ORIGINAL REPORTS

Medical Students in Breast Clinics—How Welcome Are They and How Can We Improve Their Learning Opportunities? Jonathan K.A. Mills, BMBS, Kelly V. Lambert, FRCS and Jaroslaw Krupa, FRCS University Hospitals of Leicester NHS Trust, Breast Surgery, Glenfield Hospital, Leicester, United Kingdom OBJECTIVE: Clinical examination skills are an essential com-

ponent of medical education, with students having the opportunity to practice important skills to facilitate their learning. The opportunities to practice intimate examinations, however, can be varied, with a number of patients declining to give consent, limiting the learning opportunities in clinic. This study aimed to identify whether patient demographics correlated with varying degrees of consent toward student participation. METHODS: A questionnaire was distributed to patients

attending a surgical preassessment clinic with confirmed breast pathology regarding their attitudes toward different roles they were happy for students to have in their treatment journey. These results were analyzed using SPSS 20. RESULTS: Overall, 111 patients responded, aged between 17 and 86 years; 42 (38%) were under the care of a male surgeon. Patients under the care of a female surgeon were less likely to agree to students being in clinic (p ¼ 0.009), take a history (p ¼ 0.012), or examine them (p ¼ 0.019). Increasing age was associated with increased agreement to being examined (p ¼ 0.028), but there was no correlation between clinic attendance frequency and acceptance of students. CONCLUSIONS: Our findings suggest patients under the

care of a male surgeon were more likely to consent to history taking and examination by students, though this may be owing to patient selection bias. Older patients were more likely to consent to being examined, though previous clinic attendance did not improve consent to medical students. ( J Surg C 2015 Association of Program Directors in 72:452-457. J Surgery. Published by Elsevier Inc. All rights reserved.) KEY WORDS: breast surgery, clinical experience, proce-

dure, medical students, consent COMPETENCIES: Medical Knowledge, Professionalism,

Interpersonal and Communication Skills, Practice-Based Learning and Improvement Correspondence: Inquiries to Jonathan K.A. Mills, BMBS, University Hospitals of Leicester NHS Trust, Breast Surgery, Glenfield Hospital, Leicester LE39QP, UK; e-mail: [email protected]

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BACKGROUND Learning clinical examination skills by practicing on patients is well established.1 Medical students are expected to be competent in the performance of intimate examinations by the point of graduation. However, opportunities to attain competence can be limited owing to the nature of these examinations. Ethical dilemmas can arise with some patients feeling pressurized into allowing students to practice on them, and some vulnerable patients may have difficulty providing informed consent. Although intimate examinations are low-risk procedures, with most patients tolerating them well, there is the potential for discomfort, loss of privacy, and potentially psychological damage.2 It is possible to integrate the training needs of medical students into a busy outpatient clinic. However, patient autonomy should be respected, and medical students should balance their training needs with ethical practice. Recognition of these issues has led to the introduction of guidelines on teaching vaginal examinations, particularly regarding obtaining informed consent.3 When seeking informed consent for a medical student to practice vaginal examination, Martyn and O’Connor4 found that over a quarter of women refused permission for a medical student to examine them. They described the admitting clinician explaining the examination would be beneficial to the medical student’s education and seeking informed consent on behalf of the medical student. In contrast, Broadmore et al.5 found that when students sought consent from patients, 85% agreed to vaginal examination. Another study found that patients are significantly more likely to consent to vaginal examination when the student is a woman instead of a man.6 The study also found that older women and those who had had children were more likely to consent to medical students performing intimate vaginal examination, though preference for female students remained. Female patients have expressed positive attitudes to the presence of students in gynecology outpatient clinics, with varying levels of consent for different aspects of student interaction. Over half of patients did not recall being given notice in clinic

Journal of Surgical Education  & 2015 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2014.11.007

appointment letters, and only two-thirds reporting they were asked at the clinic appointment if they objected to a medical student being present.7 Digital rectal examination (DRE) is another intimate patient examination where medical students have difficulty obtaining competence. In a study, students felt DRE was an essential skill to be able to perform, but half lacked confidence. Cited reasons for this included patient refusal (39%), ethical opposition to what was deemed “unnecessary DRE” (22%), and opposite patient sex (16%).8 Breast examination is a necessary skill that medical students need to acquire during their training. The General Medical Council, the professional body responsible for regulating all practicing clinicians within the United Kingdom, expect medical graduates to be able to perform a full physical examination by graduation.9 In the UK, patients presenting to an outpatient breast clinic are often referred via their family/general practitioner, with most referrals being for a “breast lump.” Finding a breast lump can be a distressing experience for patients, particularly before diagnosis or investigation.10 Training medical students to recognize suspicious features in a breast lump, which warrant specialist opinion, is therefore vital to provide reassurance to some patients and initiate appropriate treatment for the remainder. Despite the evidence on patient attitudes toward invasive internal examinations by medical students, data regarding patient attitudes toward an external but nonetheless considered intimate examination of breasts are lacking. This article aims to identify patient attitudes toward the presence of medical students in breast clinics and their practicing of clinical breast examination in patients with confirmed breast pathology awaiting surgery.

METHODS In our center, patients with a new breast problem are referred to the breast surgery department via their family/ general practitioner. They are then seen in one of our symptomatic breast clinics within a maximum of 2 weeks by either a consultant surgeon or a junior surgeon from their team. The clinical, radiological, and pathological assessment is completed at that visit—what we term “triple assessment.” Learners at various levels are present in these clinics —medical students who are directly supervised, foundation year trainees and core trainees who start directly supervised and progress according to their competence, and specialty trainees who work independently but discuss the cases seen either in clinic or later at our multidisciplinary team meetings. If surgery is indicated, this is discussed with the patient at a subsequent breast results clinic. At this point, they are invited by their responsible surgeon, to a nurse preassessment clinic, to identify and minimize risks before the operation. This is typical of most British breast surgical clinics within the National Health Service.

A survey (Fig.) was distributed by the surgical preassessment staff to all breast surgery patients attending a surgical preassessment clinic between July and September 2013. Patients were asked to complete the survey on their attitudes toward medical students in clinic, regardless of frequency of attendance or whether students had been present in previous consultations. Questions included whether the patient recalled the clinic letter informing them of students being present and their attitudes on a Likert scale (strongly disagree to strongly agree) on different activities such as history taking and examination, along with demographic data and responsible clinician. The data were analyzed using SPSS 20.

RESULTS In total, 138 patients attended breast surgery preassessment clinic over 16 clinic episodes; 111 patients responded (80%). Of 111 responses, clinic attendance ranged from 1 to 27 previous attendances to the breast surgery department (median ¼ 4, mean ¼ 4.96), with 2 patients having only been once before. Patients were aged 17 to 86 years (median ¼ 55, standard deviation ¼ 16), with 93 (84%) describing themselves as “white British” and 66 (60%) reporting their faith as Christianity. In addition, 42 (38%) were under the care of a male surgeon. Moreover, 41 (37%) reported a student being present previously, with 92 (83%) not recalling being informed a student could be present on the clinic invitation letter. Patients overwhelmingly felt medical students should attend breast clinics, with 68 (61%) agreeing and 31 (28%) strongly agreeing. Most believed that students should have access to medical records, with 70 (63%) agreeing and 16 (14%) strongly agreeing. In addition, 13 (12%) expressed a preference to see the doctor alone, with 15 (14%) having concerns over students breaching confidentiality. Moreover, 93 (84%) were happy to have students present, 94 (85%) happy to talk to medical students, and 88 (79%) happy to be examined by a student. Patients were less likely to accept a medical student in clinic (p ¼ 0.009), agree to their taking a history (p ¼ 0.012), or examination (p ¼ 0.019) if their surgeon was a woman (Mann-Whitney U test). Table 1 shows the responses to level of student activity given. On discriminant analysis, increasing age was associated with increased agreement for students to examine (p ¼ 0.028). There was no relationship between age and whether patients would allow a student to be present (p ¼ 0.439) or take a history from them (p ¼ 0.116). Frequency of clinic attendance bore no correlation to acceptance of differing student roles in breast clinics. Whether patients had a student present previously and whether they recalled being informed of potential student presence before assessment in clinic was examined via chi-

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Thank you for completing this survey regarding presence of medical students in our breast department. The following responses are anonymous and are designed to help us understand patient attitudes towards medical students being present in the breast surgery department. 1) Date 2) Which consultant are you under? (NB individual consultant names have been omied here) Mr X Miss X Miss X Mr X Miss X Miss X 3) How many mes have you aended a breast clinic? ……………….………………. 4) Has there been a student present at previous visits?

Yes

5) The clinic leer informed me a medical student may be present?

No

N/A

Yes

No

Please rate your level of agreement with the following statements: Strongly Disagree Neutral Disagree

Agree

Strongly Agree

6) Medical Students should aend breast clinics 7) Medical Students should have access to medical notes 8) I would prefer to see the doctor on my own 9) I am worried a medical student will discuss me outside the clinic 10) I am happy for a medical student to be present during the clinic 11) I am happy for a medical student to ask me quesons about my medical history/breast problems If you answered Strongly Disagree/Disagree, please state why:

12) I am happy for a medical student to perform a breast examinaon on me If you answered Strongly Disagree/Disagree, please state why:

Please answer the following demographic questions 13) What is your age?…………………….. 14) How would you describe your ethnicity?.................... ……………. 15) How would you describe your religious beliefs? Christian

Muslim

Hindu

Sikh

Jewish

Buddhist

None

Other

Thank you for your time in completing this survey

FIGURE. Questionnaire for patients.

square test. Those who had previously encountered students were significantly more likely to agree to them being present (p ¼ 0.033) or to take a history (p ¼ 0.041), but not statistically more likely to consent to examination (p ¼ 0.085). Table 2 shows the responses to student activity following patient’s previous experience with students in clinic. When asked to recall whether the clinic letters had 454

informed them of the possibility of students, only 17% could recall being informed that students may be present in clinic despite this being clearly recorded on clinic invitation letters. Those who could recall the letter informing them of students were more likely to agree to their presence (p ¼ 0.044), but no more likely to consent to history taking (p ¼ 0.136) or examination (p ¼ 0.148). Table 3 shows the

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TABLE 1. Surgeon Sex Strongly Disagree

Disagree

Neutral

Agree

I am happy for a medical student to be present during the clinic Surgeon Sex Male 0 0 4 22 Female 2 3 9 43 I am happy for a medical student to ask me questions about my medical history/breast problems Surgeon Sex Male 0 0 6 18 Female 2 4 5 47 I am happy for a medical student to perform a breast examination on me Surgeon Sex Male 0 0 8 18 Female 3 4 8 45

responses to student activity following recall on prior notice from clinic letters. Patients had the opportunity to provide free-text comments, particularly if they disagreed with students in clinic. A total of 9 (8%) patients responded when asked about student presence and history taking. Patient comments on student presence and history taking included: I have no problems with students being present with the doctor I understand how important their presence could be for the purpose of learning Only if [student is] female Patients could also comment on students examining them. Overall, 17 (15%) patients responded with the following comments on students examining patients: I think it is important for them to gain experience from a leading professional I would prefer only qualified doctors to do examinations Important to learn for [helping] other people

Strongly Agree

16 12 18 11 16 9

DISCUSSION High-quality medical education for the next generation of doctors depends on the teaching given by clinicians and the goodwill of patients. We need to understand patient attitudes to medical student involvement in intimate or sensitive examinations if we are to produce adequately prepared graduates. Previous studies have focused on intimate fields such as vaginal6 and DRE.8 Their studies considered the differing levels of consent based on the student as viewed from the patient perspective.6,11 To our knowledge, this work represents the first study of preoperative patients undergoing breast surgery to examine whether the responsible clinician has an influencing factor in attitudes toward students. Our results suggest that patients under the care of a male surgeon were more likely to accept students being present, and for those students to take histories and examine them than those cared for by female surgeons. Previous studies have suggested patients are less likely to consent to male medical students,6,11 with students reporting sex influencing participation in the patient experience.12 Patients appear more likely to exhibit preference for a particular sex in intimate procedures such as endoscopy,13 and in consultations with both male and female patients expressing

TABLE 2. Previous Student Strongly Disagree

Disagree

Neutral

Agree

I am happy for a medical student to be present during the clinic Student before No 2 3 11 42 Yes 0 0 2 23 I am happy for a medical student to ask me questions about my medical history/breast problems Student before No 2 4 10 40 Yes 0 0 1 25 I am happy for a medical student to perform a breast examination on me Student before No 3 4 13 37 Yes 0 0 3 26 Journal of Surgical Education  Volume 72/Number 3  May/June 2015

Strongly Agree

12 16 14 15 13 12 455

TABLE 3. Clinic Letter Strongly Disagree

Disagree

Neutral

Agree

I am happy for a medical student to be present during the clinic Letter Informed No 1 3 13 Yes 1 0 0 I am happy for a medical student to ask me questions about my medical history/breast Letter Informed No 1 4 11 Yes 1 0 0 I am happy for a medical student to perform a breast examination on me Letter Informed No 2 4 16 Yes 1 0 0

preference for a general practitioner whose sex matches their own.14 The finding that patients under the care of a male surgeon were more likely to accept students within the clinic environment may relate to selection bias, as patients can ask to see a female doctor in the clinic. More patients under the care of female surgeons will have made a request to see a clinician of that sex, and some of their reasons for doing so may also explain why they did not want to allow medical students to be present. If this is the case, actively informing patients of the reasons for medical students to be present could increase patient acceptance. Fortier et al.11found providing further information about medical students resulted in 1 in 6 patients who had not been willing to consent to change their mind and accept students. Increasing age did result in increased consent for students to examine, a finding in keeping with the study by O’Flynn and Rymer.6 Frequency of clinic attendance did not influence agreement to students; this is in contrast to the study by Simons et al.,15 who found increasing attendance correlated with increasing acceptance of student participation. Increasing familiarity with staff and the clinical environment cannot be relied on to predict patient acceptance of students. Unsurprisingly, previous attendance of students did result in increased agreement for student presence and history taking compared with those who had not encountered students before. This may represent a selection bias in the sense of those who have previously consented are likely to consent again. It may also be influenced by previous positive experiences with students, encouraging an “ambassador role” for students to promote other students through good example. Over half of patients who have encountered a student report it being a positive experience, with a minority reporting it being a negative experience.11 However, previous experience did not appear to increase agreement for examination. This may reflect an innate unease among patients for intimate examination. Free-text comments from some patients indicated that examination would depend on how they felt at the time, perhaps suggesting students need to establish a rapport 456

56 9 problems

Strongly Agree

19 9

55 10

21 8

52 11

18 7

before examination and gain the patients trust and confidence. Few patients recalled the clinic letter informing them of possible student presence, though this was associated with higher acceptance of presence, but not of consent to history or examination. This suggests firstly that clinics need to emphasize more clearly that students may be present, in addition to clarifying their role. It also suggests that although prior notice helped influence consent to attendance, the fact that it did not relate to consent for history taking or examination may further represent the need for building a rapport. Patients accept a social responsibility to contribute toward training of future doctors, though this decreases with higher income.16 Patients should not feel pressured to facilitate students if they feel uncomfortable, but equally there need to be strategies to address training needs for the future medical workforce. Our study gives support to medical education planners considering the clinicians’ sex among other factors as an influence on positive patient learning experiences within the curriculum. It will also be a reassurance to them that patient attitudes to medical students being present remain generally positive even within the context of sensitive and intimate problems. The authors suggest that encouraging students to seek their own consent in participating within clinics and to be aware that sex of the clinician may correlate to likely consent could improve learning opportunities. Students should not be deterred in seeking consent from any patient themselves. Improving the clarity of clinic letters to emphasize the teaching nature of the hospital could be one way to enhance recognition of the role patients play in educating future generations of doctors.

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Medical students in breast clinics--how welcome are they and how can we improve their learning opportunities?

Clinical examination skills are an essential component of medical education, with students having the opportunity to practice important skills to faci...
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