Medical students as family-health advocates: Arabian Gulf University experience

Abstract

Background: The Arabian Gulf University is a coeducational Islamic institution in the Kingdom of Bahrain sponsored by the Gulf Cooperative Council. The College of Medicine follows a problem-based curriculum in which science is integrated with professional skills and a community-health programme, comprising of maternal and child health, family studies, and population-health research. The family-studies programme requires all third-year students to complete a wide series of activities under family-physician supervision.

Aim: The aim of the study was to assess the performance of the programme with specific regard to students’ family-health advocacy roles.

Method: A trained community-health nurse administered a semistructured questionnaire based on family empowerment to 30 families. Themes included health-knowledge gains, positive changes in lifestyle and communication practices, and accessing community resources.

Results: All families reported a gain in relevant health knowledge, and a number of families reported positive changes in lifestyle.

Conclusions: Students proved to be valuable advocates for families in this programme. Their principal role lay in the uncovering of psychosocial distress, but they were able also to offer practical help in lifestyle behaviour changes, communication, and community-resource use.

Practice points

• Agreement exists that using the community for real-life contextual learning is useful.

• Learning in the community is a reciprocal process, with the student, patient, and patient's family all benefiting from the experience.

• Patients seem comfortable with students being involved in the management of disease.

• Patients often present medical material in greater detail to the student than to the attending physician, which both empowers and challenges the student.

• Faculty must recognise the positive effects of this learning on the students’ status and the potential harm that can occur to the unsuspecting student, and be ready to respond to this new challenge.

Introduction

As medical schools are expected to provide appropriate learning environments that simulate real-life events and develop contextual learning (General Medical Council 2003), we have to be aware of the central focus of medical learning: the patient. Patients will always have a right to decide whether to participate in the training of medical students (Department of Health 1991), and medical curricula should always place an emphasis on working with patients (National Health Service Executive 1996), particularly in community settings (Stacy & Spencer 1999, Howe 2001, Dornan et al. 2006). However, it is important to realise the impact this form of teaching can have upon the patient (Fins et al. 2003). Although the possibility arises that patients may not feel ‘safe’ in a teaching consultation, it is possible that they could learn much more about their condition, and adopt positive responses to their illness if they were included in the process (Cooke et al. 1996; Williamson & Wilkie 1997; Coleman & Murray 2002; Benson et al. 2005).

Since the early nineties, when Murray (1995) explored the issue of the social responsibility of medical schools, undergraduate medical schools have tried to respond to community health needs, and develop appropriate programmes (Lennox & Petersen 1998; Donohoe & Danielson 2004; Kaczorowski et al. 2004; Shannon et al. 2005). Fox et al. (1991) described a course in sociology, combined with a family attachment scheme in the community, that provided preclinical students with the practical dimension of important sociological concepts (e.g. illness behaviours, life events, family life course and dynamics). Abraham and Orbell (1993) described a community interview scheme, which enabled students to investigate the role of social and psychological variables in patient care and gain insight into interpersonal aspects of the interview process.

Haven & Stolz (1989) developed a health-education programme for adolescents about AIDS and other health issues, such as smoking, nutrition, and substance abuse. Teenage participants in the health-education activities responded well to talks by medical students.

It is in areas defined less by task, however, and more by time and relationships, that different dimensions of benefit begin to emerge. Marijike et al. (2001) described a programme in which pairs of medical students attended patients with chronic diseases in their homes. The students' learning objectives were clearly defined, in that they had to explore how patients experience their impairment, disabilities, and handicaps, how patients cope with them, and what expectations patients have of care providers. Although these outcomes were somewhat unusual when compared with the standard learning experiences related to knowledge acquisition, the students rated the programme positively, as they became conscious of patients’ overt and hidden experiences with disabilities and their relevance to future healthcare. Over time, they became aware of multimorbidity.

Prislin et al. (2001) found that medical students who participated in the care of patients during a longitudinal family medicine clerkship helped to improve the quality of care for patients, as reported by patients themselves in questionnaires. The authors suggested that such programmes had the potential to enhance patient satisfaction.

Communities seem to be accepting of medical students as learners, and can derive benefit from students in roles such as health educators and counsellors. However, there is a suggestion that students, in learning to communicate in real life with patients about their problems, have other, less obvious but no less important, effects on individuals and families. They may have the potential to empower patients and families in their search for better health and healthcare. The programme at the Arabian Gulf University, embraces, perhaps, this more ambitious advocacy.

The family studies programme

The Family Studies Programme at the Arabian Gulf University, an Islamic co-educational institution in the Kingdom of Bahrain sponsored by the Gulf Cooperative Council, takes place in the third year of a 6-year curriculum. It aims to encourage students to see the human face of medicine, to appreciate the role of the family in a healthy and adaptive society, and to learn about families’ day-to-day function and resourcefulness. These aims are expected to be achieved through a number of student tasks:

• describing health issues and problems facing families;

• identifying individual and family beliefs and understandings relevant to health problems;

• identifying family coping mechanisms, including the use of community resources;

• assessing impact of illness on family function;

• describing a significant life event in the history of a family, and the adaptations that occurred in response;

• describing family communication patterns and practices and decision-making processes; and

• identifying health-education and promotion opportunities.

The programme is supervised by active and experienced family physicians, whose ‘patient list’ families are assigned to pairs of students. Through preplacement anticipatory and reflective sessions, tutors prepare the students for programme tasks and challenges in small groups of 6–8 members. Key skill workshops, organised and implemented by the tutors, address students’ specific tasks throughout the programme. For their part, the tutors attend regular meetings with the programme coordinator to review progress, as well as having specific meetings for problem-solving, coordination, and possible interventions, such as for specific communication-skill needs. The study period is from October to June each year, during which time students make 10–12 visits to their assigned families. Student activities are evaluated at the end of the programme, when tutors complete evaluation forms that address each task, from the perspectives of field practice and summary overview.

Tutors are in regular contact with the students, patients and families, so they are able to relay, accurate, and immediate responses from the families for each student task.

Methods

In order to explore beyond the expected learning activities and the achievements of students, a semistructured questionnaire was prepared, based on those aims of the programme that were seen to be relevant to family affirmation and empowerment (supplementary information, available at http://www.medicalteacher.org/). Questionnaire items covered family health beliefs and behaviours, specific lifestyle habits related to nutrition, exercise, and weight management, communication patterns in terms of practices and emotional content, as well as use of community resources. The questionnaire also aimed to record changes that families had undertaken in response to the programme, as well as families’ perception of attending students as agents of change and empowerment.

A community nurse, who was sympathetic to the programme's aims and goals, interviewed all 30 families involved in the 2001–2002 academic year, in their homes, in June 2002 (60 students, in pairs, had visited these families). The nurse worked with the programme coordinator on the development of the questionnaire, its piloting, and its review before final application. Interviews were not tape-recorded because of cultural and religious beliefs. Field notes that related to the more open-ended questions were made during and after the interviews. In debriefing sessions, the coordinator and nurse reviewed the data collected, retaining, where possible, the initial questionnaire design as an organisational template.

Results

All families interviewed were Bahraini, and to put the survey in context, it is important to note that the chronic diseases and their complications that prevail in this country were reflected in the group. For example, of twelve patients with diabetes mellitus, five had suffered limb amputation, three experienced severe visual impairment, and a further two had diabetic nephropathy. Six further patients were suffering from hypertension, three of whom had experienced a cerebrovascular accident (stroke). Seven patients from this group reported to the nurse that they had become less compliant with treatment regimes.

All families interviewed agreed that their knowledge about their specific health issues had increased, which can be seen in the changes in lifestyle that were reported. When families were asked about their response to life events as a health issue, 12 families reported that they had discussed with their attending students symptoms that were related to a grieving process that was unknown to the relevant family physicians. A further 12 families were identified by students as having a member with mood disturbance (e.g. sadness, low mood, or anxiety) sufficient to affect normal daily function.

In two-thirds of the families surveyed, positive changes were reported in response to questions on lifestyle behaviours. These changes were sometimes small, sometimes more dramatic, and included dietary and exercise initiatives:

• using less salt and oil in cooking and decreasing consumption of cake and soda drinks;

• a diabetic patient mentioned she was not exercising because she was afraid of hypoglycaemia; after the program she began walking for 1 hour a day and carrying some sweets in her pocket to use in emergency;

• a hypertensive patient who only moved to go to the toilet began walking 20–30 minutes a day;

• another diabetic patient with osteoarthritis increased his walking time from 15 to 30 minutes; and

• one patient reduced his cigarette smoking, from two packs to half a pack, daily.

About two-thirds of families mentioned that they better realised the importance of maintaining their ideal weight as they became more aware of the risks of being overweight.

Attention to communication among family members was another of the student's tasks, and an important dimension of the questionnaire:

• two-thirds of all families reported an improvement in their willingness to discuss issues related to the family, with improved understanding of each other and the sharing of emotions;

• a mother who had experienced a cerebrovascular accident had been abandoned to the care of a sole housemaid; after the programme, her children resumed daily visits;

• eight families were put in contact with, or informed about, social or health agencies relevant to their health issues, such as the Diabetes Society, the Anti-Smoking Society, the Physiotherapy Association, and the Bahrain Red Crescent Society; and

• in one family, where the medical student had learned of a Down's syndrome patient not known to the attending family physician, the family was put in contact with the Down's Syndrome Society.

Concerning families’ perceptions of student attitudes and behaviours, it was reassuring that students showed appropriate respect for the families. All families agreed that students respected their choices in making decisions regarding their life and health matters and put them at ease, so that many issues could be discussed.

Discussion

The family studies programme survey has helped curriculum development in a number of ways, but is subject to the limitations of any process that is based on predetermined goals, and is open-ended in its format. Given these qualifications, however, it has provided some important information re the aims of the programme, and the performance of our students in completing them.

For instance, when we asked our students to study family responses to illness and, within that domain, to explore family beliefs, understanding, and lifestyle behaviours, they identified common areas of misinformation, misunderstanding, and practical obstacles to change, that, once identified, could be addressed. As faculty and practitioners, we need to study this area in more depth, to ascertain to what extent specific and common patterns of beliefs, or social practices, play a role in the management of chronic disease in the Kingdom of Bahrain. This, of course, would have implications for the focus and content of health-education practices.

To their surprise, and sometimes discomfort, students often found themselves on the receiving end of detailed, personal disclosures that crossed the expected boundaries; for example, in the area of sexual issues. Individuals and families revealed other psychosocial issues that were unknown to the families' health practitioners. Were these disclosures a product of continuing contact or enhanced communication skills and risk-taking, or did the students' evident lack of authority give them an advantage over their more senior colleagues? In addition, were there disadvantages associated with that lack of authority? Families were quoted often as seeing the students as daughters, sisters, sons, and brothers. In these circumstances, students may be acting as family partners, rather than as medical personnel.

Students were able to support family function through better resource identification and utilisation, whether that resource was in the existing family structure, in neighbourhoods, or in the larger community. In this regard, it seemed that our programme and its agents were truly attempting to empower families to better care for themselves. Whether or not they were successful in effecting positive change, and whether or not that change was lasting, are matters that we need to examine, for such questions have implications for the programme. For example, if we encourage students to coach families in lifestyle and adaptive changes, should we not commit ourselves to continued support and follow-up? Do our family physicians and community nurses have the time for such follow-up? The issue of constancy and continuity of care for the families involved in our programme is of concern to us, and there are other issues of equal concern. For example, the families that participated in the programme were almost exclusively Bahraini, despite the fact that there is a sizeable expatriate community in Bahrain, as there is in other Gulf States may point to an issue of the nature of services offered and experienced by native and expatriate populations and communities, and is one that is being addressed by the programme.

The health issues that emerged during this survey were not simple ones. Our students not only accepted the challenges that arose, they also persevered in sometimes difficult circumstances. Such commitment was and is a credit to them, and to their advocacy roles.

Acknowledgements

The authors gratefully acknowledge the work of Mrs Sabah Maki, Community Nurse, for her help in the research and the medical students, without whom there would be no purpose.

Additional information

Notes on contributors

Neil Grant

NEIL GRANT, MB, ChB, CCFP, FCFP, was previously the Chair of Family & Community Medicine, and had overall responsibility for the design and delivery of the Community Health Programme at the Arabian Gulf University College of Medicine.

Trevor Gibbs

TREVOR GIBBS, DA(Educational Leadership), MMedSc, FRCGP, MICGP, FHEA, is Professor of Medical Practice and Education at the Bute Medical School, and previously held the position of Professor of Medical Education at the Arabian Gulf University, Bahrain.

Tawfeeq Ali Naseeb

TAWFEEQ ALI NASEEB, MB, ChB, FRACGP, is a family physician and part-time faculty member of the Department of Family & Community Medicine at the Arabian Gulf University College of Medicine.

Ahmed Al Garf

AHMED AL GARF, FMCS (AUB), DPM Ireland, DGO(Cairo), is a family physician and part-time faculty member of the Department of Family & Community Medicine at the Arabian Gulf University College of Medicine.

Family Questionnaire

1. Did the visits of medical students increase your knowledge about health issues in your family?

  In general?

   With regard to your specific health problems?

   Explain.

1. Were you able to make changes in your life style, e.g.

   in food content and/or preparation,

    in exercise habits,

    in weight management?

    Explain.

1. Were you able to make changes in communication between family members, e.g.

  in patterns,

   understandings,

   sharing of emotions?

   Explain.

1. Were you able to access new resources, or use previous resources in a different way?

  Explain.

1. Did you perceive that students respected your decisions and choices?

  Explain.

1. Were there special subjects that you did not feel comfortable in talking about because of there being two students?

  Explain.