Abstract
This study analyses the attitudes of patients towards the presence of medical students during consultations. It was conducted in a very culturally and ethnically diverse part of London. The study aimed to investigate the factors, particularly ethnicity, which influence patients’ attitudes towards medical students. A total of 422 patients participated in the study, which was conducted in general practice and hospital outpatient waiting areas in the London Boroughs of Tower Hamlets and Hackney. In general, the results demonstrate that patients are positive towards medical student participation during consultations. In particular, older patients, patients born in the UK and patients with prior experience of medical students seem to be particularly favourable towards students. However, compared with the White-British population, the non-White-British population appears to be more negative towards medical student participation. This study highlights the need for patient education regarding the importance, for the training of future doctors, of medical student involvement in consultations.
Introduction
The days when medical students and doctors approached patients with a sense of divine right over them are thankfully gone. With increased awareness of patients’ rights and informed consent, patients can now choose whether to have medical students present during their consultations. Yet, little is known about what patients think about participating in medical education. Only a few studies (Cooke et al., Citation1996; O’Flynn et al., Citation1997) have been carried out in the UK that have studied the attitudes of patients towards the involvement of medical students in their care. Most such studies have been in the general practice setting. The majority of studies indicate that patients are, in general, positive about student participation (Anderson & Howe, Citation2003). The study by Cooke and colleagues (Cooke et al., Citation1996) showed that only 3% of patients had a negative view about the presence of a student. That by O’Flynn and colleagues (O’Flynn et al., Citation1997), conducted in London and Newcastle general practices and involving 335 analysed questionnaires, showed that patients were, overall, very favourable towards the presence of medical students. In the United States, several studies have examined patient participation in medical education in a range of settings from obstetrics and gynaecology (Ching et al., Citation2000) to dermatology (Townsend et al., Citation2003) and internal medicine clinics (Simons et al., Citation1995). Most such studies have also reported positive patient attitudes.
A study by Adams et al. (Citation1999) in the USA showed that Caucasian patients were in general more receptive towards medical student involvement in their care than non-Caucasian patients. In areas like London, where the cultural diversity of the population is virtually unrivalled, patients’ attitudes towards medical students can be surprisingly varied.
We decided to examine the relationship between the ethnicity of patients and their perception of medical student involvement in their care. The background to this study arose from the experience of the medical student authors in outpatient clinics at hospitals in the East End of London. We observed that patient consent to the presence of students during the consultation and physical examination was extremely varied, even in specialties where minimal physical exposure was required. The aims of this study were twofold. The first was to determine the overall views of patients towards the presence of medical students during the consultation with their doctors in general practice and hospital outpatient settings in East London. The second was to gain an idea about the factors that influence these views. Being in an extremely ethnically diverse area of the UK, we thought it would be interesting to see if ethnicity influenced the way patients perceived medical students. We also aimed to find out what factors, other than ethnicity, played a part in determining patient attitudes and whether the clinical setting—outpatient clinics or general practice—had any influence on patient decisions.
Methods
The study was conducted in the London Boroughs of Tower Hamlets and Hackney. Tower Hamlets has a large population from the Indian subcontinent, which makes up 36.6% of the population, with the Bangladeshi population accounting for 91.3% of that population. The Afro-Caribbean population comprises 22.3% of the population of Hackney, which also houses a growing Turkish community. A total of 422 patients participated in the study. A 13-question, anonymized questionnaire was used (). Half the patients completed questionnaires at general practices, split between two practices in Shadwell (Tower Hamlets) and Hackney. The other half completed questionnaires in outpatient clinic (medical specialty clinics) waiting areas at the Homerton Hospital, Hackney and the Royal London Hospital, Whitechapel (Tower Hamlets). Permission was obtained from the relevant authorities at each site. Questionnaires were prepared in four languages: English, Bengali, Turkish and Somali. The medical student authors introduced themselves and distributed the questionnaires. The patients were selected sequentially and informed of the anonymous nature of the study and were given the choice of accepting or refusing to fill in the questionnaire. The questionnaire contained a brief description of the aims of the study, information on the anonymous nature of the study and a list of contacts, in case they had any queries. A note was made of the number of patients who refused to take part in the study. No attempt was made to guess their ethnicity. Ethics approval for the study was obtained from the East London & the City Research Ethics Committee.
Figure 1. Questionnaire used in study.
Statistical analysis of results
All analyses were performed using STATA version 8. The category of unknown ethnic origin was not included in the analysis when a patient had not answered the question on ethnicity as no correlation with a specific ethnic group could be made using this category. Of the 13 questions, the answers to seven were considered in our null hypothesis to have possible dependence on some or all of the answers to the five other questions. These five questions were age, gender, ethnicity, length of time the patient had been living in the UK (categories combined to whether or not a patient was born in the UK or not) and also whether a patient had prior experience of a medical student when they had been to see their doctor before. The possible answers to the seven outcome questions were ordinal and the number of categories for each outcome question was large, often resulting in sparse data in each category. Therefore, they were combined into two or three categories for the majority of the analyses.
The data collected were summarized by calculating the percentage of patients giving different answers to each question. Univariate odds ratios were calculated for each outcome question for each of the explanatory questions. Multivariate logistic regression models were fitted using the stepwise procedure, comparing the responses given by White-British patients with non-White-British (i.e. all other ethnic groups other than White-British patients) patients and then comparing responses given by White-British patients to the responses of seven other ethnic groups (ethnicities with statistically insignificant numbers were placed into the ‘Other’ group). For all analyses, statistical significance was taken as p < 0.05.
Results
A total of 422 questionnaires were collected and analysed. Ten patients were unable to complete the questionnaire due to time constraint and not all patients managed to answer every question. A total of 16 patients refused to participate in the study. Of the 401 people who answered the question on their gender, 39% were male (n = 157); 389 patients (92%) provided their age. The mean age of this sample was approximately 45.2 years. Nearly half (48%) of the respondents were White-British. shows the ethnic distribution of the patient sample; 6% of patients refused to divulge their ethnicity. More than half (58%; n = 236) of the patients had been born in the UK. Almost a tenth (9%) had been living in the UK for less than 10 years. Approximately two-thirds (68%) of the respondents could recall prior experience of a medical student being present during a consultation.
Figure 2. Breakdown of ethnic groups represented in the patient sample participating in the study.
Results for whole sample and effect of factors other than ethnicity
gives the responses to the outcome questions for the total sample group.
Table 1. Results of the outcome questions
The majority of patients were positive towards the presence of medical students during consultations and examinations. Three of the questions investigated whether the gender of the student and/or the body part being examined would determine a patients’ opinion of a student being present. Whether or not a patient allowed a student to be present whilst he/she was talking with their doctor depended on the gender of the student for 21.5% of patients (70.5% of patients would allow the student to be present regardless of gender). The gender of the student was less important than the body part: 31.1% of patients would allow a medical student to watch an examination depending only on the body part that was being examined and 23.4% of patients would allow a medical student to watch depending on the gender of the student or both the gender and body part. Similarly, 28.5% would allow the student to examine depending only on the body part and 20.3% would allow the student to examine depending on the gender of the student or both the gender and the body part.
Odds ratios of a negative response calculated univariately showed that the clinical setting (hospital or general practice) and gender of the patient were not found to be significantly associated with the answers to any outcome question. Older patients were less likely to provide negative responses to each of the outcome questions; however, the p-values associated with the corresponding odds ratios were less than 0.05 for questions 2, 5 and 6 only. Patients born outside the UK were more likely to provide negative answers than patients born in the UK with these odds ratios being statistically significant for questions 3, 6 and 9 but not for other questions. Patients without prior experience of medics present during a consultation were consistently more likely to answer a question negatively and the corresponding odds ratios were significant for all questions apart from question 3.
The main factors cited by patients as being important in determining their attitudes towards the presence of medical students during consultations were their personality (34.25%) and their condition (42.19%) (Question 7; n = 365); 12.88% gave both of these reasons. In addition, 9.32% of patients provided an answer related to the educational benefits to the student, although this was not one of the tick-box options in the questionnaire.
Effect of ethnicity
Compared with White-British patients, non-White-British patients were more likely to be negative about medical students with statistical significance obtained for all outcome questions apart from question 8. Non-White-British patients were found to be more than twice as likely (age adjusted OR = 2.22, 95% CI 1.14–4.30) to feel uneasy/extremely uneasy about a medical student being present while talking to their doctor than the White-British patients. Furthermore, the patients from ethnic minorities were three and a half times more likely not to allow medical students to be present (OR = 3.50; 95% CI 1.52–8.10) compared with the White-British group. Some 40% of White-British patients would be comfortable with more than two students being present compared with only 24% of patients from other ethnic groups.
Adjusting for prior experience of medical students, non-White-British patients were over three times more likely to say they would not allow a medical student to watch while they were being examined (OR = 3.16; 95% CI 1.64–6.11) compared with the White-British group. The former were also nearly three times more likely to say they would not allow a medical student to examine them under supervision (OR = 2.72; 95% CI 1.52–4.88) compared with White-British patients.
The perceived importance of the involvement of medical students for the training of future doctors varied between ethnic groups. Adjusting for prior experience of medical students, patients from other ethnic groups were over twice as likely to be unsure or think it unimportant that medical students examine patients (OR = 2.1; 95% CI 1.07–4.12) compared with the White-British group.
shows the odds ratios of a negative answer and their 95% confidence intervals when comparing six ethnic categories with White-British patients. This was obtained using multivariate logistic regression models fitted using the stepwise procedure. The horizontal red line on each plot represents an odds ratio of one (representing the White-British patients). Age was also found to be significant in the answers to question 2 and the odds ratios for ethnicity were adjusted for this. The odds ratios associated with question 6 have also been adjusted for prior experience of a medic being present during a consultation.
Figure 3. Odds ratios of a negative answer to outcome question by the different ethnic groups. Odds ratios with confidence intervals above 1 are significant. Answer to question 3 is missing for White-European due to statistically insignificant numbers of responses.
Analysis of the individual ethnic groups compared with the White-British group revealed that Bangladeshi patients were particularly negative about the presence of medical students during consultations. The odds of a Bangladeshi patient answering a question negatively were consistently greater than the odds of a White-British patient answering a question negatively. Where the ratio of these odds had an associated p-value of less than 0.05, Bangladeshi patients were over eight times more likely (OR = 8.43; 95% CI 3.14–22.68) to say they would not allow a medical student to be present while talking to their doctor. Furthermore, they were six times more likely (OR = 5.80, 95% CI 2.48–13.57) to say they would not allow a medical student to watch while they were being examined and over three times more likely (OR = 3.32, 95% CI 1.46–7.57) not to allow a student to examine them. Indian and Pakistani patients were also negative about medical students being present during consultations with their doctors, but less so than Bangladeshi patients. They were over three and a half times more likely (OR = 3.59, 95% CI 1.16–11.12) not to allow a student to watch whilst being examined and over three times more likely (OR = 3.15, 95% CI 1.12–8.83) not to allow the student to examine them compared with White-British patients. Due to the wide confidence intervals, the relative likelihood of a negative answer to whether patients allow a medical student to watch or to examine cannot be inferred. The odds ratios were greater than one but not significant for all other questions. Turkish patients were approximately eight times more likely to be uneasy about students being present while talking to their doctor than the White-British patients (OR = 7.97, 95% CI 2.21–28.71) and six times more likely to think it unimportant that students examine patients as part of their training (OR = 6.00, 95% CI 1.62–22.25). Again, due to wide confidence intervals, the relative likelihood of a negative answer to these questions cannot be inferred. For all other outcome questions, odds ratios were greater than one, although these had associated p-values of less than 0.05 only for questions 2 and 9. They were also more likely to view students examining patients to be unimportant for the future training of doctors. Although the odds ratio for a negative answer was usually greater than one for other White-European and Afro-Caribbean patients, these odds ratios were not statistically significant. Patients from other ethnic groups were consistently more likely to give negative answers and, apart from question 2, the odds ratios had an associated p-value of less than 0.05.
Discussion
Participation of patients in medical education is an important tool in undergraduate medical teaching. The results of this study demonstrate that the majority of patients (∼92%) agreed to allow a medical student to be present during the consultation. These results are in agreement with that previously obtained by other studies (Cooke et al., Citation1996). However, certain factors seem to have a marked influence on the attitudes of patients towards the involvement of medical students during consultations. It was generally noted that the elderly patients and patients with previous experience of medical students tend to hold less negative views. The younger patient groups are more likely to feel vulnerable being examined by ‘young’ students. This highlights the need for more patient education and information regarding the importance of medical student involvement for medical training. The finding that patients with previous experience of medical students were less negative shows that their previous encounters had in general been positive. Personality and condition were rated as the two most important factors influencing patients’ attitudes. These factors are difficult to influence by patient education. However, a considerable proportion of patients viewed the involvement of medical students as an important learning tool. Further patient education to highlight this important point could perhaps help to change patient attitudes.
Ethnicity was found to be a major factor associated with patient attitudes towards the participation of medical students in consultations. The multicultural setting of this study was ideal to study the effect of ethnicity on patients’ attitudes. The results show that compared with the indigenous White population, the non-White-British population are considerably less receptive towards medical students. Furthermore, the perception of the importance of medical student involvement for future medical training also seems to be considerably undervalued by the non-White-British population. Of note are patients from the Indian subcontinent (particularly Bangladeshis) and the Turkish population, who appear to be considerably negative towards medical students’ participation during consultations. These findings raise some important issues. London houses five large medical schools and produces more doctors than any other region in the country. London, together with other major UK cities, has a very ethnically diverse population. Students’ clinical experience in these cities could be compromised considering that a significant proportion of patients in hospitals in these cities are from ethnic minorities. This raises the question of what can be done to change the attitudes of the patients from the various ethnic groups. Patient education is an important consideration. The importance of student participation for the training of future doctors, assurance of confidentiality and no compromise in patient care would have to be stressed to patients. The local community leaders, ethnic newspapers, leaflets at general practices and hospital waiting rooms are all avenues for consideration. However, at the same time, it should be stressed that there must be no compromise on patient choice and consent. In our view, further studies would be necessary to outline the important factors that influence their views. It may be that experience of a very different healthcare system in another country could be an important influencing factor. It would be interesting to note whether the second generation of patients from ethnic minorities, who have been born and brought up in this country, hold similar views to those of their older counterparts. We did not consider it appropriate to investigate the relevance of the ethnicity of the doctor or medical student. This small study has attempted to study the attitudes of patients towards the participation of medical students during consultations. However, a much larger sample size would be needed for a more detailed analysis of patients’ views.
The importance of clinical experience in medical education cannot be overstated. In a few years’ time, these medical students will be expected to deliver patient care. Thus, patient involvement in medical education is critical. Although the majority of patients are positive about having medical students present, this study highlights the variation in patient attitudes towards medical students according to ethnicity, age of patients and previous experience of medical students. In conclusion, the study highlights the need for patient education and information regarding the importance of medical student participation for the training of future doctors.
Acknowledgements
The authors gratefully acknowledge the following people: the staff at Well Street Surgery, Dr Mary Edmondson and Ms Lynn Owens at Jubilee Street Practice, the Modern Matron at Homerton Hospital and the staff at the outpatients department at the Royal London Hospital.
Additional information
Notes on contributors
Tawfiqur Rahman Choudhury
TAWFIQUR RAHMAN CHOUDHURY is a final-year medical student at Barts and the London School of Medicine and Dentistry, University of London. He did an intercalated BSc in Molecular Medicine at University College London. His research interests include medical education.
Ali A. Moosa
ALI MOOSA is a final-year medical student at Barts and the London School of Medicine and Dentistry, University of London. He has a keen interest in vascular dynamics and medical education.
Annie Cushing
ANNIE CUSHING, PhD FDSRCS BDS, is a Reader in Communication Skills and Head of CCLSU at Barts and the London School of Medicine and Dentistry, University of London. Her research interests include teaching and learning methodologies, and assessment in communication and interpersonal skills.
Jonathan Bestwick
JONATHAN BESTWICK is a Junior Statistician at the Wolfson Institute of Preventive Medicine, Barts and the London Queen Mary's School of Medicine and Dentistry.
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