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Original Research Paper

Involving Patients in Medical Education: Ethical

Issues Experienced by Syrian Patients
H Bashour1, R Sayed-Hassan2, A Koudsi3
1
Department of Family and Community Medicine, Faculty of Medicine, and Centre for Medical Education Development,
Damascus University, Damascus, Syria
2
Department of Internal Medicine, Faculty of Medicine, Damascus University, Damascus, Syria
3
Department of Family & Community Medicine, Faculty of Medicine, Damascus University, Syria
Submitted: 25 July 2011 • Revised: 12 April 2012 • Accepted: 16 April 2012 • Published: November 2012

ABSTRACT
Introduction: Patients’ involvement and their willingness to cooperate in clinical teaching is a vital element of medical education. Clinical
teaching at the Faculty of Medicine of Damascus University relies heavily on inpatients at teaching hospitals but also on patients brought
to teaching rooms. The purpose of this study was to identify patients’ experiences and their attitudes toward the involvement of medical
students in clinical consultations within teaching rooms conducted mainly for students’ benefit. Methods: In-depth interviews were carried
out by a sociologist using an interview guide with 14 patients whose clinical cases were presented to a large group of students in the
teaching room at Damascus University teaching hospitals. Data analysis involved content analysis. Findings: Main themes were identified
with negative ethical aspects, such as the lack of patient’s involvement in decision making and approving to be part of clinical teaching.
Risk and benefits were experienced by patients and identified in their experiences. Some felt that they were treated inhumanely and
with a lack of dignity. Patients nevertheless felt a responsibility to be part of the teaching process. They expressed their positive attitudes
towards involvement in the teaching process to serve medical students as well as the greater community. Discussion: Findings provide
perspectives and insights into the current clinical teaching at Damascus University Faculty of Medicine. The findings highlight the need in
our institution to carry out medical education involving patients in a more ethical manner. Medical students and their teachers need more
training in the ethical involvement of patients in students’ learning process, as well as the need to better regulate patients’ involvement in
education.

Keywords: Clinical teaching, confidentiality, ethical principles, informed consent, medical education, medical ethics, patients’
involvement, Syria

Introduction from the patient has been repeatedly emphasized in the

literature.[1-5]
One of the most well-known and internationally recognized
dictums is that of Sir William Osler “it is a safe rule to have The general principles of bioethics, including respect for
no teaching without a patient for a text and the best teaching is individuals, beneficence, non-maleficence and justice extend in
that taught by the patient himself”. The importance of learning their application to patient participation in medical education.
Unfortunately, current practice of medical education does not
always accord adequate respect to patients and they are not
always happy about the students’ presence and involvement
Access this article online
in their care.[6-9]
Quick Response Code:
Website:
www.educationforhealth.net Patients have always been vital to medical education. Howe
and Anderson argued that there is a need for better approaches
to involving patients in the training process, including the
DOI:
10.4103/1357-6283.103453 need for informed consent and the creation of a more equal
partnership in shared decision making in clinical practice.[1-10]

Address for correspondence:

Prof. Hyam Bashour, Faculty of Medicine, Damascus University, P. O. Box: 9241, Damascus, Syria. E-mail: hbashour@scs-net.org

Education for Health • Volume 25 • Issue 2 (November 2012) 87

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Bashour, et al.: Ethical Issues Experienced by Syrian Patients
Patients’ concerns towards their participation in medical
education include matters of consent and confidentiality,
as well as receiving information in advance about student
and trainee involvement in their care.[1] Understanding how
patients view community-based and bedside teaching has
received a good deal of research, including through the use
of patient’ surveys, but this has occurred largely within the
developed world.[11-19] Bodies such as the British Medical
Association argued that these concerns can have an impact on
patients and on the learning outcomes for medical students
and doctors themselves.[1] As Jagsi and Lehmann put it “an
ethical dilemma results from the fact that patients may
not benefit from doctors in training and medical students
participating in their care, and may even be harmed by it”.[9]
Clinical teaching is an integral component of the curriculum
in Damascus University Faculty of Medicine. Teaching occurs
mainly in hospital wards and less so in outpatient clinics,
operating theatres and other consulting rooms. The clinical
skills laboratory is very new and is not yet functioning. The
Faculty of Medicine admits over 500 students each year. Clinical
teaching starts in the fourth year and continues for three years
up to the final year. This clinical training takes the shape of
rounds and visits with clinical teachers. In addition, selected
cases relevant for teaching are brought to teaching rooms with
about 40 students present, for an extensive case presentation
in the presence of patient and discussion.
Reviews of student and patient perspectives regarding
the teaching environment can be effective tools to inform
curriculum development. Curriculum development has been
high on the agenda of the Damascus University Faculty of
medicine for the past three years. The purpose of this study is
to identify patients’ experiences and their attitudes towards
involving medical students in their clinical consultations in
lecture theatre settings conducted principally for students’
benefit.
Methods
This qualitative study included 14 semi-structured, in-depth
interviews with patients conducted at two teaching hospitals
affiliated with Damascus University. All individuals interviewed
were male patients seen at the Internal Medicine and Surgery
departments at the two main teaching hospitals in Damascus
(al-Mouassat and al-Assad teaching hospitals). Patients were
recruited to represent all who served as a “teaching tool” in
lecture theatre, where their cases were fully discussed in front of
the patient himself, medical students (around 40 in number) and
the clinical teacher. These patients came from a larger sample
of 400 who were recruited for a quantitative component of this
study.[20] All patients who moved from wards to the teaching
room for teaching purposes were recruited. Data collection was
done in May 2011 during the 2010–2011 academic year.
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The study was approved by the Institutional Review Board at
Damascus University. Written informed consent was obtained
prior to data collection. For ethical reasons, all names used
in the presentation of our findings are pseudonyms. The
interviews were conducted in Arabic by an experienced
female field worker who has a background in social sciences
and is trained in asking probing questions, using the study’s
interview guide. The interview guide was designed by the
researchers based on literature review.[21] The interview guide
included items related to the experience of the patients in the
classroom, experience with being interviewed and examined
by students, likes and dislikes feelings and expectations about
involvement in teaching of students. All interviews were
tape-recorded and their length varied according to patients’
responses, but generally took between 30 and 90 minutes to
complete.
The process of data analysis occurred simultaneously with
ongoing data collection. Data saturation was determined
when the interview responses of the final participants fit
within the emergent coding scheme. The interviews were
transcribed verbatim and initially read as narrative accounts
in order to gain an overall sense of each patient’s experience.
Coding was then performed by one of the authors in order
to identify general themes. The content analysis method of
analysing qualitative data was used.[22] All quotes and excerpts
presented here are translated from Arabic into English to best
describe the original meaning.
Findings
Patients who participated in this study were aged 21–67 years.
All were male and all had finished at least elementary level
education. Almost all were in clinical condition that allowed
them to move from the wards of the internal medicine and
surgery departments to the teaching room. Their clinical
illnesses fell principally within the fields of endocrinology,
nephrology and gastroenterology. The selection of those
patients by clinical teachers was based solely on the relevance
of the case to students’ learning and the appropriateness of
their clinical condition as a “teaching tool”.
In what follows we present the main themes that emerged
from interviews to describe patients’ experiences. Many of
these themes are not mutually exclusive; rather, they appear
simultaneously in many of the interviews.
Involvement in decision making
The most striking theme that emerged in this study was
patients’ lack of involvement in the decision to be brought
to the teaching room for their cases to be presented to the
medical students. Many of the interviewed patients explained
that they were approached by senior doctors or postgraduate
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Bashour, et al.: Ethical Issues Experienced by Syrian Patients
students and moved to the teaching room without knowing
where they were going. Some expected that they were going
for further investigations or to the radiology department and
ended in the classroom in front of numerous students. Patients
expressed frustration about this: They had not consented to
be part of the teaching process at these two hospitals. Sami,
a 28-year-old, explained his experience:
“At the beginning I did not know, I did not know. I did not expect
that they will ask me about my disease. I was not comfortable. I
am ok now, but I wish they had told me. Something like saying,
‘We need your help, you know.’ If one wants any help, he needs
to ask, he needs to tell, not taking me like a blind person to the
classroom.”
Another patient (67 years old) described the following:
“The doctor came and said let’s go down. He did not tell me
where to. I ended in a teaching hall; there were many people,
including young ladies. They put me on the table and asked
me about my case. I had to repeat everything I said to doctors
up in the ward. They were many, around 50 of them, and I had
two who examined me.”
Risk and benefit
Another theme that emerged from interviews is related to
the concepts of risk and benefit. “Do good” and “do no harm”
are important principles in medical ethics. This emerged
very clearly in patients’ excerpts as they looked into their
experiences in various ways.
Sharing information and the opportunity to further discuss
their clinical case in front of the medical students was regarded
of great value. Patients felt that the thorough discussion of
their case for teaching purposes is a good opportunity for
them to learn more about their case.
“Having the teacher as well as the students asking is very good,
as they might discover things I did not know about” (Issam,
21 years old).
Getting general knowledge was felt by Adham (47 years old)
as a beneficial thing that he enjoyed the experience.
“Now I know the location of the spleen. The teacher put his hand
on my abdomen and kept repeating the thing to the students.
Students then examined me. The teacher’s hand was lighter
on me. Now I understand more.”
As for the potential risks felt and expressed by the patients,
they included having to disclose information they wished not
to reveal. This was the case of 65-year-old Karim, who was not
happy disclosing information about drinking alcohol before
a class with many students. Drinking alcohol is forbidden for
religious reasons among Muslims.
“Yes, I had to tell them that I drink alcohol. The student
asked me; [Karim talking in an ironic way] ‘Yes I drink’ I
had to say.”
Education for Health • Volume 25 • Issue 2 (November 2012)
Another example given by Bassim (65 years old) concerned
the lack of comfort by being in the classroom for a long time.
He stated:
“The students benefited from me. But I lost the visit of my
family. They were coming to see me. The timing was not good.
I wish I was there for shorter time.”
Many other patients felt that one hour to one hour and a half
is a long period for them to be caught in teaching rooms. One
patient was worried that this might have negatively affected
his health.
Dignity
Dignity and respect for the patients is undoubtedly one of the
main guiding principles in the ethics of medical education.
However, there were instances in which patients felt that
they were treated inhumanely by the medical students. Ali
(38 years old) who is a patient in the chest disease unit
described his experience as being the “most inhumane
instance” he had ever experienced.
“I wished I had died before they had laughed at me. These
two students were laughing. I did not know why. One student
was asking me a few questions. I said I was going to give the
sputum. Well I was extremely annoyed by their behaviour. They
laughed at me. That laugh killed me.”
Patients also described instances of embarrassment that
annoyed them:
“I had to uncover my chest in front of them.”
Another patient said:
“I kept repeating the same story and being examined by many
students. Their hands were light on me but definitely the teacher
is different. He was telling them how to examine my body.”
Evidently, having one’s body used as a teaching tool for the
students carried a sense of indignity. Houssam said:
“Why should they bring me four times to the classroom. This
is too much.”
The Role of the patient in serving medical students and the
community
In the Syrian culture, serving community is particularly
appreciated. Bringing beneficence and good to medical
students emerged as a common theme identified in most
interviews. Enthusiasm to those young medical students
and keenness to bring benefit to them and their future
as doctors serving in their community was expressed in
the words of many patients interviewed. The following
excerpt of an interview with Karim, a 65-year-old patient,
reveals this:
“God bless them, I wish them bright future. I came here [to the
classroom] for their benefit. Why not? I could also benefit. I
liked them and was happy. Their words were really sweet.”
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Bashour, et al.: Ethical Issues Experienced by Syrian Patients
Masri (47 years old) was very keen to bring good by educating
medical students:
“Let them learn. Why not, they should learn. I was happy that
my case was presented to them, the teacher was explaining
and they must have benefited from this.”
Discussion
The inclusion of humanities in medical education may offer
significant benefits to individual future physicians and to
the medical community as a whole. The in-progress work on
curriculum transformation at Damascus University’s Faculty
of Medicine revealed the current focus on biomedicine in
the curriculum with little space for humanities and patient–
doctor communication. This apparently has had serious
implications for the care of patients and the teaching of
medical students. The narratives of patients recruited for our
study illustrate their lack of proper involvement in consenting
to be involved in students’ education and the lack of empathy
and professionalism on the part of medical students and their
supervisors when dealing with them.
The ethical principles of patient autonomy, beneficence, and
non-maleficence would argue for fully informing the patient
about their involvement in teaching medical students. Bedside
or even classroom teaching in the presence of the patient is the
dominant practice of medical education at many universities,
as it is at ours. The findings from this qualitative study bring
clear evidence of the lack of adherence to the ethical principles
of autonomy, beneficence and non-maleficence where patients
are not informed about being moved to teaching room where
they are to be interviewed and examined in front of a crowd
of students. As with regard to the ethical principle of justice,
we might argue that repeatedly selecting the same patients
for classroom instructions, at the expense of their comfort and
expectations, is unjust.
Altruism, rather than perceived benefit to self, seems to be the
primary motivation for patients’ participation in the medical
education process.[9,11] Many previous studies indicate that
patients have, in general, shown positive attitudes towards
medical students for different reasons.[20-23] In agreement with
other literature, our study highlighted this very clearly, as Syrian
patients were very keen to serve the community by allowing
themselves to be used in the teaching of medical students.
Lack of dignity and respect for the patient have emerged
as dominant themes in our study. This can be prevented
if a greater focus on humanities teaching is given at our
faculty and if codes of ethics were formulated and adhered
to. Interestingly, patients who indicated that they were
uncomfortable still allowed student involvement for altruistic
reasons. There is therefore an additional ethical obligation
to make patients as comfortable as possible and to carry out
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medical education in an ethical manner. Empathy and respect
for patients is an integrated part of medical education.[24,25]
This study alerted us to the need to study further the role of
senior doctors and postgraduate students, for it was them, not
the medical students, who took patients to the teaching room
without telling them where and why they are going. Observing
this unethical behaviour in their seniors will remain part of
a vicious cycle if today’s medical students copy this practice
when they become postgraduates at these same hospitals and
later pass on this behaviour to their juniors.
The main limitation in our study is that it included only male
patients, as female patients receive positive discrimination
in our setting by not being brought to the teaching room
for teaching purposes. Furthermore, this is a qualitative
study that aims to give in-depth understanding rather than
create generalisable findings. To our knowledge, there have
not been previous studies on this topic in our setting, where
most clinical teaching is carried out in front of the patient,
whether at the bedside or in teaching rooms or in the corridor.
Although teachers in other settings may generally avoid
bedside teaching out of concern for patient comfort, this type
of teaching is still common in Syria, as well as in the region
and globally. A recent article by Fischer put it very clearly, that
professionalisation in medical education should start with a
close look at bedside teaching because it is the core of training
medical doctors.[26] In principle, teaching in the presence of
patients, when conducted with sensitivity and respect, can
add to rapport and proper communication.
Conclusion
In conclusion, ethical issues brought out in this study suggest
that medical students at Damascus University need to be taught
the importance of respecting the patient’s autonomy and
showing empathy for patients. The gap between biomedicine
and the humanities should be bridged. Training and enforcing
ethical guidelines, if not legislation, could contribute to more
professional and quality medical education in our setting and
also in other settings where bedside teaching is still common.
Acknowledgement
The authors are grateful to Damascus University for funding this
study. The authors thank their colleague Dr. Nizar Abazid for kindly
reviewing this manuscript.
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How to cite this article: Bashour H, Sayed-Hassan R, Koudsi A. Involving
Patients in Medical Education: Ethical Issues Experienced by Syrian
Patients. Educ Health 2012;25:87-91.
Source of Support: Nil. Conflict of Interest: None declared.
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