Attitudes of elderly patients to medical students D KING, S J BENROW, J ELIZABETH & M L Y E I>rpnrtmen t of C;t‘t in t n c .Z frdrCIti
(2,
K o y a 1 L I vevp (I o I Horp I fd /
Summary. T h e attitudes of‘ eldcrly patients towards clinical teaching of medical students was assessed by a structured interview carried out by a doctor unknown to the patient iinnicdiately prior to discharge. O n e hundred and thirty alert patients were approached o n three acute geriatric medicine wards in the Royal L.iverpoo1 (Tcaching) Hospital. A totdl o f 106 (81.5%) patients were suitable for inclusion in the study (mean age, 80.2 years). Twenty-nine per cent did not k n o w what a niedical student was despite having been interviewed and examined by one. Fifty-nine per cent of patients had n o prior knowledge that clinical teaching occurred. Fourteen patients (13 women, 1 man, P < 0.05) objected to bcing examined. Nineteen w o m e n patients were examined b y a nian student without a chaperon. Students usually (95%) asked permission t o interview and examine the patients whereas doctors only asked patients in the context o f bedside teaching (33%).Elderly patients were sympathetic towards (‘They have t o learn’) and positive about (‘It’s good to have thcni’) medical students. Howcver, 29% o f paticnts were not aware that a medical student was going to be a doctor despite being interviewed and examined. W e suggest that the term should be used either with explanation o r abandoned in favour o f ‘student doctor’. T h e level of awareness o f clinical teaching was poor and examination of w o m e n patients without a chaperon caused distress and should be rectified.
education, medical, undergraduatc; tcaching; patient satisfaction; Great Britain
Introduction Bedside teaching is a time-honoured way of clinical teaching first adopted by Franciscus dc la Boe Sylvius (16161672). This and student clcrking would not be possible without the cooperation o f patients. Guidelines for teaching o n patients have been provided b y the Department o f Health (1’391). These state that patients should be forewarned before coming into hospital, preferably by their general practitioner, that teaching o f students occurs. Hospitals should have an explanation in their introductory booklet o f the irnportancc o f clinical teaching and there should be a clear statement that patients can decline to participate without prejudice to treatment. Howcver, the booklet should not be a subsitute for personal explanations b y the teacher or student w h o should effectively obtain informed consent from the patient before teaching occurs. Although there have been recent studies of medical students’ attitudes to elderly patients (Miller e l a / . 1990; Sainsbury el a / . 1992), there have been no studies ofelderly patients’ attitudes to medical students. Previous studies of patients’ attitudes to students have involved younger patients (Feletti & Carney 1984), o r highly selected groups; Richardson’s (1986) study discussed the attitude of young w o m e n on a maternity unit to students w h o participated in the delivery of their babies. Demographic changes lead to increased age of patient populations and students must acquire
Key words: *attitude; students mcd/*psychol; aged/*psychol; *professional patient relations; Correspondence: Dr D. King, Cardiology and Hypertension Unit, Clatterbridge Hospital, Bebington, Wirral, Merseyside L63 4JY, UK. 360
Attitudes ofthe elderly to medical students
those skills particular to dealing with the elderly patient. In achieving this training the attitudes and potential problems for elderly patients themselves may need to be addressed.
Subjects and methods The survey was carried out over a 4-month period on the three 25-bedded acute geriatric wards at the Royal Liverpool (Teaching) Hospital. The project received approval from the hospital ethics committee. Third-year (first clinical year) and final-year medical students in Liverpool are attached to the Geriatric Unit for 6 weeks and 1 week respectively . They clerk elderly patients individually as well as taking part in bedside teaching sessions. Each group comprises six to eight students at one time. Patients for clerking are allocated to third-year students each week and their names recorded. Similarly, patients who had been subjects for bedside teaching wcre noted. These patients who we knew had been in contact with a student were questioned. Each patient was approached immediately prior to discharge by a doctor whom he/she did not know and was asked to take part in the survey. It was stressed that the survey was anonymous. An abbreviated mental test score was carried out and only those scoring 10 out of 10 were included in the study. Patients were asked if they knew what a medical student was and only answers including 'doctor' were accepted as correct. If the patient did not know what a student was then the interviewer explained and the patient's previous contact with that student recalled before continuing with the questionnaire. The questionnaire (available from the authors) assessed the frequency of teaching sessions and patients' attitudes towards them. Results were analysed using the x2 test and Fisher's exact test as appropriate.
Results One hundred and thirty patients were approached to take part in the survey and all consented. One hundred and six (81.5%) patients had a mental test score of 10/10 and were eligible to complete the interview. The average age was
36 1
Table 1. Mode of admission of the patients studied
Mode of admission General practitioner Domiciliary visit Accident and emergency Other
Oh
patients 53 17
25 5
80.2 years (range 62-92, SD 6.1) and there were 68 women. The average length of stay was 26.6 days (range 1-365 days). The mode of admission is shown in Table 1. The commonest diagnoses were cerebrovascular disease (17%) and heart failure (16%) and 23% of patients had more than one diagnosis, consistent with multiple pathology, which is common in the elderly. Only 71% of patients appreciated that a medical student was training to be a doctor. The remainder had no idea at all (15'/0) or thought they wcre either students of nursing (9%) or pharmacy (5%). The majority ofpatients did not know that clinical teaching of medical students occurred in the Royal Liverpool (Teaching) Hospital although the name of the hospital indicated this to 20 patients (see Fig. 1). All 106 patients had been interviewed (clinical history) by a medical student alone (mean 1.9 times each, range 1-6). Forty-one per cent of patients had taken part in bedside teaching with a doctor present (mean 2.2 times each, range 1-9). The students sought permission of the patient to interview him/her in 95% of cases. This figure compar'cs with 33% of doctors who only tended to ask when conducting bedside teaching. Sixtytwo per cent of patients were physically examined by a medical student alone (mean 1.7 times each, range 1 4 ) and 56% of these were physically examined with the doctor present in a bedside teaching setting. There were 19 instances (16% of physical examinations) where a woman patient 'was examined by a man medical student without a chaperon. Students did not ask permission to examine patients physically in 12% of cases as compared with 61Yo of cases not asked by doctors. One hundred and three (97.2%) patients did not object to being interviewed by students. O f the remaining 2.8% (two women, one man), one woman felt too ill and one thought students were
L).K i q et a1 General practitioner (2) Booklet (6) Friend/relative Newspaper (8)
Name of hospital (20)
None (63*)
* Patients had no awareness before contact with student
Total 106 patients
Figure 1. Patients’ awareness of clinical teaching
too rude. The man patient thought studeuts were too nosey. The 103 who did not mind being interviewed were asked why and the most frcquent responses are given in Table 2. There were no significant sex differences. Fourteen (13.2%) patients objected to bcing physically examined by students (13 women, one man, P = 0.035). The single man patient felt that the students were too inexperienced to examiue whereas 10 women felt embarrassed. O n e woman patient specifically would have liked a doctor present and one would have liked a chaperon. All patients questioned had no previous experience o f students prior to admission. When asked if they would like to be intcrviewed or examined during a future admission, five (four women, one man) said they would not like to see students again and 16 (15 womcn, one man) said that they would be happy to talk to students but would not like to be examined.
their illness better as a result. O u r study confirms this in that most of the elderly questioned (95.3%) had positive attitudes towards students: ‘I feel it’s a bonus’, ‘It’s good to have them’. Only a minority were reluctant to be involved in clinical teaching; five (four wonicn, one man) not wanting to see students again and 16 (15 women, one man) prcfcrring not to be examined. These groups mainly contained embarrassed women. Thc principle ofinformed consent is called into question when 29% of the patients did not know that a medical student was going to be a doctor. O n e female patient said, ‘I didn’t know I could refuse’, further demonstrating the lack of informed consent. Nineteen instances of a woman patient bcing examined by a n unchaperoned man student is a cause for concern. Obviously nurses chaperoning men medical students has implications on resources but none the less it must be considered essential if the patient is to be made to feel comfortable during physical examination.
Discussion Bedside teaching aud clerking of patients is the mainstay o f clinical undcrgraduatc education. Patients’ attitudes to medical students are usually favourable. Romano (1941) in his study of the effects of bedside presentation o n 100 patients found that ‘ward round teaching, when conducted tactfully and sympathetically. . . is not a traumatic emotional experience to patients but educates and reassures them’. Other studies, Linfors & Neelson (1980) have shown that 95% of patients found bedside teaching a positive experience and 66% thought they understood
Table 2. The attitudes of patients w h o responded positively to medical students Response ‘I want to help’ ‘Someone t o talk to’ ‘I felt I could discuss m y illncss iiiorc frankly with the student than the doctor’ ‘I felt more at ease with the student than with the doctor’ ‘I liked thc extra attcntion’
?A patients 85
31
IY
24 17
Attitudes ofthe elderly to medicd students
Despite the Department of Health guidelines expressing that patients should be forewarned of students before admission to a teaching hospital the majority of patients in our study (60%) had no prior knowledge of student teaching before they came into contact with it and only two ofthe 56 patients (3.6%) admitted by their general practitioners had been told of the possibility of student teaching. It should be borne in mind, however, that the majority ofthese patients were emergency medical admissions. Even though a section on student teaching is included in the Royal Liverpool Hospital’s introductory booklet the level of awareness was poor among patients. As the majority of the elderly were admitted by their general practitioners it would be preferable if they could discuss the possibility of teaching before admission. However, it should be a routine part of the doctor and nurse’s introductory consulation with the patient wherever possible on admission. It would be helpful if comparative studies were carried out in other teaching hospitals to establish whether the attitudes described are similar nation-wide. It would also be pertinent to carry out a similar study in general practice as an increasing proportion of medical teaching is occurring outside hospitals. This study confirms the positive attitudes of the large majority of elderly patients to student doctors and so the valuable technique of bedside teaching should continue as an essential tool described by its founder Sylvius when in 1664 he
363
wrote: ‘My method. . . is to lead my students by the hand to the practice of medicine, taking them every clay to see patients in the public hospital, that they may hear the patients’ symptoms and see their physical findings.’ References Department of Health (1991) Medical Students in Hospitals. HC(91) 18. Department of Health, London. Feletti G.1. & Carney S.L. (1984) Evaluating patients’ satisifaction with medical students’ interviewing skills. Medical Education 18, 15-20. Linfors E.W. & Neelon F.A. (1980) The case for bedside rounds. N e w England Journal of Medicine 303, 1230-3. Miller h4.D., Oppenheimer K.C. & Melcher R. (1990) Medical students’ attitudes toward elderly patients: effects of social attractiveness. Family Medicine 22, 25r32. Qureshi K.N. & Hodkinson H.M. (1974) Evaluation of a ten-question mental test in the institutionalized elderly. Age and Ageing 3, 152-7. Richardson P.H., Curzen P. & FoGagy P. (1986) Patients’ attitudes to student doctors. Medical Educatiori 20,314-17. Romano J . (1941) Patients’ attitudes and behaviour in ward round teaching. Journal ofthe American Medical Association 117, 664-7. Sainsbury R., Wilkinson T.J. & Smith C.W. (1992) Attitudes of medical students to old people: a cross-national comparative study. Medical Education 26, ;!86-90.
Received 3 January 1992; editorial comments to authors 6 March 1992; accepted f o r publication 19 March ‘1992
(2,
K o y a 1 L I vevp (I o I Horp I fd /
Summary. T h e attitudes of‘ eldcrly patients towards clinical teaching of medical students was assessed by a structured interview carried out by a doctor unknown to the patient iinnicdiately prior to discharge. O n e hundred and thirty alert patients were approached o n three acute geriatric medicine wards in the Royal L.iverpoo1 (Tcaching) Hospital. A totdl o f 106 (81.5%) patients were suitable for inclusion in the study (mean age, 80.2 years). Twenty-nine per cent did not k n o w what a niedical student was despite having been interviewed and examined by one. Fifty-nine per cent of patients had n o prior knowledge that clinical teaching occurred. Fourteen patients (13 women, 1 man, P < 0.05) objected to bcing examined. Nineteen w o m e n patients were examined b y a nian student without a chaperon. Students usually (95%) asked permission t o interview and examine the patients whereas doctors only asked patients in the context o f bedside teaching (33%).Elderly patients were sympathetic towards (‘They have t o learn’) and positive about (‘It’s good to have thcni’) medical students. Howcver, 29% o f paticnts were not aware that a medical student was going to be a doctor despite being interviewed and examined. W e suggest that the term should be used either with explanation o r abandoned in favour o f ‘student doctor’. T h e level of awareness o f clinical teaching was poor and examination of w o m e n patients without a chaperon caused distress and should be rectified.
education, medical, undergraduatc; tcaching; patient satisfaction; Great Britain
Introduction Bedside teaching is a time-honoured way of clinical teaching first adopted by Franciscus dc la Boe Sylvius (16161672). This and student clcrking would not be possible without the cooperation o f patients. Guidelines for teaching o n patients have been provided b y the Department o f Health (1’391). These state that patients should be forewarned before coming into hospital, preferably by their general practitioner, that teaching o f students occurs. Hospitals should have an explanation in their introductory booklet o f the irnportancc o f clinical teaching and there should be a clear statement that patients can decline to participate without prejudice to treatment. Howcver, the booklet should not be a subsitute for personal explanations b y the teacher or student w h o should effectively obtain informed consent from the patient before teaching occurs. Although there have been recent studies of medical students’ attitudes to elderly patients (Miller e l a / . 1990; Sainsbury el a / . 1992), there have been no studies ofelderly patients’ attitudes to medical students. Previous studies of patients’ attitudes to students have involved younger patients (Feletti & Carney 1984), o r highly selected groups; Richardson’s (1986) study discussed the attitude of young w o m e n on a maternity unit to students w h o participated in the delivery of their babies. Demographic changes lead to increased age of patient populations and students must acquire
Key words: *attitude; students mcd/*psychol; aged/*psychol; *professional patient relations; Correspondence: Dr D. King, Cardiology and Hypertension Unit, Clatterbridge Hospital, Bebington, Wirral, Merseyside L63 4JY, UK. 360
Attitudes ofthe elderly to medical students
those skills particular to dealing with the elderly patient. In achieving this training the attitudes and potential problems for elderly patients themselves may need to be addressed.
Subjects and methods The survey was carried out over a 4-month period on the three 25-bedded acute geriatric wards at the Royal Liverpool (Teaching) Hospital. The project received approval from the hospital ethics committee. Third-year (first clinical year) and final-year medical students in Liverpool are attached to the Geriatric Unit for 6 weeks and 1 week respectively . They clerk elderly patients individually as well as taking part in bedside teaching sessions. Each group comprises six to eight students at one time. Patients for clerking are allocated to third-year students each week and their names recorded. Similarly, patients who had been subjects for bedside teaching wcre noted. These patients who we knew had been in contact with a student were questioned. Each patient was approached immediately prior to discharge by a doctor whom he/she did not know and was asked to take part in the survey. It was stressed that the survey was anonymous. An abbreviated mental test score was carried out and only those scoring 10 out of 10 were included in the study. Patients were asked if they knew what a medical student was and only answers including 'doctor' were accepted as correct. If the patient did not know what a student was then the interviewer explained and the patient's previous contact with that student recalled before continuing with the questionnaire. The questionnaire (available from the authors) assessed the frequency of teaching sessions and patients' attitudes towards them. Results were analysed using the x2 test and Fisher's exact test as appropriate.
Results One hundred and thirty patients were approached to take part in the survey and all consented. One hundred and six (81.5%) patients had a mental test score of 10/10 and were eligible to complete the interview. The average age was
36 1
Table 1. Mode of admission of the patients studied
Mode of admission General practitioner Domiciliary visit Accident and emergency Other
Oh
patients 53 17
25 5
80.2 years (range 62-92, SD 6.1) and there were 68 women. The average length of stay was 26.6 days (range 1-365 days). The mode of admission is shown in Table 1. The commonest diagnoses were cerebrovascular disease (17%) and heart failure (16%) and 23% of patients had more than one diagnosis, consistent with multiple pathology, which is common in the elderly. Only 71% of patients appreciated that a medical student was training to be a doctor. The remainder had no idea at all (15'/0) or thought they wcre either students of nursing (9%) or pharmacy (5%). The majority ofpatients did not know that clinical teaching of medical students occurred in the Royal Liverpool (Teaching) Hospital although the name of the hospital indicated this to 20 patients (see Fig. 1). All 106 patients had been interviewed (clinical history) by a medical student alone (mean 1.9 times each, range 1-6). Forty-one per cent of patients had taken part in bedside teaching with a doctor present (mean 2.2 times each, range 1-9). The students sought permission of the patient to interview him/her in 95% of cases. This figure compar'cs with 33% of doctors who only tended to ask when conducting bedside teaching. Sixtytwo per cent of patients were physically examined by a medical student alone (mean 1.7 times each, range 1 4 ) and 56% of these were physically examined with the doctor present in a bedside teaching setting. There were 19 instances (16% of physical examinations) where a woman patient 'was examined by a man medical student without a chaperon. Students did not ask permission to examine patients physically in 12% of cases as compared with 61Yo of cases not asked by doctors. One hundred and three (97.2%) patients did not object to being interviewed by students. O f the remaining 2.8% (two women, one man), one woman felt too ill and one thought students were
L).K i q et a1 General practitioner (2) Booklet (6) Friend/relative Newspaper (8)
Name of hospital (20)
None (63*)
* Patients had no awareness before contact with student
Total 106 patients
Figure 1. Patients’ awareness of clinical teaching
too rude. The man patient thought studeuts were too nosey. The 103 who did not mind being interviewed were asked why and the most frcquent responses are given in Table 2. There were no significant sex differences. Fourteen (13.2%) patients objected to bcing physically examined by students (13 women, one man, P = 0.035). The single man patient felt that the students were too inexperienced to examiue whereas 10 women felt embarrassed. O n e woman patient specifically would have liked a doctor present and one would have liked a chaperon. All patients questioned had no previous experience o f students prior to admission. When asked if they would like to be intcrviewed or examined during a future admission, five (four women, one man) said they would not like to see students again and 16 (15 womcn, one man) said that they would be happy to talk to students but would not like to be examined.
their illness better as a result. O u r study confirms this in that most of the elderly questioned (95.3%) had positive attitudes towards students: ‘I feel it’s a bonus’, ‘It’s good to have them’. Only a minority were reluctant to be involved in clinical teaching; five (four wonicn, one man) not wanting to see students again and 16 (15 women, one man) prcfcrring not to be examined. These groups mainly contained embarrassed women. Thc principle ofinformed consent is called into question when 29% of the patients did not know that a medical student was going to be a doctor. O n e female patient said, ‘I didn’t know I could refuse’, further demonstrating the lack of informed consent. Nineteen instances of a woman patient bcing examined by a n unchaperoned man student is a cause for concern. Obviously nurses chaperoning men medical students has implications on resources but none the less it must be considered essential if the patient is to be made to feel comfortable during physical examination.
Discussion Bedside teaching aud clerking of patients is the mainstay o f clinical undcrgraduatc education. Patients’ attitudes to medical students are usually favourable. Romano (1941) in his study of the effects of bedside presentation o n 100 patients found that ‘ward round teaching, when conducted tactfully and sympathetically. . . is not a traumatic emotional experience to patients but educates and reassures them’. Other studies, Linfors & Neelson (1980) have shown that 95% of patients found bedside teaching a positive experience and 66% thought they understood
Table 2. The attitudes of patients w h o responded positively to medical students Response ‘I want to help’ ‘Someone t o talk to’ ‘I felt I could discuss m y illncss iiiorc frankly with the student than the doctor’ ‘I felt more at ease with the student than with the doctor’ ‘I liked thc extra attcntion’
?A patients 85
31
IY
24 17
Attitudes ofthe elderly to medicd students
Despite the Department of Health guidelines expressing that patients should be forewarned of students before admission to a teaching hospital the majority of patients in our study (60%) had no prior knowledge of student teaching before they came into contact with it and only two ofthe 56 patients (3.6%) admitted by their general practitioners had been told of the possibility of student teaching. It should be borne in mind, however, that the majority ofthese patients were emergency medical admissions. Even though a section on student teaching is included in the Royal Liverpool Hospital’s introductory booklet the level of awareness was poor among patients. As the majority of the elderly were admitted by their general practitioners it would be preferable if they could discuss the possibility of teaching before admission. However, it should be a routine part of the doctor and nurse’s introductory consulation with the patient wherever possible on admission. It would be helpful if comparative studies were carried out in other teaching hospitals to establish whether the attitudes described are similar nation-wide. It would also be pertinent to carry out a similar study in general practice as an increasing proportion of medical teaching is occurring outside hospitals. This study confirms the positive attitudes of the large majority of elderly patients to student doctors and so the valuable technique of bedside teaching should continue as an essential tool described by its founder Sylvius when in 1664 he
363
wrote: ‘My method. . . is to lead my students by the hand to the practice of medicine, taking them every clay to see patients in the public hospital, that they may hear the patients’ symptoms and see their physical findings.’ References Department of Health (1991) Medical Students in Hospitals. HC(91) 18. Department of Health, London. Feletti G.1. & Carney S.L. (1984) Evaluating patients’ satisifaction with medical students’ interviewing skills. Medical Education 18, 15-20. Linfors E.W. & Neelon F.A. (1980) The case for bedside rounds. N e w England Journal of Medicine 303, 1230-3. Miller h4.D., Oppenheimer K.C. & Melcher R. (1990) Medical students’ attitudes toward elderly patients: effects of social attractiveness. Family Medicine 22, 25r32. Qureshi K.N. & Hodkinson H.M. (1974) Evaluation of a ten-question mental test in the institutionalized elderly. Age and Ageing 3, 152-7. Richardson P.H., Curzen P. & FoGagy P. (1986) Patients’ attitudes to student doctors. Medical Educatiori 20,314-17. Romano J . (1941) Patients’ attitudes and behaviour in ward round teaching. Journal ofthe American Medical Association 117, 664-7. Sainsbury R., Wilkinson T.J. & Smith C.W. (1992) Attitudes of medical students to old people: a cross-national comparative study. Medical Education 26, ;!86-90.
Received 3 January 1992; editorial comments to authors 6 March 1992; accepted f o r publication 19 March ‘1992
