Patients' attitudes towards medical students in a teaching family practice: a sri lankan experience.

BACKGROUND: Faculty of Medicine, University of Kelaniya, Sri Lanka conducts a one month under graduate training programme during their fourth year at the University family practice centre. Students get training in history taking, clinical examination, patient management and practice management during this attachment. This study was conducted to look at the patients' attitude towards student participation during consultation.
MATERIALS AND METHODS: This was a descriptive cross sectional study. All the patients who were 16 years and above during a 2 month period were included in the study. Structured questionnaire was administered by demonstrators following a consultation where students were present. Their demographic data, number of consultations with student participation and questions related to presence of students at various stages of the consultation were asked.
RESULTS: Total of 85 patients took part in the study and 81.3% of them were females. 88.8% were of the opinion that they benefited by the interaction with medical students while 93.8% thought students understood their problems. 26.3% patients preferred a medical student of the same sex during consultation while 71.3 had not expressed any opinion in this regard. Only 3.8% and 5% wanted the doctor alone during history taking and examination respectively. Almost every patient was happy that they could help the undergraduate training. DISCUSSION: As expected results of the study showed that patients were willing to take part in undergraduate training without any reservation. These results are compatible with the previous studies done in the western world and data is not available form either Sri Lanka or other Asian countries.

Introduction

With the introduction of family medicine into the undergraduate curriculum, teaching of undergraduate medical students in the setting of family/general practice has increased considerably during the past 20 years in Sri Lanka. Undoubtedly in future the contribution of general practice will see an incremental trend towards the student's training. Therefore, more practices will be needed to provide necessary training.

Medical schools globally[1234] have increased the share of community teaching by the increasing number of general practitioner teachers.[5678] General practitioner teachers have developed from their original role as teachers of behavioral science and general practice[9] into teachers of clinical skills, with excellent access to a wide range of patients.[1011] The General medical council's directive “Tomorrow's doctors (GMC,1993)”[12] recognized that the community setting offers a wealth of teaching opportunities to the medical students. This move has also been supported by the findings that community-based teaching is as effective as hospital-based teaching of basic clinical skills.[131415]

The growing recognition of the fact that patients in teaching hospitals are not representative of the general population and an emphasis on community management of chronic disease have further strengthened the importance of undergraduate training in general practices.[16]

Teaching in family practices converts a duo activity into a trio one[17] and already complex interaction between patient and doctor becomes further complicated by the presence of a third party.

In a family practice patients are autonomous and majority of the patients are ambulatory. They spend only a limited time in a family practice unlike the admitted patients in hospitals and student participation could lead to delays. The personal and ongoing relationship with the family doctor is also a key part of the interaction in a family practice and involvement of students in the consultation could affect the doctor–patient relationship and interaction. Patient's consent to participate in medical education is often taken for granted and patients are not always aware of teaching activities.[18]

Researches in UK, USA and Australia looking at teaching in general practices suggest that patients are happy for a student to be present during consultation with their GP.[192021222324] One of the studies revealed that patients are a willing, but potentially under used resource for training medical students in general practice.[24]

No study has looked at the effect of students’ presence on patients in hospitals or general practices in Sri Lanka and study could not be traced from the south Asian region either.

Faculty of Medicine, University of Kelaniya, Sri Lanka conducts a one month under graduate training program during their fourth year at the University family practice center and students get training in history taking, clinical examination, patient management and practice management during this attachment. One student is present during a consultation inside the consultation room. This study looks at the patient's attitudes toward participation of students during consultation. It will also shed light on the present trend of creating teaching practices toward more patient centered approach.

Materials and Methods

This descriptive, cross-sectional study was conducted at the University Family Practice. All the patients who were 16 years and above and consulted a doctor in the presence of a student during a 2 month period were included in the study. Seriously ill patients, confused or cognitively impaired patients and patients below 16 years were excluded. Younger patients were excluded since they may not be able to respond to the questionnaire and the opinion of the guardian could vary depending on the relationship to the patient. Structured questionnaire was administered by trained interviewers following a consultation where a student was present. Their demographic data and number of previous consultations with student participation were obtained in addition to the questions related to the presence of students at various stages of the consultation. Patients were also given an opportunity to express their views about participation of students in the clinic.

Results

A total of 85 patients were included in the study and 81.3% of them were females. This clinic is conducted only in the mornings from Monday to Friday and therefore employed males find it difficult to attend [Figures 1 and 2].

Figure 1

Age distribution

Figure 2

Educational status

Previous consultations with student presence

For 34.4% of patients current consultation was the first consultation in the presence of medical students. For another 34.4% there were 1-3 previous consultations in the presence of students. The rest (31.2%) had more than 3 consultations with student participation prior to this.

Discussion

The vast majority of patients had positive feedback about student participation during the consultation. In fact 88.6% patients were of the view that they rather benefited from interacting with the patients and all the patients have enjoyed interacting with students [Table 1]. These findings are in agreement with that previously obtained by other studies. Devera –Sales et al.,[25] in a questionnaire study, found that 90% of patients would agree to students taking part in their care while Fiona and colleagues[19] found 97% patients had either positive or neutral feelings about the presence of students. Choudry, et al.[26] in a study conducted in London concluded that 92% agreed to allow a medical student to be present during consultation. Kevin Sweeney and colleagues has revealed that 97.5% of the patients would be willing to have a student during consultation in a study carried out in general practice settings in Australia.[22]

Table 1

Responses of patients

Patients have expressed that they were able to know more details about the illness from students and students helped in revealing details to the doctor [Box 1]. Previous studies have revealed perceived benefits of student participation. Improvement of knowledge and improvement of care have been expressed as gains of student participation by Katie Coleman and colleagues.[27] Same study showed altruistic attitudes such as providing a service to the community through training future doctors, repaying the National Health Service (NHS) as well as assisting their doctor who provides ongoing care by taking part in teaching as reasons for their willingness to take part in teaching. Another study revealed patients were proud to be part of teaching or pleased to be part of the advancement of medicine.[18]

Box 1

The fact that 95.5% patients felt comfortable even discussing personal problems in front of students is encouraging. This shows that doctor–patient interaction or the relationship is not affected to a greater extent by the presence of a student. This is in contrast to Wright[17] who found that the presence of a student may interfere with eliciting psychosocial components during consultation among 40% of the participants. O’Flynn, et al.[20] demonstrated that 30% of patients found it difficult to talk about personal matters. According to the views of general practice patients in Australia,[23] it is problematic to have students present during consultations that involve worrying test results, emotional upset, internal examinations, and sexual problems. GP teachers should be aware of circumstances where patients are less likely to want a student present and should talk to patients without students when sensitive personal information need to be elicited.

Preference by 26.3% of the patients for a student of the same gender needs to be considered seriously. The percentage of female patients who expressed this view was much more than males [Table 2]. Fiona, et al.[19] found that even though the large majority was unconcerned about the gender of the student, out of those who were concerned majority were females. In her study those who were concerned had commented that the nature of the complaint would influence the views on the importance of the gender of the student. According to Choudry, et al.[26] for 21.5% patients, gender of the student mattered.

Table 2

Patients’ preference for student of same gender

15.9% expressed that they wanted time alone with the doctor during consultation and doctors should be alert to this and offer that opportunity to patients. This fact has been revealed by Fiona, et al.[19] also. That study has further revealed that patients would rarely directly ask the doctor if they could consult the doctor alone.

When specifically questioned about students’ presence during history taking and examination there was a slight increase in the number who likes doctor only during examination compared to history taking [Figure 3]. Karen Salisbury and colleagues found that 89.7% patients would accept students during history taking compared to 70.4% during examination.[23]

Figure 3

Patients’ views on student participation during history taking and examination

Even though there was only one negative comment that needs to be taken seriously [Box 2], Shier and colleagues[28] found considerable ignorance among students on the confidentiality issue and in O’Flynn's study,[20] patients expressed concern that students would talk about them after work. Students should be instructed not to discuss patients in a careless manner.

Box 2

Acceptance of students by the vast majority of the patients may be an expression that the over all quality of the consultation is not affected by the presence of students. Fiona, et al.[19] concluded that most respondents (83%) felt that the presence of a student made no difference while 17% felt that presence of a student improved the quality of interaction.

Price and colleagues revealed that the quality of general practice consultations was not adversely affected by the presence of medical students[29] and another study showed patients’ enablement or satisfaction was not reduced after teaching consultations compared with non-teaching consultations.[30]

Response to specific questions as well as their free expressions are quite reassuring and revealed the positive attitude of the over helming majority of the patients attending this clinic. The findings of this research will be reassuring for doctors who are presently involved in teaching and those who plan to be involved in the future.

Limitations

This clinic is a non fee levying family practice attached to the university. Further studies should be carried out in fee levying general practices with a larger study sample to determine whether the attitudes and responses are similar among patients in fee levying practices.

Conclusions

Patients are willing to have students during consultation and the doctor–patient interaction or the relationship is not affected to a greater extent by the presence of a student. Trainers and medical educationists should consider the preference by a significant proportion of the patients for a student of the same gender. Opportunity should be given to patients to talk to the doctor without students and patients’ consent should be obtained before proceeding with examination. Students should be advised to maintain confidentiality and the findings of this study are reassuring for doctors involved in training undergraduates in ambulatory care settings. This study reflects the positive attitude of the patients towards students which is the trend in western countries as well.

Take home message

Patients have positive attitudes towards students. Patients think interaction with students is beneficial. Patients should be given the opportunity to consult the doctor without students if they wish. Students should be strictly advised to maintain confidentiality [Box 3].

Box 3