|ORIGINAL RESEARCH PAPER
|Year : 2008 | Volume
| Issue : 2 | Page : 69
Patient Attitudes towards Medical Students in Riyadh, Saudi Arabia
HM Abdulghani, MO Al-Rukban, SS Ahmad
King Saud University, College of Medicine, Dept of Family & Community Medicine, Riyadh, Saudi Arabia
|Date of Submission||03-Jul-2007|
|Date of Acceptance||07-May-2008|
|Date of Web Publication||23-Aug-2008|
H M Abdulghani
King Saud University, College of Medicine, Dept of Family & Community Medicine, Riyadh
Source of Support: None, Conflict of Interest: None
Context: A key element of medical education is patients' willingness to and cooperation in involving a medical student in their care.
Objective: To assess patients' attitudes and their associated factors toward involving medical students in their care.
Methods: This study was conducted over a period of two months in two hospitals in Riyadh, Saudi Arabia. Six hundred patients were approached to participate in outpatient and inpatient settings of four medical specialty services. A pre-tested questionnaire was used to collect the data.
Results: There were 492 respondents (82%), of whom 50% were males, 74% were married, and 51% were outpatients. Sixty percent identified medical students on the team of doctors that had treated them. Eighty-one percent of respondents felt that students' general appearance and manner were important to their willingness to have them participate in their care, and 64% would not object to the presence of medical students during physical examinations. Most (63%) preferred to be informed about students' involvement beforehand. Fifty-five percent believed that they had the right to refuse medical students, with women, married and less educated individuals and those seen in particular departments more likely to believe so. The preferred role for students also varied with gender, marital status and department.
Conclusion: This study finds that most Saudi patients view medical students' involvement in their care positively. They prefer to be told in advance about students' presence, asked for their permission, and have students' involvement restricted to certain times.
Keywords: Patients′ attitude, medical students, Saudi Arabia
|How to cite this article:|
Abdulghani H M, Al-Rukban M O, Ahmad S S. Patient Attitudes towards Medical Students in Riyadh, Saudi Arabia. Educ Health 2008;21:69
A vital part of medical students’ education is learning through direct interaction with patients. While many medical schools have begun to use standardized patients and simulations as part of the education process, hospitals and clinics often provide the only viable opportunity for students to gain practical clinical experience. This is particularly true in clinical rotations in obstetrics/gynecology and surgery, when clinical findings are best learned through demonstration in actual patients, and where standardized patients and simulations are difficult to obtain or unavailable. Thus, a key element of medical education is the willingness and comfort of patients to involve a medical student in their care.
Previous studies have found that patients generally accept medical students' involvement in their hospital and outpatient care. This may be so due to their desire to contribute to medical education, the extra time physicians may spend with them when there is a student present, the potential for gaining fresh insight into their medical problem through the student’s contributions and the perception that they themselves learn more when their doctor is teaching a medical student (Adams et al., 1999; Simons et al., 1995; Birkinshaw et al., 1999; Devera-Sales et al., 1999; York et al., 1995, Grasby & Quinlivan, 2001; Hartz & Beal, 2000).
The patients' willingness and comfort level with involving medical students in their care may be affected by their previous experiences with medical students, their understanding of the roles and responsibilities of medical students, and the nature of their medical problem, and the student’s gender (Adams et al., 1999; Simons et al., 1995; York et al., 1995; Richardson et al., 1986).
Obstetrics patients anticipate medical students to perform few clinical procedures and are more likely to refuse intimate pelvic examination (Grasby & Quinlivan 2001; Hartz & Beal, 2000). Privacy needs can be the main reason for a patient’s refusal to involve medical students in their care (Magrane et al., 1994).
Recent evidence has shown that patients generally accept medical students’ presence and typically regard them positively (Howe & Anderson, 2003). A comprehensive literature review did not uncover any local studies relating to patient perceptions of student involvement, particularly in Saudi Arabia. This study was designed to identify Saudi patients’ views and the factors associated with acceptance of medical students. The objectives of this study were:
- To assess patients’ attitudes toward involving medical students in their care in a teaching and a public general hospital.
- To assess factors that may affect patients’ opinions toward their right to refuse medical students and their preferences for medical student involvement and the role of medical students.
This study was conducted over a period of two months, from December 2004 to January 2005, in Riyadh, Saudi Arabia, at King Khalid University Hospital (KKUH), a teaching hospital for the college of medicine, King Saud University, and Riyadh Medical Complex (RMC), a public general hospital with a unit for teaching medical students. Ten third-year medical students were employed as research assistants. After a comprehensive review of previous related studies, the authors designed a self-administered questionnaire which included 12 statements of patients' attitudes towards student involvement in their health care. This questionnaire was piloted initially with 20 patients attending KKUH, and minor alterations were made. The questionnaire was distributed to 600 patients who were either waiting for a scheduled outpatient visit or were inpatients in various hospital departments. The patients were selected at set time intervals during three working days of the week. Although the questionnaire was prepared in the Arabic language, the research assistants were available to help any patients who could not understand any item or could not read. All patients spoke Arabic fluently.
Patients were asked to provide information about their age, gender, and education level, whether a medical student was among their team of doctors, whether a medical student had ever been present during their previous visits, their perceptions about the role of medical students, and their preferences regarding medical students’ involvement. A five-point Likert Scale (“strongly agree” to “strongly disagree”) was used to assess patients’ responses. The study was approved by the Department of Family Medicine Research Committee, which examines proposed research ethical issues.
Data were analyzed using SPSS version 12.0 statistical software. Five-point Likert Scale responses were collapsed into meaningful dichotomous responses (Everitt, 1997). Pearson's chi-square test was used to test for associations between different attitudes and other categorical variables. The student’s t-test and One-Way Analysis of Variance were used to compare the mean values across the two and three levels of categorical variables (Field, 2005). A p-value of <0.05 was considered statistically significant.
A total of 492 of 600 approached patients participated in the survey, for a response rate of 82%; 240 (49%) were inpatients from Departments of Medicine, Surgery and Obstetric and Gynecology (OB/Gyn), and 252 (51%) were outpatients from Departments of Surgery, Primary Health Care, Medicine, and OB/Gyn outpatient clinics. The participants were 50% male, 74% were married and the mean + standard deviation of their age was 33 + 14.6 (Table 1).
Table 1: Demographic and clinical site characteristics (n=492)
Attitudes towards medical students
Sixty percent of study subjects identified a medical student among the doctors who had treated them. Most of the subjects (81%) felt that the general appearance and manner of students effected their co-operation (Table 2). Sixty-four percent indicated that they would not object to the presence of a medical student during an examination, whereas 90% would not object if a student only asked questions. Nearly two thirds of patients (63%) indicated that they would like to be informed about the presence of a medical student in advance of a clinical examination and 58% preferred to have students of the same gender if they were to examine them. Approximately 68% of patients did not mind giving details about their illness and providing personal history to medical students, and 70% would not feel humiliated if they were asked questions about alcohol intake and extramarital sexual activities. However, 74% would feel embarrassed if a doctor examined their genitalia in front of medical students. About 84% of patients felt they do co-operate with medical students just as they do with their physicians. No statistically significant differences were observed in these attitudes between the patients of two hospitals.
Table 2: Patients’ attitudes towards medical students
Refusal of medical students
The distribution of a dichotomous response (Yes=55%; No=45%) to agree that they have the right to refuse a medical student’s presence was statistically significantly associated with other study variables (Table 3). Two thirds of patients (67%) at KKUH believed they had a right to refuse medical students in comparison to just 12% of the patients at RMC. Most patients in the primary care (100%) and surgery departments (64%) responded positively to the question about their right to refuse having a medical student involved in their care. In contrast, only 32% of patients of the Departments of Medicine (32%) and OB/Gyn (45%) responded positively to the same question. Many of the patients who were female (70%), married (58%) and illiterate (77%) voiced their right to refuse the presence of a medical student.
Table 3. Associations between the views on patients’ right to refuse medical student and other variables
About 48% of male patients preferred medical care to be offered by both the physician and medical student, whereas 52% of female patients preferred a physician alone (Table 4). The marital status of patients also correlated with their preferences: 45% of married patients preferred physicians alone, compared to 39% of single patients. Preference also varied with the patient’s age, as patients who preferred involving both a physician and medical student were older than patients who preferred seeing a physician alone or had no preference. A higher proportion (66%) of female patients preferred students of their same gender, as compared to 34% of male patients.
Table 4. Associations between the preferences of patients towards the role of medical students and other variables
Patients’ opinion on the role of medical students
Thirty percent of respondents felt that students should be active team members in their care, 36% felt students should be physician helpers, 12% felt students should be treating physicians and 22% were unsure what roles students should play (Table 5). Respondents’ preferred roles for students varied with the type of hospital: 42% of patients at KKUH felt that the medical students should play the role of physician helper, whereas only 19% of RMC patients held that opinion. The type of department patients were attending was also associated with patients’ opinions on the appropriate role for medical students. Sixty percent and 45% of patients attending Primary Health Care and Ob/Gyn departments, respectively, felt that students should play the role of physicians' helpers, whereas 34% and 38% of patients attending the Medicine and Surgery Departments felt that the medical student should be active team members. Thirty-three percent of patients with postgraduate university degrees and 44% of those who graduated college recognized medical students as physicians’ helpers, compared to 27% of patients with a secondary education or less and 23% of those who were illiterate.
Table 5. Associations between patients’ opinion on the preferred role of medical students and other variables
To our knowledge, this is the first study from the Middle East to investigate patients' opinions about involving medical students in their care. As the interactions between patients and doctors are the cornerstone of medical practice, the interactions between patients and medical students must be the foundation of clinical training. The interest in patient-medical student interaction can be traced back more than two decades (Thompson & Anderson, 1982) and its importance has become increasingly clear. Interactions with patients provide a major contribution to medical education as well as to the satisfaction of patients. Neither of these should be pursued to the detriment of the other. This delicate balance has been the focus of several investigators (Feletti & Carney, 1984, Ries et al., 1980, Santulli, 1993).
This study reveals patients’ attitudes towards medical students at two major hospitals in Riyadh, Saudi Arabia. We expected that patients' opinion about the "right to refuse" student involvement would be lower in a teaching hospital (KKUH) than in a general hospital (RMC), but the opposite was found. This could be due to the presence of large numbers of students in addition to the difficulty in obtaining permission during the first visit. Informed consent is a vital element in patient-student interaction. A significant number of patients in this study preferred being informed in advance about the presence of a medical student and about the specific roles they will play during clinical examination, consistent with earlier reports (Kim et al., 1998; Salisbury et al., 2004). We also found that patients preferred that student participation be requested, rather than imposed, as Magrane et al. (1996) previously found.
This study showed that a significant number of patients felt embarrassed when the doctor examined their genitalia in front of medical students. An earlier study by Ryder et al. (2005) similarly found that many patients feel uncomfortable with medical student involvement in sexual health consultations.
Many patients preferred that the accessibility of medical students to inpatients be restricted to specific times and that the timing be individualized according to their wishes. Most patients in this study did not object to having a medical student as an active team member, but more preferred this to be as a physician helper rather than as a treating physician (Santen, 2004). In either of these two roles the student can perform minor procedures in addition to physical examinations.
Findings from this study generally supported those of previous studies of patients’ opinions of medical students conducted in other parts of the world. Our patients had positive attitudes toward cooperating with medical students while performing physical examinations and interviews, but only as members of their health care team, rather than on their own. A study by Graber et al. (2003) similarly showed that patients were reluctant to be cared for by students when it came to practical procedures in the emergency department.
On the other hand, a significant proportion (84%) of patients in this study responded negatively to the question "do you cooperate with medical students as you cooperate with your physicians?" This finding could be important when planning clinical teaching sessions, as patients may not cooperate fully with medical students. It also may effect students’ assessments in clinical examinations such as OSCE, long and short cases, where patients' cooperation is essential.
Acceptance of medical students by patients of departments of OB/Gyn and Surgery was lower than that at Departments of Primary Care and Medicine. Grasby and Quinlivan (2001) similarly found patients reluctant to accept student involvement in their intra-partum care. Females and married patients preferred a physician rather than a medical student when compared to males and unmarried patients, indicating that these patients could be having predetermined (fixed) ideas on the role of medical students in their care and also wished to maintain their privacy. More female than male patients preferred medical students of same sex, as has been seen in other local and international studies (Adams et al., 1999; Grasby & Quinlivan, 2001; Cooke et al., 1996; Shann & Wilson, 2006; Al-Faris et al., 1994). Saudi Culture is a reserved and conservative culture, where male and female patients are generally separated. Even male and female medical students undertake their studies in separate male and female sections of a medical school.
Certain characteristics of patients—female gender, married, and illiterate—were associated with the belief in the right to refuse medical students in their health care. For medical students to be more accepted by these groups, intervention strategies are needed.
Conclusion and recommendations
This study found that 60% of Saudi Arabian patients identified a medical student on the team of doctors who cared for them. It also identified general characteristics of Saudi patients, namely gender, marital and educational status, that correlate with various attitudes about involving medical students in their care. Apart from the patient characteristics, the type of the hospital (teaching and general), department (primary care, medicine, surgery, OB/Gyn) and the student’s appearance and manners are associated with patients’ attitudes toward medical students. Data from this study suggest that providing information in advance to patients about the involvement of medical students in their care may help foster acceptance and establish a positive patient-medical student relationship. Patients prefer students' participation to be permitted only with their consent, that their visits be restricted to individually specified times, and that their numbers not be overwhelming. Improved collaboration with patients may provide better learning opportunities for students at most levels of training.
Limitations of the study
The present study has two principal limitations. First, the data were based on responses to a subjective, self-administered questionnaire which was completed in the presence of medical students, which might have biased responses in favor of students. Second, the majority of study subjects were literate, hence the findings of the group as a whole do not necessarily reflect the views of the 22% of general population of the Kingdom of Saudi Arabia that are illiterate (Khoja & Farid, 2000). Future qualitative studies are needed to address these limitations and to explore further patients' perceptions of student involvement in their care.
The authors would like to thank all patients who participated in the study, and the medical students for their contribution as research assistants.
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