Attitudes towards the doctor-patient relationship: a prospective study in an Asian medical school

Context Patient‐centredness is an accepted guiding principle for health system reform, patient care and medical education. Although these attitudes are strongly linked with cultural values, few studies have examined attitudes towards patient‐centredness in a cross‐cultural setting. Objectives This prospective study evaluated attitudes towards patient‐centredness in a cohort of Asian medical students and examined changes in these attitudes in the same students on completion of their junior clinical clerkships. Methods The study was conducted in a cohort of 228 medical students entering Year 3 in medical school. The Patient–Practitioner Orientation Scale (PPOS), a validated instrument which scores an individual’s level of patient‐centredness, was used. Results Being female and having personal experience of continuing care were significantly associated with higher scores. Students in the USA were previously reported to have similar ‘caring’ but higher ‘sharing’ scores on the same scale. At the end of the junior clinical clerkship, there were improvements in the ‘caring’ subscale, but no change or a reduction in ‘sharing’. Students who did not have previous personal experience with continuing care experienced a greater increase in overall PPOS score. Conclusions When compared with students in the USA, the students in our study appear to have a lower propensity to view the doctor–patient relationship as a partnership. This may be a reflection of differences in cultural norms and expectations of doctor–patient interaction in different societies. Our finding that attitudes towards patient‐centredness did not decline over the course of the year, which contrasts with findings of other studies, may be attributed to various factors and warrants further study.     

Changes in students' perceptions of clinical teaching as a result of general-practice clerkships

This study investigated whether a 3-week clerkship for third-year medical students in general-practice doctors' offices changed the students' perceptions of clinical teaching. The Preceptor Evaluation Questionnaire was administered to 138 junior medical students before and after their clerkships. The result of the study indicated that the clerkship had a positive effect on the students' perceptions. This finding was not related to their experiences in other clerkships nor to the grades they received for the clerkship.
The results indicate that the teaching relationship established between student and family doctor significantly affects students' perceptions of aspects of effective clinical teaching.     

Continuity in a longitudinal out-patient attachment for Year 3 medical students

Context  Concerns about the quality of medical student learning experiences during traditional clerkships have prompted calls to restructure clinical education around continuity. Many US medical schools have added longitudinal out-patient attachments to enhance student continuity with patients and supervising doctors. However, continuity with patients can be difficult to achieve and little is known about the independent effect of continuity with a supervising doctor and setting. This study describes students' perceptions of the types of continuity experienced in longitudinal attachments and the learning associated with continuity.
Methods  This is a qualitative study using a grounded theory approach. Interviews were conducted with 12 Year 3 medical students about their continuity experiences with patients, supervisors and settings during their attachment. The resulting data were subjected to thematic analysis.
Results  Continuity with supervising doctors provided students with career mentorship and personal support. Student autonomy varied and was most dependent on the supervisor and setting. Students with patient continuity were more likely to report learning about chronic illness and communication skills. Students described the longitudinal attachment as helping them to develop their clinical skills and gain self-confidence within their role as future doctors, and as influencing their career choice.
Conclusions  There is much variation in student experiences of patient continuity during a longitudinal attachment. Continuity with patients, supervisors and settings affects student learning in different ways. Additional dimensions of the experience, such as the nature of the patient–doctor relationship, the pace of work and the patient population, impact learning outcomes and should be considered when continuity experiences are being designed.     

Unintentional failure to assess for experience in senior undergraduate OSCE scoring

Context One goal of undergraduate assessment is to test students’ (future) performance. In the area of skills testing, the objective structured clinical examination (OSCE) has been of great value as a tool with which to test a number of skills in a limited time, with bias reduction and improved reliability. But can OSCEs measure undergraduate internship expertise in basic clinical skills? Methods Undergraduate students (n = 32) were given a questionnaire listing 182 basic clinical skills. We asked them to score the number of times they had performed each skill during their internships (a 12‐month period in Year 6). We assessed the students at the end of Year 5 (before the start of their internships) and again at the start of Year 7 (undergraduate training takes 7 years in Belgium, with internships during Year 6), using a 14‐station OSCE assessing basic clinical skills. Global ratings were used to score performance. The relationship between internship experience and the OSCE Year 7 score was analysed using a linear regression model, controlling for variation in OSCE scores from Year 5. A multi‐level analysis was performed considering students as level‐1 units and stations as level‐2 units. Results Year 7 OSCE scores (post‐internships) were not affected by the number of times that students practised basic medical skills during their internships. Discussion Scores on OSCEs do not seem to reflect clinical expertise acquired during internships. Other more integrated assessment methods may prove to be more valid for testing final undergraduate skills levels.     

Medical students’ professional identity development in an early nursing attachment

Medical Education 2010: 44 : 674–682 Objectives The importance of early clinical experience for medical training is well documented. However, to our knowledge there are no studies that assess the influence of very early nursing attachments on the professional development and identity construction of medical students. Working as an assistant nurse while training to be a doctor may offer valuable learning experiences, but may also present the student with difficulties with respect to identity and identification issues. The aim of the present study was to describe first‐year medical students’ perceptions of nurses, doctors and their own future roles as doctors before and after a nursing attachment. Methods A questionnaire containing open questions concerning students’ perceptions of nurses, doctors and their own future roles as doctors was administered to all Year 1 medical students (n = 347) before and directly after a 4‐week nursing attachment in hospitals and nursing homes. We carried out two confirmatory focus group interviews. We analysed the data using qualitative and quantitative content analyses. Results The questionnaire was completed by 316 students (response rate 91%). Before starting the attachment students regarded nurses as empathic, communicative and responsible. After the attachment students reported nurses had more competencies and responsibilities than they had expected. Students’ views of doctors were ambivalent. Before and after the attachment, doctors were seen as interested and reliable, but also as arrogant, detached and insensible. However, students maintained positive views of their own future roles as doctors. Students’ perceptions were influenced by age, gender and place of attachment. Conclusions An early nursing attachment engenders more respect for the nursing profession. The ambivalent view of doctors needs to be explored further in relation to students’ professional development. It would seem relevant to attune supervision to the age and gender differences revealed in this study.     

Fear of death and dying in medical students: effects of clinical experience

Changes in the perception of death and dying during medical training were assessed, to test the hypothesis that fear is increased by exposure to dying patients. In general, clinically experienced medical students did not consistently differ from clinically inexperienced students in the intensity of fear of death. The two groups did differ in the frequency with which they thought about death. Students with clinical experience reported thinking more frequently about their own dying process and about interacting with a dying patient.     

Help,I’m losing patient‐centredness! Experiences of medical students and their teachers

Medical Education 2010: 44 : 662–673 Objectives Despite all educational efforts, the literature shows an ongoing decline in patient‐centredness during medical education. This study explores the experiences of medical students and their teachers and supervisors in relation to patient‐centredness in order to gain a better understanding of the factors that determine its development. Methods We conducted 11 focus groups on the subject of learning and teaching about patient‐centredness. We then carried out a constant comparative analysis of prior theory and the qualitative data collected in the focus groups using the ‘sensitising concepts’ provided by the Attitude–Social Influence–Self‐Efficacy (ASE) model. Results Although students express positive attitudes towards patient‐centredness and acquire patient‐centred skills during medical education, this study indicates that these are not sufficient to attain the level of competent behaviour needed in today’s challenging hospital environment. Clinical clerkships do provide students with ample opportunity to encounter patients and practise patient‐centred skills. However, when students lack self‐efficacy, when they face barriers (time pressure, tiredness) or when they are surrounded by non‐patient‐centred role models and are overwhelmed by powerful experiences, they lose their patient‐centred focus. The study suggests that communication skills training protects students from negative social influences. Moreover, personal development, including developing the ability to deal with emotions and personal suffering, self‐awareness and self‐care are important qualities of the central phenomenon of the ‘doctor‐as‐person’, which is identified as a missing concept in the ASE model. The student–supervisor relationship is found to be key to learning patient‐centredness and has several functions: it facilitates the direct transmission of patient‐centred skills, knowledge and attitudes; it provides social support of students’ patient‐centred behaviour; it provides support of the ‘student‐as‐person’; it mirrors patient‐centredness by being student‐centred, and, lastly, it addresses supervisor vulnerability. Finally, participants recommend that student‐centred education and guidance be offered, self‐awareness be fostered and more opportunities to encounter patients be created, including more time in general practice. Conclusions Supportive student–doctor relationships, student‐centred education and guidance that addresses the needs of the doctor‐as‐person are central to the development of patient‐centredness. Medical education requires patient‐centred, self‐caring and self‐aware role models.     

Year 1 medical undergraduates’ knowledge of and attitudes to medical error

Context To improve patient safety, medical students should be taught about human error and the factors influencing adverse events. The optimal evaluation of new curricula for patient safety requires tools for baseline measurement of medical students’ attitudes and knowledge. Objectives The aim of the study was to design and evaluate a questionnaire for measuring the attitudes of Year 1 medical students to patient safety and medical error. Methods A questionnaire entitled ‘Medical Students’ Patient Safety Questionnaire (Year 1)’ was designed to assess Year 1 medical students’ attitudes and anticipated behaviours relating to medical error and patient safety. This was administered to two cohorts of Year 1 medical students in a UK medical school during 2008 (n = 296) and the data subjected to psychometric analyses. Results Medical students’ attitudes to good patient safety practices were generally positive, but the students had little knowledge of how to report errors and were unsure about what to do if a colleague made an error or if a patient indicated that an error had been made. On the five scales of the questionnaire, Cronbach’s α values ranged from 0.59 (Attitudes to patient safety scale) to 0.88 (Knowledge of error and patient safety scale) and three scales showed internal consistencies below the recommended value of 0.70. Exploratory factor analysis showed that the five factors explain 51.7% of variance. Conclusions With some minor item trimming and re‐allocation, the Medical Students’ Patient Safety Questionnaire (Year 1) can function as an instrument with which to assess the attitudes of new medical students to patient safety and medical error. To assess the suitability of the instrument beyond the UK would require additional work.     

Trends in childhood renal cancer mortality in Brazil, 1980-2000

Mortality from childhood cancers has shown substantial declines in developed countries since 1960, with smaller favourable trends in South America. This study describes mortality trends in renal childhood cancer mortality in São Paulo state, Brazil, from 1980 to 2000. The age‐standardised mortality rates among the boys decreased from 0.36 per 100 000 inhabitants in 1984 to 0.09 in 1992, whereas the observed corresponding decline among girls was from 0.43 per 100 000 inhabitants in 1981 to 0.07 in 1990. Statistically significant declining trends in mortality rates were observed for boys (adjusted r² = 0.51, P < 0.001) and also for girls (adjusted r² = 0.40, P = 0.002), achieving in this group a significant reduction in age‐standardised mortality rates in the period (annual percentage change = ?4.21). Consistent decrease in mortality rates from childhood renal cancer was noted at São Paulo state. In the absence of changes in incidence rates, this decline could be attributed to the improvement in treatment protocols and supportive measures.     

Serious,frightening and interesting conditions: differences in values and attitudes between first-year and final-year medical students

Context and objective During medical education and training, the values and attitudes of medical students are shaped both by knowledge and by role models. In this study, the aim was to compare the views of first‐ and final‐year students concerning patients with different medical conditions. Participants and method In the spring of 1998 all first‐ and final‐year medical students at Göteborg and Lund Universities, Sweden, were invited to answer a questionnaire. A total of 20 medical conditions were to be rated on visual analogue scales, according to three aspects: their perceived seriousness, the student's own fear of them and interest in working with these conditions in the future. Results The overall response rate was 75%. Concerning seriousness, there was a high degree of concordance between the first‐ and final‐year students. Concerning their own fear, the concordance was less pronounced. When the conditions were rated from the aspect of interest, for the final‐year students, gastric or duodenal ulcer replaced infection with Ebola virus for the first‐year students, among the five highest‐ranked conditions. The correlations between seriousness and fear were lower among the final‐year students, but this reached statistical significance only in a few cases. Discussion A reasonable interpretation of the results is that the values and attitudes of the students were influenced by increased knowledge, as well as by role models encountered during the clinical parts of the training. Conditions less likely to be contracted become less feared, and conditions with effective treatment become more interesting; and the converse was true for each of these changes.     

Ethnic disparities in undergraduate pre-clinical and clinical performance

Medical Education 2012: 46: 575–585 Context Research from numerous medical schools has shown that students from ethnic minorities underperform compared with those from the ethnic majority. However, little is known about why this underperformance occurs and whether there are performance differences among ethnic minority groups. Objectives This study aimed to investigate underperformance across ethnic minority groups in undergraduate pre‐clinical and clinical training. Methods A longitudinal prospective cohort study of progress on a 6‐year undergraduate medical course was conducted in a Dutch medical school. Participants included 1661 Dutch and 696 non‐Dutch students who entered the course over a consecutive 6‐year period (2002–2007). Main outcome measures were performance in Year 1 and in the pre‐clinical and clinical courses. Odds ratios (ORs) with 95% confidence intervals (CIs) were estimated by logistic regression analysis for ethnic subgroups (Surinamese/Antillean, Turkish/Moroccan/African, Asian, Western) compared with Dutch students, adjusted for age, gender, pre‐university grade point average (pu‐GPA), additional socio‐demographic variables (first‐generation immigrant, urban background, first‐generation university student, first language, medical doctor as parent) and previous performance at medical school. Results Compared with Dutch students, Surinamese and Antillean students specifically underperformed in the Year 1 course (pass rate: 37% versus 64%; adjusted OR 0.40, 95% CI 0.27–0.60) and the pre‐clinical course (pass rate: 19% versus 41%; adjusted OR 0.57, 95% CI 0.35–0.93). On the clinical course all non‐Dutch subgroups were less likely than Dutch students to receive a grade of ≥ 8.0 (at least three of five grades: 54–77% versus 88%; adjusted ORs: 0.17–0.45). Conclusions Strong ethnic disparities exist in medical school performance even after adjusting for age, gender, pu‐GPA and socio‐demographic variables. More subjective grading cannot be ruled out as a cause of lower grades in clinical training, but other possible explanations should be studied further to mitigate the disparities.     

Growth of analytical thinking skills over time as measured with the MATCH test

Context Ber’s Comprehensive Integrative Puzzle aims to assess analytical clinical thinking in medical students. We developed a paediatric version, the MATCH test, in which we added two irrelevant options to each question in order to reduce guessing behaviour. We tested its construct validity and studied the development of integrative skills over time. Methods We administered a test (MATCH 1) to subjects from two universities, both with a 6‐year medical training course. Subjects included 30 students from university 1 who had completed a paediatric clerkship in Year 4, 23 students from university 2 who had completed a paediatric clerkship in Year 5, 13 students from both universities who had completed an advanced paediatric clerkship in Year 6, 28 paediatric residents and 17 paediatricians. We repeated this procedure using a second test with different domains in a new, comparable group of subjects (MATCH 2). Results Mean MATCH 1 scores for the respective groups were: Year 4 students: 61.2% (standard deviation [SD] 1.3); Year 5 students: 71.3% (SD 1.6); Year 6 students: 76.2% (SD 1.5); paediatric residents: 88.5% (SD 0.7), and paediatricians: 92.2% (SD 1.1) (one‐way anova F = 104.00, P < 0.0001). Students of both universities had comparable scores. MATCH 1 and 2 scores were comparable. Cronbach’s α‐values in MATCH 1 and 2 were 0.92 and 0.91, respectively, for all subjects, and 0.82 and 0.87, respectively, for all students. Conclusions Analytical clinical thinking develops over time, independently of the factual content of the course. This implies that shortened medical training programmes could produce less skilled graduates.     

Medical ethics contributes to clinical management: teaching medical students to engage patients as moral agents

Objectives  In order to teach medical students to engage more fully with patients, we offer ethics education as a tool to assist in the management of patient health issues.
Methods  We propose that many dilemmas in clinical medicine would benefit by having the doctor embark on an iterative reasoning process with the patient. Such a process acknowledges and engages the patient as a moral agent. We recommend employing Kant's ethic of respect and a more inclusive definition of patient autonomy drawn from philosophy and clinical medicine, rather than simply presenting dichotomous choices to patients, which represents a common, but often suboptimal, means of approaching both medical and moral concerns.
Discussion  We describe how more nuanced teaching about the ethics of the doctor–patient relationship might fit into the medical curriculum and offer practical suggestions for implementing a more respectful, morally engaged relationship with patients that should assist them to achieve meaningful health goals.     

An evaluation study of the didactic quality of clerkships

CONTEXT: Previous qualitative research at the University of Antwerp revealed dissatisfaction amongst medical students about clinical clerkships. OBJECTIVE: To use quantitative methods to further explore student perceptions of their clinical teaching. METHOD, SAMPLE AND SETTING: Monthly questionnaire administered to final-year medical students at the University of Antwerp, Belgium. RESULTS: The response rate was 83.9%. Many of the qualitative findings were reproduced. Educational resources were not optimally used. The junior doctor was the most important clinical teacher. Many activities were passive experiences. Coaching, feedback and supervision associated most with general satisfaction of the clerkship, however, these dimensions were often considered suboptimal. CONCLUSIONS: Clinical clerkships do not automatically provide an ideal learning environment for medical students.     

Therapeutic itineraries of Congolese refugees in the city of São Paulo

ABSTRACT

São Paulo, the most populous Brazilian city, has been the main destination for refugees and it is home to the majority of Congolese, who are the second largest nationality to request refuge in Brazil. In the context of these migrations, previous experiences in displacement and in places of welcome can trigger illness and suffering. The purpose of this article was to analyse the therapeutic itineraries of refugees from the Democratic Republic of Congo who reside in the city of São Paulo. The research followed an ethnographic approach and included focus group, ethnographic observation and in-depth interviews with 15 Congolese men in refuge in São Paulo between 2015 and 2016. The difficulties faced in the dignified reconstruction of lives include housing, precarious work and racism. Different systems are actuated in healthcare, treatment in health centres and hospitals regarding acute and chronic physical problems, in addition to self-care, identified in the preparation of teas for gastrointestinal ailments. When confronted by suffering, religious social networks, and those of friends and family are activated, in addition to alcohol consumption. The family is sought when facing financial and, principally, emotional problems. The itineraries include multiple therapeutic systems and a dialectic relationship with free, universal services perceived as inequitable.     

Dissatisfied patients: improving general practitioners' initial reactions

Summary. General practitioners often have difficulty in dealing with dissatisfied patients. One underlying reason could be the disturbed relationship between the doctor and the dissatisfied patient. A training course has been developed taking the relationship as a starting-point. Based on Watzlawick et al.'s theory on communication GPs have been trained to react to a dissatisfied patient on a relational level (‘Are you dissatisfied with my treatment?’) rather than on a contents level (‘How long have you been suffering from this?’). This method seeks to improve the relationship and the satisfaction of both doctor and patient. Three types of initial reaction to dissatisfied patients were offered to four groups of GPs (19 trainees in general practice and 19 trainers in general practice). Pre-and post-measurement were executed by means of registering the initial reactions on videore-corded vignettes of re-enacted dissatisfied patients. Subsequently the reactions were categorized blind by two judges. The 12 possible categories can be subdivided into categories primarily aimed at the contents or primarily aimed at the relationship. The results show that, as compared to the pre-measurement, GPs more frequently use empathic reactions and reactions in which they bring their own actions up for discussion. The number of responses in which doctors ask a further clinical question or in which GPs expect a solution whether from themselves or from others, decrease. It is concluded that the course appears to change for the better the GPs' initial reaction to dissatisfied patients.     

A Cross-Cultural Comparison of Eating Behaviors and Home Food Environmental Factors in Adolescents From São Paulo (Brazil) and Saint Paul–Minneapolis (US)

ObjectiveDescribe cross-cultural differences in nutrition-related factors among adolescents from São Paulo, Brazil and St Paul–Minneapolis, US.DesignTwo large-population-based studies with cross-cultural comparisons.SettingTwelve São Paulo and 10 St Paul–Minneapolis high schools in 2009–2010.ParticipantsA total of 1,148 adolescents from São Paulo and 1,632 adolescents from St Paul–Minneapolis.Main Outcome Measure(s)Meal consumption, family meals, fast-food consumption, and home food availability.AnalysisBinomial regressions, weighted for age distributions and adjusted for gender, were used to compare identical measures from each sample.ResultsGenerally, São Paulo adolescents reported healthier nutritional outcomes than St Paul–Minneapolis adolescents. São Paulo adolescents were 7 times less likely to report high fast-food consumption than St Paul–Minneapolis adolescents (P < .001). Whereas most measures of the home environment indicated healthier home environments in São Paulo, more São Paulo adolescents reported that sugar-sweetened beverages were usually available at home than did St Paul–Minneapolis adolescents (P < .001).Conclusions and ImplicationsSão Paulo youth tended to have healthier eating behaviors and home food environment factors than St Paul–Minneapolis youth. Brazilian eating patterns tend to be healthier and support a connection with food and culture. Interventions are needed to encourage youth and their families to maintain these patterns.