What Do Patients Attending an Antenatal Clinic Know About the Role of Resident Physicians?

Transcription

1 EDUCATION What Do Patients Attending an Antenatal Clinic Know About the Role of Resident Physicians? Meriah Fahey, MD, BSc(Hons), FRCSC, Margaret Burnett, MD, BA(Hons), MA, FRCSC Department of Obstetrics, Gynecology and Reproductive Sciences, University of Manitoba, Winnipeg MB Abstract Objective: To assess antenatal patients working knowledge of resident physicians involved with their care. Methods: A prospective short-answer survey was distributed to a convenience sample of 12 consecutive patients of a busy obstetrical practice in a teaching hospital in 26. Patients were asked about resident physicians roles and responsibilities, level of education, hours of work, and relationship to the attending physician. Results: The majority of patients had attended the teaching hospital within the preceding year and had also previously delivered a baby at the hospital. Only 7% of patient participants correctly identified a resident as actively involved in their care and only 18% correctly identified the attending physician as the residents supervisor and/or educator. Most patients correctly identified the resident s highest level of education as university (9%) and knew that the resident was under the supervision of the attending physician (7%). Except the 5% of participants who answered don t know, all respondents greatly underestimated residents average weekly hours of work. Conclusions: Patient knowledge of the role of the resident physician in the health care team is lacking. Increasingly, patients wish to be educated and engaged in their health care management. Given the significant role of residents in patient care in Canada s teaching centres, further attention should be paid to finding out what patients wish to know about their care providers and providing them with that knowledge. Résumé Objectif : Évaluer la connaissance pratique des patientes prénatales à l égard des médecins résidents participant aux soins qui leur sont offerts. Méthodes : En 26, un sondage prospectif à court développement a été distribué à un échantillon de commodité de 12 patientes consécutives fréquentant une pratique obstétricale achalandée, au sein d un hôpital universitaire. Nous avons posé des questions aux patientes au sujet des rôles et des responsabilités des Key Words: Resident physician, antenatal patients, patient education, patient knowledge, health education, health literacy Competing Interests: None declared. Received on June 16, 29 Accepted on July 28, 29 médecins résidents, de leur niveau de scolarité, de leurs heures de travail et de leur relation envers le médecin traitant. Résultats : La majorité des patientes avaient fréquenté l hôpital universitaire en question au cours de l année précédente et y avaient également déjà accouché d un enfant. Seulement 7% des participantes ont correctement identifié le résident comme participant activement aux soins leur étant offerts et seulement 18 % ont correctement identifié le médecin traitant comme étant le superviseur et/ou le formateur des résidents. La plupart des patientes ont correctement identifié le niveau de scolarité le plus élevé du résident comme étant un diplôme universitaire (9 %) et savaient que le résident était sous la supervision du médecin traitant (7 %). Exception faite des 5 % des participantes qui ont répondu «je ne sais pas», toutes les répondantes ont grandement sous-estimé le nombre moyen d heures de travail par semaine des résidents. Conclusions : Les connaissances des patientes quant au rôle du médecin résident au sein de l équipe de soins de santé sont incomplètes. De plus en plus, les patientes souhaitent se renseigner au sujet des soins de santé qui leur sont offerts et participer à leur gestion. Compte tenu du rôle important que jouent les résidents en ce qui concerne les soins offerts aux patientes dans les hôpitaux universitaires du Canada, une attention accrue devrait être portée aux renseignements que les patientes souhaitent obtenir à leur sujet et aux modalités nous permettant de leur offrir ces renseignements. J Obstet Gynaecol Can 21;32(2): INTRODUCTION Resident physicians fulfill very different roles in centres across Canada depending on their area of specialty training, the care provided in their region, and the physician who supervises and is responsible for the resident s work at any given time. Some patients may have their care provided exclusively by residents; others, particularly inpatients, may see the resident as the physician most consistently involved in their hospital care via daily rounds and direct contact. Residents are integral to the provision of patient care in Canada, especially in our current climate of increasing patient volumes and complex health issues. While resident is a term familiar to medical personnel, to others this word may mean very little. Despite ongoing public education campaigns at the local, provincial, and national levels about what residents do, 1 anecdotal evidence suggests that a 16 FEBRUARY JOGC FÉVRIER 21

2 What Do Patients Attending an Antenatal Clinic Know About the Role of Resident Physicians? lack of knowledge by those using the health care system seems to persist. It is generally unclear whether patients understand what residency is, the capacity in which a resident may act in their care, and the level of supervision by the attending physician. A study of patients in the emergency department of a teaching hospital in the United States revealed that less than half of patients knew that residents were always supervised by an attending physician, and almost one-third thought that the resident supervised the attending physician. 2 Another US study reported that approximately one in four parents could not correctly identify the physician responsible for their child s care during hospitalization. 3 We undertook a survey to assess patients baseline knowledge regarding the residents involved in their care, in a busy antenatal clinic staffed by resident physicians. To our knowledge, this represents the first attempt to explore patients knowledge of the resident s role in Canada. METHODS We approached patients for participation in the study between May 1 and August 31, 26 in an antenatal teaching clinic at the Women s Hospital, Winnipeg, Manitoba. Each patient who attended the outpatient clinic at less than 2 weeks gestation during this four month interval was enrolled after providing consent. Patients were recruited at this gestational age because we intended to provide half with an information brochure and then resurvey the population later to determine whether their knowledge of residents roles improved over the course of their pregnancy, and how the brochure influenced their knowledge. Unfortunately, distribution of the follow-up survey was poor and did not provide an adequate sample size to complete that portion of the study. Patients were excluded from the study if they did not speak English and did not have an interpreter with them at the time of their prenatal visit. Patients were approached in person and if they provided verbal consent to participate, they were given a written consent form that was then reviewed and signed. Out of 124 patients approached, two declined participation, two were excluded from participation, and the remaining 12 provided written consent. The number of patients approached reflected the volume of new patients available in the clinic during the study period; as this was a pilot study, no sample size calculation was performed. The consent form was reviewed with each patient by the principal investigator and signed by the patient. A one-page, open-ended questionnaire (Appendix) was then provided to the patient for completion while she waited for her clinic appointment. Each patient was given a pen to complete the Table 1. Patient demographics Demographic Respondents, n (%) Age, years 2 18 (15) (47) (2) 3 22 (18) Parity 4 (33) 1 28 (23) 2 16 (13) 3 12 (1) 3 24 (2) Highest level of education Grade (33) Grade (34) Grade 12 4 (33) Number of visits to study hospital within last year 38 (32) (6) 3 1 (8) Self-reported heritage Aboriginal/Native 48 (4) Métis 1 (8) European 58 (48) Asian 4 (3) questionnaire and to keep as an acknowledgement of participation. The survey consisted of five demographic questions and seven questions related to the patient s knowledge of resident physicians. Patients were instructed to write don t know if they did not know the answer to a question. No other information was provided. Completed questionnaires were retrieved by the principal investigator, who obtained clarification from the patient if any completed fields were illegible. The average number of hours spent caring for patients (> 5%), hours on-call (24), and hours of work per week (7) used for marking patient answers correct or incorrect were taken from the responses to a Canadian survey of residents conducted in Work hours per week and hours spent with patients were similar for all residents in obstetrics and gynaecology across Canada in 25. Data were then tabulated, summarized, and analyzed using Jump-In Statistical Software (version 3, Duxbury Press, Scarborough ON). FEBRUARY JOGC FÉVRIER

3 Table 2. Summarized long answer responses Question Response with correct answer in bold font Number of respondents (%) Resident's level of education achieved 1 (8) 1 (8) 48 (4) High school only 2 (2) University 18 (9) Equal Resident relationship to attending physician Below 84 (7) No 82 (68) Learner only 64 (53) Above 22 (18) Is the resident a doctor? Yes 28 (23) Learner and caregiver 5 5% 7 (6) Resident's roles and responsibilities Full physician Resident hours spent with patients 1 (8) 5% 97 (81) 5% 24 hours 12 (1) Resident hours in one on-call shift 12 hours 48 (4) 12 hours 52 (43) 24 hours Resident hours per week 2 hours 43 (36) 2 4 hours 52 (43) 41 6 hours 19 (16) 6 hours Ethics approval for the study was obtained from the Health Research Ethics Board at the University of Manitoba. RESULTS As outlined in the Table 1, the majority of the study population was comprised of multiparous women of European or Native Canadian descent. Most had completed a high school education and had visited our health centre in the 12 months preceding the survey. They therefore likely had previous contact with residents, as residents provide the initial physician assessment at our hospital, and physician assessment is a requirement for discharge. A summary of patient responses to the questionnaire is provided in the Table 2. Ninety percent of patients correctly placed a resident s education at the university level. Approximately half the patients believed that residents were undergoing university training but had not yet graduated or obtained a university degree. Seventy percent of patients were aware that residents were under the supervision of their attending physician, while 68% incorrectly responded that a resident is not a doctor. Many patients used the terms resident and medical student interchangeably in describing the roles and responsibilities of a resident, indicating that patients may not see a distinction between these two groups of medical learners. Patient descriptions of the roles and responsibilities of a resident ranged from observer to someone who does everything a doctor does. Other responses showed that some patients thought it was within the roles and responsibilities of residents to do what the doctor has no time to do, to be the doctor s right-hand man, or to learn how to be a good doctor. The majority of patients said residents were observers and did not participate in patient care or treatment. Seven percent of patients identified residents as both learners and caregivers, including some aspects of both roles in their descriptions. Patient responses regarding resident hours of work revealed that most underestimated the time residents spend in hospital, on call, or with patients. Only 5% knew that the majority of a resident s work involves patient care, and 1% were aware of the resident s 24-hour on-call coverage; the majority estimated an on-call shift at eight hours or less. None of the patients were aware of the average number of hours a resident works per week. The majority of patients believed that residents spend less than two hours of a 4-hour work week in care of patients. Patient responses did not vary significantly with increasing parity or number of visits to the teaching institution within the previous year. DISCUSSION Patients appear to receive little direct education about the health care system and much less about the individuals who provide their care. Media reports often use the terms medical student and resident interchangeably, which serves to further misinform our patient population. 5,6 Trends in health literacy are evolving to better educate and empower patients to ask the critical questions of their caregivers that will enable them to understand what care they are receiving and why, and what options exist. 7 While patients who enter hospital may have a superficial understanding of the education of a physician, the nuances 162 FEBRUARY JOGC FÉVRIER 21

4 What Do Patients Attending an Antenatal Clinic Know About the Role of Resident Physicians? may elude them. Are these nuances important to the average patient? For some patients, whose care is largely dependent on their interactions with the various levels of house staff, these encounters may be an important contributor to the perceived quality of the patient s in-hospital experience. For example, if provided with conflicting information by the attending physician and resident, a patient may become confused and mistrustful without an understanding of the relationship between medical students, residents, and attending physicians. However, were the patient to begin with an understanding of the various roles and positions of those caring for her, she might be better able to weigh the importance of information from any particular individual in the context of the team as a whole, and know who to ask for confirmation, instead of perceiving contradictory messages. Information provided by caregivers that will help patients distinguish their roles include introduction with title, hospital photographic identification, and attire. 3 We have noted in our centre that patients tend to direct their questions to the member of their care team with the most senior appearance; age, height, and gender appear to be distinguishing factors in a patient s interpretation of seniority. These factors often do not reflect actual levels of medical seniority and confusion may arise if positions are not clarified early in the patient s care. Confusion is further compounded by the similarities in hospital attire between individuals with very different roles. Visible name tags and labels may serve to identify positions more clearly, but only if they are prominent enough to be legible. The lack of distinguishable identifiers of hospital staff, at all levels, contributes to patient confusion. Each member of the care team should convey their position clearly at the first patient encounter. Inviting further questions may be sufficient to inform the patient, to her individual level of comfort, about the care she is receiving and from whom she receives it. It may be appropriate to ask, for example, Do you know what I mean by resident? The length of resident work hours may be an important area of information for patients. If patients are aware of the extent to which residents participate in patient care and the time devoted to such care, they may feel more comfortable interacting with residents. On the other hand, knowledge of long work hours may negatively influence a patient s perception of their care by residents or attending physicians. Compromised physician performance and medical errors have been correlated with prolonged hours of work. 8,9 A limitation of this study is the lack of a validated survey tool. Terminology used for the survey may have limited patient responses. Had an open-ended interview format, rather than a short questionnaire, been used, we may have gained a better idea of the patients understanding of their physician caregivers. Furthermore, the antenatal patients attending this outpatient clinic may not be representative of the general population. Further study should be undertaken of how patients wish to be educated regarding their care givers. In the meantime, we must ensure that patients are informed on a level with which they are comfortable. The labouring patient may be wheeled urgently into a room and delivered without so much as an introduction, trusting the facility she has entered is staffed with caregivers carrying the requisite knowledge to provide excellent care to her and her newborn child. When the situation is not so urgent, we should take the opportunity to give her a realistic basis for that trust. CONCLUSIONS Despite the immersion of residents in patient care, patients do not appear to understand the roles or functions of resident physicians. Given the significant role of residents in patient care in Canada s teaching centres, further attention should be paid to finding out what patients wish to know about their care providers and providing them with that knowledge. ACKNOWLEDGEMENTS Funding for this study was provided by the University of Manitoba, Department of Obstetrics, Gynecology and Reproductive Sciences Student Research Fund. REFERENCES 1. Canadian Association of Internes and Residents (CAIR). Resident Awareness Day 21. Available at Accessed December 2, Santen SA, Hemphill RR, Prough EE, Perlowski AA. Do patients understand their physician s level of training? A survey of emergency department patients. Acad Med 24;79(2): Brewer TL, Key JD, O Rourke K. Identification of resident and attending physicians: do parents know who is caring for their hospitalized child? Ambul Pediatr 24;4(3): Cohen JS, Leung Y, Fahey M, Hoyt L, Sinha R, Cailler L, et al. The Happy Docs Study: A Canadian Association of Internes and Residents well-being survey examining resident physician health and satisfaction within and outside residency training in Canada. BMC Res Notes 28;1: Branswell, H. Sleep-deprived interns a danger. The Hamilton Spectator. January 13, 25:A Palmer, K. Doctors leave door open for private health care. The Toronto Star. August 17, 25: A Manitoba Institute for Public Safety (MIPS). It s safe to ask. Winnipeg: MIPS; 27. Available at: its-safe-to-ask/. Accessed November 25, Arnedt JT, Owens J, Crouch M, Stahl J, Carskadon MA. Neurobehavioral performance of residents after heavy night call vs after alcohol ingestion. JAMA 25;294(9): Gaba DM, Howard SK. Fatigue among clinicians and the safety of patients. N Engl J Med 22;347(16): FEBRUARY JOGC FÉVRIER

5 APPENDIX Resident Awareness Survey What is your age? What is your ethnic background (optional)? What is your highest level of education reached? How many visits have you had to the Women s or St. Boniface Hospital (including Clinic, Emergency Room, and admission) in the last year? How many pregnancies have you carried past 2 weeks gestation? With regard to Obstetrical Residents, please answer the following questions with your level of understanding (answer don t know if you do not have an answer): What is the highest level of education the resident has completed? What are a resident s roles and responsibilities? How many hours does a resident spend with patients in one work day? Is a resident a doctor? What is the resident s professional relationship with your doctor? How many hours would a resident spend at work in an average week? How many hours would a resident spend in hospital on one on-call-shift? 164 FEBRUARY JOGC FÉVRIER 21