown and stories shared, but flexible pre-session work and supportive facilitation, to ensure student wellbeing, were also crucial.We acknowledge that the shift in attitudes seen during this session may also have been driven by positive role modelling from the facilitator, a factor recognised as being influential on the development of PCC. 8 F I U R E 5 Themes from thematic analysis of the focus group data.
An unexpected consequence of the session was enhanced student bonding.
We contend that this work is relevant to educators across the spectrum of health professions and that there may be value in employing such initiatives to a multidisciplinary audience.This session may help push back against the recognised decline in empathy towards older people that is evident in clinical environments. 9It may also help enhance familiarity between members of multi-disciplinary teams, a key component of effective health care teams. 10is session may help push back against the recognised decline in empathy towards older people.
Whilst the number of contributors to the focus group was small and self-selecting, the method produced rich data and deeper insight into the impact on students and why the session was valued.The cloud findings support the conclusion that students' perceptions of frailty changed during the session, increasing the credibility of this finding through methodological triangulation. 5r work could have been enhanced through serial follow up of learners over time.This may have enabled us to determine whether learners changed their behaviour in light of the session and whether such changes were sustained over time.This could be an important focus for future work.
The students had insight that providing PCC in the context of busy, demanding clinical roles is challenging.Future research could explore how to promote retention of empathy amongst medical students as they make the transition into working as doctors.
The implication of this work locally has been incorporation of this session into earlier stages of the curriculum.We would encourage fellow educators to consider employing this cheap and simple strategy in their own practice-prompting students to reflect on the person behind the older patient, using visual images as a trigger, can be a powerful stimulus for attitudinal development.

Figure 2
Figure 2 outlines the PDSA cycles undertaken to introduce and evaluate this novel teaching session.After planning and running the 2019 session, we studied the written evaluation provided by students alongside tutor reflections to aid further development.We received Health Research Authority ethical approval to store, evaluate and publish data obtained from students as part of a mixed methods Students' perceptions of people living with frailty moved from detached, clinically focussed connotations to more positive,F I G U R E 1 Outline of the session.connected,human characteristics.Telling the story of their own older person reminded them to consider the person behind the patients we label as frail.They described that hearing personalised stories about older people drove reconceptualization of frailty from a perjorative label to an experience that 'someone's grandma' was living with.

F
I G R E 2 Plan, Do, Study, Act cycles undertaken to introduce and evaluate this novel teaching session.F I G U R E 3 Word clouds showing the words students associated with frailty before and after the 2020 session.F I G U R E 4 Content analysis of the words students associated with frailty, comparing the nature of the words students submitted before and after 2020 session.It's a much better way of teaching it … you can't teach empathy by just telling people to be empathetic.

I
think [the image] was a good tool to use as well to kind of guide you in what you were saying, which was quite useful.