Patients Attitudes and Comfort Levels Regarding Medical Students Involvement in Obstetrics Gynecology Outpatient Clinics

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1 R E S E A R C H R EPORT Patients Attitudes and Comfort Levels Regarding Medical Students Involvement in Obstetrics Gynecology Outpatient Clinics M. Brian Hartz, MD, and James R. Beal, PhD ABSTRACT Purpose. To identify patients attitudes toward the role of medical students, their preferences regarding medical student involvement, and their comfort level with a medical student s presence during common clinical situations in obstetrics gynecology. Method. A self-administered questionnaire was distributed to patients waiting for an office visit with the obstetricians or gynecologists who served as preceptors for both male and female medical students. The questionnaire asked patients about their comfort levels with having medical students present during commonly encountered clinical situations. A random subsample of these patients were also asked whether they would allow a medical student to be present during future visits, and why or why not. Results. A total of 229 patients completed the survey and 124 responded to the supplemental survey. Sixteen respondents were excluded due to missing data or a lack of an adequate comparison group. A majority responded they would feel comfortable having a medical student present during most clinical situations. Almost half of the patients preferred to see the doctor and medical student together, while less than a quarter wanted to see just the physician. Patients with more experience with medical students were more likely to favor medical student involvement and would feel more comfortable having a medical student present during obstetrics or gynecology clinical situations. Conclusion. Patients are willing to involve and feel comfortable with medical students in the obstetrics gynecology clinic. However, physicians and clinics need to take steps to ensure that patient willingness and comfort are maintained by asking patients about their comfort with medical student involvement, clearly outlining the roles and responsibilities of participating medical students, and gradually increasing medical students responsibilities as patients gain more experience with them. Acad. Med. 2000;75: A vital part of medical students education is learning through interaction and direct contact with patients. While many medical schools have begun to At the time the study was done, Dr. Hartz was a medical student at the University of North Dakota School of Medicine. He is now a second-year internal medicine resident, University of Iowa Hospitals and Clinics, Iowa City, Iowa. Dr. Beal is assistant professor and director of research and program development, Department of Family Medicine, University of North Dakota School of Medicine and Health Sciences, Grand Forks, North Dakota. Correspondence and requests for reprints should be addressed to Dr. Beal, Family Medicine, UND School of Medicine, P.O. Box 9037, Grand Forks, ND ; jrbeal@medicine.nodak.edu. use standardized patients and simulations as part of the medical education process, often hospital and clinic patients provide the only viable handson option. This is particularly true in clinical rotations such as those in obstetrics gynecology and surgery, where standardized patients and simulations are often difficult to obtain or unavailable. Thus, a key element of medical education is a patient s willingness and comfort level with involving a medical student in his or her care. Studies have found that patients generally accept medical student involvement in hospital and clinic care, citing reasons such as a desire to contribute to medical education, the extra time precepting physicians may spend with the patient, and the potential for fresh insight into a medical problem. 1 7 A patient s willingness and comfort level with involving a medical student in care may be affected by his or her previous level of experience with medical students, his or her understanding of the role and responsibilities of medical students, and the nature of the medical problem, combined with the student s gender. 1,2,5,8 Obstetrics patients expected medical students to perform few clinical procedures and were more likely to de A CADEMIC M EDICINE, V OL. 75, N O. 10/O CTOBER 2000

2 cline a student s participation if they thought the student s involvement was at too high a level of responsibility. 2 4 Other studies found that patients lack knowledge and awareness of medical students clinical responsibilities as well as the extent to which medical students are involved. 4,9,10 The purpose of this study was to identify the views of obstetrics gynecology patients on the roles of medical students, their preferences for medical student involvement in their care, and their comfort levels with the presence of medical students during clinical situations. METHOD This study was conducted for one month in 1998 at two obstetrics gynecology clinics located in an upper Midwest city of approximately 50,000 people. A self-administered questionnaire was distributed to patients waiting for a scheduled office visit with one of seven male physicians who served as preceptors for both male and female medical students. The physicians were included whether or not they were serving as preceptors at the time the study was conducted. Patients of the clinics female physicians were excluded since these physicians served as preceptors for female medical students only. Patients were asked to supply demographic information, i.e., age, race, and education level, whether a medical student had ever been present during their previous visits, their perceptions of the role of medical students; and their preferences regarding medical student involvement. A five-point Likert scale was used to assess patients comfort levels with having a medical student present during commonly encountered clinical situations: giving private and/or personal information during a medical history, physical exam without pelvic exam or Pap smear, physical exam with pelvic exam and Pap smear, a new problem such as pelvic pain or changes in menstruation, birth control advice, prenatal checkup, and evaluation and planning for surgery such as hysterectomy. A random subsample of patients was also given a supplemental survey, which asked whether they would allow a medical student to be present during future visits and why or why not. Patients that stated they would not allow a medical student to participate in future visits were asked whether there were conditions in which they would allow a medical student to participate in their care. These patients were also asked for their opinions on the best way for medical students to learn. A total of 229 patients completed the survey, of whom 124 were those randomly chosen to complete the supplemental survey. Sixteen questionnaires were excluded from the study due to lack of an adequate comparison group and/or missing data. Of these, seven were questionnaires completed by minority (non-white) patients that were removed because there was not a large enough sample to make a valid comparison between the two racial ethnic groups, and nine others lacked key information. In sum, 213 patients were in the overall analysis and 114 were in the analysis of the supplemental survey. Data were analyzed using Pearson s chi-square test for categorical variables, one-way analysis of variance (ANOVA) for interval or ratio variables, the Mann Whitney U test, and the Kruskal Wallis one-way ANOVA on ranks for ordinal variables. If a significant difference was obtained using the Kruskal- Wallis ANOVA, Dunn s method for all pairwise multiple comparisons procedure was used to locate the source of significance. An alpha level of p <.05 was used. RESULTS The 213 patients in the analysis had a mean age of 34.9 years, and 73% had attended or graduated from college. Among the patients, 16% reported no prior obstetrics or gynecology visit involving a medical student, 41% reported one to two such visits, 23% had had three to four such visits, and 20% reported five or more. There was no significant difference in age (f = 1.172, df =3,p =.322) or education ( 2 = 5.644, df = 3, p =.130) between the different groups. The patients perceptions of the role of medical students differed: 40% viewed the student as a student, 30% viewed the student as a member of the health care team, 22% as an assistant to the physician, 7% as a doctor, and 1% as other. There was no significant difference in patients views of the role of a medical student (student versus all others) with respect to the numbers of previous visits that had included a medical student ( 2 = 1.746, df = 3, p =.627), or between patients views regarding the role of medical students and whether or not the patient had attended college ( 2 =.006, df = 1, p =.941). The patients preferences for medical student involvement during a visit revealed that 49% of them preferred to see the doctor and student together, 28% had no preference if the student was involved in the office visit, while 20% preferred to see the physician alone and 3% had another preference. A significant difference was found between patients who would allow a medical student to be involved (doctor and student together or doesn t matter) and those who would not (doctor only or other) with respect to the number of previous visits involving a medical student ( 2 = , df = 3, p =.001). Patients with fewer previous visits with a medical student present were more likely to decline a student s involvement. There was no significant difference in patients preferences for medical student involvement with respect to whether or not the patients had attended college ( 2 = 1.358, df = 1, p =.244). A majority of patients reported they A CADEMIC M EDICINE, V OL. 75, N O. 10/O CTOBER

3 Table 1 Patients Reported Comfort Levels with Having a Medical Student Present during Common Clinical Situations, Based on a 1998 Survey of 213 Patients at Two Obstetrics Gynecology Clinics* Clinical Situation Very Uncomfortable Uncomfortable Neutral Comfortable Very Comfortable Giving personal information during medical history 4 (8) 7 (15) 23 (48) 48 (103) 18 (39) Physical exam without pelvic exam and Pap smear 5 (10) 6 (12) 19 (41) 39 (83) 32 (67) Physical exam with pelvic exam and Pap smear 15 (31) 18 (37) 26 (54) 31 (65) 12 (25) Office visit for a new problem, such as pelvic pain 6 (12) 14 (30) 29 (61) 36 (77) 15 (32) Birth control advice 3 (6) 3 (6) 26 (53) 42 (85) 25 (51) Prenatal check 4 (8) 2 (4) 26 (50) 40 (77) 28 (55) Evaluation and planning for surgery 8 (16) 7 (15) 30 (60) 37 (75) 18 (36) * Individual items may not equal 213 because of missing data. Table 2 Patients Reported Comfort Levels with Having a Medical Student Present during Common Clinical Situations by Number of Previous Obstetrics Gynecology Visits Involving a Medical Student, Based on a 1998 Survey of 213 Patients at Two Clinics* Mean Rank Sum, by Number of Previous Visits Involving a Medical Student Clinical Situation None (n = 35) 1 2 (n = 88) 3 4 (n = 48) 5 (n = 42) Chi-square df=3 p Giving personal information during medical history Physical exam without pelvic exam and Pap smear Physical exam with pelvic exam and Pap smear* Office visit for a new problem, such as pelvic pain* Birth control advice* Prenatal check* Evaluation and planning for surgery* * Totals for some groups may not equal n because of missing data. Kruskal-Wallis one-way ANOVA. would feel comfortable having a medical student present during most clinical situations, with the highest levels of comfort being associated with a physical exam without a pelvic exam and Pap smear (71%), prenatal visits (68%), and birth control advice (67%) (see Table 1). Only 43% of the patients would have felt comfortable if a medical student were present during a physical exam with a pelvic exam and Pap smear. The patients reported comfort levels with having a medical student present differed significantly by numbers of visits for all clinical situations (see Table 2). Patients with five or more previous visits involving a medical student responded they would feel significantly more comfortable giving personal information in a medical history and during a physical exam without pelvic exam and Pap smear than did patients in the category of one to two previous visits or the category of no previous visits. Patients with three or more previous visits involving a medical student responded they would feel significantly more comfortable during a physical exam with a pelvic exam and Pap smear than did patients with only two or fewer previous visits involving a medical student. Patients with three or more previous visits would feel significantly more comfortable if a medical student were present for a new problem, birth control advice, and prenatal checkups than did patients with no previous visits. Group differences for evaluation and planning for 1012 A CADEMIC M EDICINE, V OL. 75, N O. 10/O CTOBER 2000

4 surgery could not be determined at p <.05. The level of a patient s education had an impact on comfort level only in the clinical situation of a physical exam with a pelvic exam and Pap smear (W = 5,013, n1 = 56, n2 = 155, z = 2.426, p =.015). Patients who had attended college reported that they would be significantly more comfortable with a medical student present than did patients who had not attended college ( versus mean rank). The vast majority of patients, 78% (89/114), said they would allow a medical student to be present during future visits. A desire to contribute to student learning was cited most often among reasons for allowing student participation. Another important reason cited by patients was the perception that they themselves learn more when their doctor is teaching the medical student. Privacy issues and preferring to speak to the physician alone were the reasons most commonly cited by the 22% of patients (25/114) who stated that they would not allow a medical student to be present during future visits. When asked whether there were any conditions (more than one response could be selected) in which they would allow a medical student to participate, these patients listed the following: student would not perform a pelvic exam or Pap smear (9/25), student was known from a previous visit (7/25), doctor would be in the room the entire time (6/25), and student was a woman (5/25). Patients comments on the best ways for medical students to learn were grouped into general themes. The most commonly occurring theme, which was mentioned by 36 patients, recognized the importance of hands-on patient contact for students to learn procedures and physical exam skills. Sixteen patients said they felt students learned best from observing physicians as they interacted with patients in the clinic or hospital. DISCUSSION Our study s findings show that these patients tended to view medical students as more than just students, would want or would not mind student involvement, and would feel comfortable having a medical student present during most clinical situations. Patients with more previous visits in which a medical student had been present were more willing to have a medical student involved and would feel more comfortable with a medical student present during clinical situations. A vast majority of the patients we asked responded that they would allow a medical student to be present during future visits. A desire to contribute to the education of medical students and learning or receiving more information from the doctor when a medical student is present were the major reasons patients gave for allowing student participation. Patients who said they would decline student participation in the future most often mentioned privacy-related issues and the desire to speak with their physicians alone. Hands-on patient contact and observing physician patient interaction were the most common themes listed by patients as the best way for a medical student to learn. Our study had some limitations. The patients we surveyed were white and well educated. Also, 84% of the patients had had at least one previous visit in which a medical student was present. Finally, neither the patients comfort levels with physicians in general nor the impact of a physician s gender were examined. Medical students education depends on the patients comfort level with and willingness to allow students participation in their care. The rather private nature of the examinations and procedures in the obstetrics gynecology clinic may not allow a patient to feel truly comfortable, regardless of whether a medical student is involved. Further complicating the process is that medical students usually spend only one to two months on each rotation, which limits the opportunity for them to form relationships with patients. However, steps can be taken to achieve high levels of willingness and comfort among patients. First and foremost, preceptors should ask their patients whether they will allow a medical student to be present. Second, preceptors should reduce the patients uncertainty about the extent of the student s involvement. For those patients who have had limited experiences with medical students, medical student involvement should be confined to observing the physician patient encounter during clinical situations such as giving birth control advice or medical history taking. Once patients have had several visits involving medical students, they should be approached about having a medical student being present and possibly performing procedures under the physician s supervision during such clinical situations as a physical exam with a pelvic exam and Pap smear. CONCLUSION Patients willingness to have students involved in their care is vital to medical education. This study was designed to assess the patient medical student relationship in an obstetrics gynecology clinic. While most patients would welcome and feel comfortable with medical student involvement, preceptors need to take steps to ensure their patients willingness and comfort by inquiring about their feelings regarding the involvement of medical students in their care and clearly outlining the role and responsibilities of medical students. REFERENCES 1. Cooke F, Galasko G, Ramrakha V, et al. Medical students in general practice: how do patients feel? 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