Diversity of learning & teaching
Medical students in gynaecology clinics Jenny Yang, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia Kirsten Black, Obstetrics and Gynaecology, Central Clinical School, Royal Prince Alfred Hospital, The University of Sydney, New South Wales, Australia
Factors that influence a patient’s acceptance of a medical student’s involvement in a consultation
SUMMARY Objective: This study aimed to investigate factors that influence a patient’s acceptance of a medical student’s involvement in their consultation when attending a public hospital gynaecology clinic. Methods: This was an observational study of women attending gynaecology clinics at Royal Prince Alfred Hospital (RPAH) from January to December 2011. The questionnaire sought demographic information and asked women about their knowledge of medical student attendance at the clinics, if they would allow a student to be present during their consultation
and whether they would allow a student to examine them. It also sought reasons for their responses. Results: Of the 460 questionnaires distributed, 97 per cent (446) were completed. Overall, 85.6 per cent (382) of patients expressed an acceptance of medical students being present in their consultation, and 63.9 per cent (285) said they would allow students to examine them. Factors significantly associated with an increased acceptance of examination by medical students included being aware that a student may be present (p = 0.003), and being married or
in a committed relationship (p = 0.023). Age and education level were not significantly associated with acceptance of being examined by a student, and ethnicity was too diverse to assess any possible bias. All groups maintained a preference for female students. Conclusion: This study has found that being aware that medical students may be present in gynaecology clinics may increase patient acceptance of being examined by a student. This demonstrates a role for information to be distributed to patients prior to their appointment to facilitate medical training.
254 © 2014 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2014; 11: 254–258
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INTRODUCTION
G
ood clinical skills are fundamental towards best medical practice, and need to be developed through as much exposure during training as possible. Herein lies a dilemma: how can medical students gain proficiency in the gynaecological examination, which is an intimate and uncomfortable process, when many patients refuse to allow students to have such exposure? Health professionals are obligated to both fulfil their teaching role and support the training of future doctors, whilst respecting the autonomy and privacy of their patients.
There is limited data investigating patient acceptance of medical students in gynaecology clinics and factors influencing this. Only two studies specifically investigated patients’ acceptance of being examined in such clinics, reporting rates of 31–40 per cent acceptance.1,2 Some studies found an increased acceptance of medical students being present in consultations to be associated with age, previous experience, parity and female student gender1,2; however, evidence for these relationships is inconsistent, as other studies have found age and previous experience to be insignificant, in addition to education level and ethnicity.1,3,4 One study found that 12.5 per cent of patients thought ‘prior awareness’ was an area requiring improvement in patient–student interaction in gynaecological consultations, which suggests that pre-informing patients may increase patient acceptance.5 Westberg conducted a randomised double blind trial to investigate whether being given information about a gynaecology clinic prior to arrival would increase the patients’ acceptance of medical students.6 Although
there was no difference in acceptance rates (100 per cent in both groups), the pre-informed group were more comfortable with student involvement, suggesting a benefit from this. To our knowledge, this is the first Australian study that aimed to identify factors influencing patient acceptance of medical student involvement in gynaecology clinics. We wanted to compare this with international data, and more importantly we wanted to identify factors that could be targeted to maximise the training opportunities for medical students in gynaecological examination.
METHODS A questionnaire was distributed to women attending gynaecology clinics at Royal Prince Alfred Hospital (RPAH) from January to December 2011. Participation was voluntary and all data were de-identified. The questionnaire was distributed in English and Chinese, the second most commonly used language in the patient population. The questionnaire collected demographic data, including age, relationship status, education level and ethnicity, whether patients knew a medical student might be present, whether patients would allow a student to be present during their consultation and whether they would allow a student to examine them. Respondents were asked to provide free-text responses for their preferences, which were coded with similar responses. Ethics approval was obtained from the Sydney South West Area Health Service (RPAH zone). An IBM SPSS Statistics program was used for data analysis, and associations were considered to be significant for p < 0.05 using the Pearson chi-squared test. We assessed the
relationship between the patient’s acceptance of a student being present, or examining them, and the variables above.
How can medical students gain proficiency in the gynaecological examination when many patients refuse to allow students to have such exposure?
RESULTS Of the 460 surveys distributed, there was a response rate of 97 per cent (446). Fourteen questionnaires were not completed. Demographics The patient’s ages ranged from 14 to 80 years, with the majority being between 25 and 34 years old (29.8%, 133). Slightly over half were married or in a committed relationship (54.5%, 243). Half of the participants (50.2%, 224) had obtained a postgraduate qualification, whereas 17.3 per cent (77) had not graduated from high school. Patients represented 11 ethnic groups, with the majority being from Australasia (36.5%, 163). This ethnic diversity meant that a relationship with the outcome of interest could not be assessed. Acceptance of the involvement of medical students A total of 85.7 per cent (382) of participants allowed a medical student to be present during their consultation, whereas only 63.9 per cent (285) were agreeable to being examined by a student. One hundred and fifty four women (40.3%) only allowed female students to be present and refused males, and 49.5 per cent (141) only allowed females to examine them. The remainder
© 2014 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2014; 11: 254–258 255
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This study also found a patient preference for female students being present in consultations
allowed the involvement of either gender (Table 1).
Table 1. Patient acceptance of medical students No n (%)
The main reason that participants gave for allowing medical student involvement was to contribute to the education of future doctors (42.2%, 188). Reasons given for refusing student involvement mostly involved embarrassment and issues of privacy (18.8%, 84). Other negative responses included fears of pain or misdiagnosis, time constraints and previous bad experiences (Table 2). Forty-one per cent of patients (183) reported being aware that a medical student may be present, even though there is no formal system for pre-informing patients of this at RPAH. There was a statistically significant relationship between this knowledge and an increased acceptance of being examined by a medical student (p = 0.003). Being married or in a committed relationship was also significantly associated with patients allowing a medical student to examine them (p = 0.023). Both prior awareness and relationship status demonstrated increased acceptance rates of having students present, but these were not statistically significant. No association could be identified between age or education level with the acceptance of medical students being present or examining patients (Table 3).
DISCUSSION This study identified that the rate of gynaecology clinic patients at RPAH allowing examination by medical students is greater than those documented in international studies (63.9 versus 31–40% in the UK and USA).1,2 This is fortunate, as our students only obtain limited experience with professional patients because of poor availability, even though
Agreeable with student presence
Yes: male or Yes: female female n (%) only n (%)
Yes: total n (%)
64 (14.3) 228 (51.1)
154 (34.5)
382 (85.7)
Agreeable with 161 (36.1) 144 (32.3) student examination
141 (31.6)
285 (63.9)
Table 2. Reasons for responses Percentagea
Reason
Frequency
Student education
188
42.2
Too personal
84
18.8
No response
82
18.4
Wants qualified doctor only
33
7.4
Comfortable with females only
11
2.5
Previous bad experience
11
2.5
Comfortable if doctor present
10
2.2
Fears bad outcome/misdiagnosis
10
2.2
Don’t care
6
1.3
Time consuming
6
1.3
Too many previous examinations
2
0.4
Might learn something
1
0.2
Previously examined
1
0.2
Worried about encountering the student
1
0.2
Total
b
446
100
a
Percentage of responses given, excluding missing data.
b
The total number is less than the total number of questionnaires collected because of missing data.
experience with such patients appears to improve pelvic examination skills.7 This study also found a patient preference for female students being present in consultations and performing examinations, which correlates with other studies,5 and reiterates the extra challenge that male students face in obtaining such skills.8 Reasons expressed by patients for accepting or refusing the involvement of medical students were similar to those recognised in other studies. The decision involved balancing altruistic intentions to contribute towards medical training with the private
nature of gynaecological issues and the examination itself.4,5 Data on the association between demographic factors and the acceptance of medical student involvement have been inconsistent. Indeed, similarly to Ryder,3 we could not replicate the positive association with older age found in other studies.1,2 Some studies found parity to be associated with the increased acceptance of students, with no studies contradicting this finding.1,2 This study is the first that has investigated marital status as a factor, and we found it to be significantly associated with an increased
256 © 2014 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2014; 11: 254–258
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6/4/2014 12:59:56 PM
Table 3. Univariate associations between acceptance of examination by medical students and potential covariates Acceptance of examination by student Yes (n = 285)
No (n = 161)
n (%)
n (%)
Given clinic information
0.012
Yes
90 (73.2)
33 (26.8)
No
195 (60.4)
128 (39.6)
Had knowledge that student may be present Yes
0.003
131 (72)
No
pa
154 (58.3)
52 (28) 110 (41.7)
b
Age
0.428
Medical students in gynaecology clinics Jenny Yang, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia Kirsten Black, Obstetrics and Gynaecology, Central Clinical School, Royal Prince Alfred Hospital, The University of Sydney, New South Wales, Australia
Factors that influence a patient’s acceptance of a medical student’s involvement in a consultation
SUMMARY Objective: This study aimed to investigate factors that influence a patient’s acceptance of a medical student’s involvement in their consultation when attending a public hospital gynaecology clinic. Methods: This was an observational study of women attending gynaecology clinics at Royal Prince Alfred Hospital (RPAH) from January to December 2011. The questionnaire sought demographic information and asked women about their knowledge of medical student attendance at the clinics, if they would allow a student to be present during their consultation
and whether they would allow a student to examine them. It also sought reasons for their responses. Results: Of the 460 questionnaires distributed, 97 per cent (446) were completed. Overall, 85.6 per cent (382) of patients expressed an acceptance of medical students being present in their consultation, and 63.9 per cent (285) said they would allow students to examine them. Factors significantly associated with an increased acceptance of examination by medical students included being aware that a student may be present (p = 0.003), and being married or
in a committed relationship (p = 0.023). Age and education level were not significantly associated with acceptance of being examined by a student, and ethnicity was too diverse to assess any possible bias. All groups maintained a preference for female students. Conclusion: This study has found that being aware that medical students may be present in gynaecology clinics may increase patient acceptance of being examined by a student. This demonstrates a role for information to be distributed to patients prior to their appointment to facilitate medical training.
254 © 2014 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2014; 11: 254–258
tct_12122.indd 254
6/4/2014 12:59:54 PM
INTRODUCTION
G
ood clinical skills are fundamental towards best medical practice, and need to be developed through as much exposure during training as possible. Herein lies a dilemma: how can medical students gain proficiency in the gynaecological examination, which is an intimate and uncomfortable process, when many patients refuse to allow students to have such exposure? Health professionals are obligated to both fulfil their teaching role and support the training of future doctors, whilst respecting the autonomy and privacy of their patients.
There is limited data investigating patient acceptance of medical students in gynaecology clinics and factors influencing this. Only two studies specifically investigated patients’ acceptance of being examined in such clinics, reporting rates of 31–40 per cent acceptance.1,2 Some studies found an increased acceptance of medical students being present in consultations to be associated with age, previous experience, parity and female student gender1,2; however, evidence for these relationships is inconsistent, as other studies have found age and previous experience to be insignificant, in addition to education level and ethnicity.1,3,4 One study found that 12.5 per cent of patients thought ‘prior awareness’ was an area requiring improvement in patient–student interaction in gynaecological consultations, which suggests that pre-informing patients may increase patient acceptance.5 Westberg conducted a randomised double blind trial to investigate whether being given information about a gynaecology clinic prior to arrival would increase the patients’ acceptance of medical students.6 Although
there was no difference in acceptance rates (100 per cent in both groups), the pre-informed group were more comfortable with student involvement, suggesting a benefit from this. To our knowledge, this is the first Australian study that aimed to identify factors influencing patient acceptance of medical student involvement in gynaecology clinics. We wanted to compare this with international data, and more importantly we wanted to identify factors that could be targeted to maximise the training opportunities for medical students in gynaecological examination.
METHODS A questionnaire was distributed to women attending gynaecology clinics at Royal Prince Alfred Hospital (RPAH) from January to December 2011. Participation was voluntary and all data were de-identified. The questionnaire was distributed in English and Chinese, the second most commonly used language in the patient population. The questionnaire collected demographic data, including age, relationship status, education level and ethnicity, whether patients knew a medical student might be present, whether patients would allow a student to be present during their consultation and whether they would allow a student to examine them. Respondents were asked to provide free-text responses for their preferences, which were coded with similar responses. Ethics approval was obtained from the Sydney South West Area Health Service (RPAH zone). An IBM SPSS Statistics program was used for data analysis, and associations were considered to be significant for p < 0.05 using the Pearson chi-squared test. We assessed the
relationship between the patient’s acceptance of a student being present, or examining them, and the variables above.
How can medical students gain proficiency in the gynaecological examination when many patients refuse to allow students to have such exposure?
RESULTS Of the 460 surveys distributed, there was a response rate of 97 per cent (446). Fourteen questionnaires were not completed. Demographics The patient’s ages ranged from 14 to 80 years, with the majority being between 25 and 34 years old (29.8%, 133). Slightly over half were married or in a committed relationship (54.5%, 243). Half of the participants (50.2%, 224) had obtained a postgraduate qualification, whereas 17.3 per cent (77) had not graduated from high school. Patients represented 11 ethnic groups, with the majority being from Australasia (36.5%, 163). This ethnic diversity meant that a relationship with the outcome of interest could not be assessed. Acceptance of the involvement of medical students A total of 85.7 per cent (382) of participants allowed a medical student to be present during their consultation, whereas only 63.9 per cent (285) were agreeable to being examined by a student. One hundred and fifty four women (40.3%) only allowed female students to be present and refused males, and 49.5 per cent (141) only allowed females to examine them. The remainder
© 2014 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2014; 11: 254–258 255
tct_12122.indd 255
6/4/2014 12:59:55 PM
This study also found a patient preference for female students being present in consultations
allowed the involvement of either gender (Table 1).
Table 1. Patient acceptance of medical students No n (%)
The main reason that participants gave for allowing medical student involvement was to contribute to the education of future doctors (42.2%, 188). Reasons given for refusing student involvement mostly involved embarrassment and issues of privacy (18.8%, 84). Other negative responses included fears of pain or misdiagnosis, time constraints and previous bad experiences (Table 2). Forty-one per cent of patients (183) reported being aware that a medical student may be present, even though there is no formal system for pre-informing patients of this at RPAH. There was a statistically significant relationship between this knowledge and an increased acceptance of being examined by a medical student (p = 0.003). Being married or in a committed relationship was also significantly associated with patients allowing a medical student to examine them (p = 0.023). Both prior awareness and relationship status demonstrated increased acceptance rates of having students present, but these were not statistically significant. No association could be identified between age or education level with the acceptance of medical students being present or examining patients (Table 3).
DISCUSSION This study identified that the rate of gynaecology clinic patients at RPAH allowing examination by medical students is greater than those documented in international studies (63.9 versus 31–40% in the UK and USA).1,2 This is fortunate, as our students only obtain limited experience with professional patients because of poor availability, even though
Agreeable with student presence
Yes: male or Yes: female female n (%) only n (%)
Yes: total n (%)
64 (14.3) 228 (51.1)
154 (34.5)
382 (85.7)
Agreeable with 161 (36.1) 144 (32.3) student examination
141 (31.6)
285 (63.9)
Table 2. Reasons for responses Percentagea
Reason
Frequency
Student education
188
42.2
Too personal
84
18.8
No response
82
18.4
Wants qualified doctor only
33
7.4
Comfortable with females only
11
2.5
Previous bad experience
11
2.5
Comfortable if doctor present
10
2.2
Fears bad outcome/misdiagnosis
10
2.2
Don’t care
6
1.3
Time consuming
6
1.3
Too many previous examinations
2
0.4
Might learn something
1
0.2
Previously examined
1
0.2
Worried about encountering the student
1
0.2
Total
b
446
100
a
Percentage of responses given, excluding missing data.
b
The total number is less than the total number of questionnaires collected because of missing data.
experience with such patients appears to improve pelvic examination skills.7 This study also found a patient preference for female students being present in consultations and performing examinations, which correlates with other studies,5 and reiterates the extra challenge that male students face in obtaining such skills.8 Reasons expressed by patients for accepting or refusing the involvement of medical students were similar to those recognised in other studies. The decision involved balancing altruistic intentions to contribute towards medical training with the private
nature of gynaecological issues and the examination itself.4,5 Data on the association between demographic factors and the acceptance of medical student involvement have been inconsistent. Indeed, similarly to Ryder,3 we could not replicate the positive association with older age found in other studies.1,2 Some studies found parity to be associated with the increased acceptance of students, with no studies contradicting this finding.1,2 This study is the first that has investigated marital status as a factor, and we found it to be significantly associated with an increased
256 © 2014 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2014; 11: 254–258
tct_12122.indd 256
6/4/2014 12:59:56 PM
Table 3. Univariate associations between acceptance of examination by medical students and potential covariates Acceptance of examination by student Yes (n = 285)
No (n = 161)
n (%)
n (%)
Given clinic information
0.012
Yes
90 (73.2)
33 (26.8)
No
195 (60.4)
128 (39.6)
Had knowledge that student may be present Yes
0.003
131 (72)
No
pa
154 (58.3)
52 (28) 110 (41.7)
b
Age
0.428
