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Context This paper presents a critique of current knowledge on the engagement of patients and the public, referred to here as patient and public involvement ( PPI), and calls for the development of robust and theoretically informed strategies across the continuum of medical education. Methods The study draws on a range of relevant literatures and presents PPI as a response process in relation to patient-centred learning agendas. Through reference to original research it discusses three key priorities for medical educators developing early PPI pedagogies, including: (i) the integration of evidence on PPI relevant to medical education, via a unifying corpus of literature; (ii) conceptual clarity through shared definitions of PPI in medical education, and (iii) an academically rigorous approach to managing complexity in the evaluation of PPI initiatives. Results As a response to these challenges, the authors demonstrate how activity modelling may be used as an analytical heuristic to provide an understanding of a number of PPI systems that may interact within complex and dynamic educational contexts. Conclusion The authors highlight the need for a range of patient voices to be evident within such work, from its generation through to dissemination, in order that patients and the public are partners and not merely objects of this endeavour. To this end, this paper has been discussed with and reviewed by our own patient and public research partners throughout the writing process. [ABSTRACT FROM AUTHOR]