Keywords
healthcare - medical student - gender - outpatient care - gynecology
Palavras-chave
atenção à saúde - estudante de medicina - gênero - atendimento ambulatorial - ginecologia
Introduction
The participation of medical students in gynecologic consultations appears to be critical
for an effective educational experience in women's medicine. Crucially, such experiences
enable the enhancement of the clinical skills of the students through patient interaction
and by partaking in gynecological care under the careful guidance of the medical team.
As a result, the students will hopefully be able to meet women's health needs as future
primary care physicians.
Therefore, the willingness of the women to consent to student engagement during consultations
is critical. However, student participation in gynecological care creates a difficult
interpersonal situation given the intimate nature of the clinical procedures. Not
all patients are willing to have medical students present during their appointments,
and this mostly depends on the age, expectations, and willingness of the women.[1]
[2]
[3]
[4] Moreover, gender bias commonly occurs, and restrictions regarding the assistance
of male students in gynecological care lead to adverse outcomes, as several authors
have reported.[5]
[6]
[7]
Additionally, most patients in these reports voice a preference for a female obstetrics-gynecology
(Ob-Gyn) physician.[8]
[9] Underlying their gender preference (among other reasons), many women may hold a
negative stereotype of male Ob-Gyn physicians, which is related to their expectations
regarding their desired gynecological care.[10]
Barriers to student participation and gender bias could thwart not only the adequate
clinical training but also the student's choice to specialize in Ob-Gyn. Any such
tendency could be detrimental in times of increased demand for women's health services.
A recent report[11] from our institution revealed a significant decrease in the number of male, but
not female, graduates that chose an Ob-Gyn medical residency over a two-decade period.[11] One could ask whether a generational trend among patient attitudes was related to
the decline in the specialty's popularity.
The purpose of the present study was to analyze the relationship between patient acceptance
(receptivity) and their reasons to consent to or refuse student attendance during
gynecological outpatient care, while considering the participants' demographic characteristics,
consultation experience, and gender bias.
Methods
A cross-sectional study was undertaken at the gynecological outpatient unit of Hospital
Universitário de Brasília (HUB). We interviewed 471 women who had a medical appointment
for any condition over 24 nonconsecutive weeks during 2016and 2017. No exclusion criteria
were employed based on demographic characteristics or diagnoses, but two cases were
excluded because of failure to answer critical questions. All of the patients that
were contacted agreed to participate in the survey. Patients aged ≥ 18 years signed
an informed consent form, and those under 18 years of age signed an assent form, as
did their parents.
Based on a literature review,[1]
[4]
[12]
[13]
[14] we developed and pretested 29 outpatient volunteers with a 32-item questionnaire
in face-to-face interviews while they waited in the appointment room. The instrument
included questions about demographic features, the number of their consultations attended
by medical students, their previous experiences with medical students attending a
consultation, whether they had received previous information about the presence of
medical students, how comfortable they were with the prospect of student attendance,
permission for a gynecological examination, if they felt comfortable refusing, and
their gender preference regarding their Ob-Gyn physician. The demographic features
included age, marital status, parity, schooling, and family monthly income based on
the Brazilian monthly minimum wage. In 2016, the monthly minimum wage was R$880.00
(∼ US$271.60), and in 2017, it was R$937.00 (∼ US$289.00).
The questionnaire also included 16 Likert-type questions (with results that range
from 5 [strongly agree] to 1 [strongly disagree]) from which we tallied three composite
variables. There were six questions about the patients' reasons to refuse student
attendance, four on the reasons to consent to it, and six on their appraisal of the
students' professional (student-doctor behavior) demeanor in a previous consultation.
The student deportment questions included whether the student had asked for permission
and showed respect, care, responsibility, communication, and social skills.
Frequency distributions were used to summarize the categorical data. After an analysis
of the main components (in which we found a unique component that explained over 40%
of the variance in each case), we tallied 3 composite variables using the sum of the
participants' responses to the respective questions. The composite variables (and
their respective standardized Cronbach α values) included a 6-item index of student-doctor
demeanor (α = 0.81), a 6-item index of the motivations for refusal (α = 0.71) and
a 4-item index of the motivations for consent (α = 0.62).
We also defined two emergent variables: the first was an index of the patients' receptivity
to student participation in their gynecological care, which was tallied by adding
the dichotomous responses to the following three ways of acceptance: the comfort with
student presence (1 = at ease with either male or female students); the number of
students allowed in the consultation (1 = 3 or more students); and a pelvic examination
performed by a student of any gender (1 = acceptance). The other emergent variable
was the consent inclination index, which was tallied as the difference between the
indexes of the reasons for consent and refusal (adjusted to the respective number
of questions).
The International Business Machines Statistical Package for the Social Sciences (IBM
SPSS Statistics, IBM Corp., Armonk, NY, US) software was used to process the data.
The analyses included correlation and crosstabs statistics to measure the relationships
and compare the proportions among the identified variables. We reported the measures
of association as effect sizes, namely, the values for Cramér V or Spearman ρ. Values
of p < 0.05 were considered statistically significant.
The Committee of Ethics in Research in Human Beings of Faculdade de Medicina da Universidade
de Brasília approved the study (1.126.648).
Results
The patients had a mean age of 43.06 ± 14.1 years (range: 12–78). Among them, 53.4%
were married, 27.4% were unmarried, and the remaining 19.1% were divorced or widowed.
A total of 21.7% were nulliparous, 61.4% had given birth 1 to 3 times, and 16.8% had
given birth 4 or more times. As for schooling, 23.9% had higher education, 38.6% had
finished high school, and the level of schooling of the remaining 37.5% was only up
to junior high school. Regarding family income, 63.9% earned less than 3 times the
monthly minimum wage, 26.3% earned 3 or 4 times the monthly minimum wage, and 9.8%
earned 5 or more times the monthly minimum wage. A majority 290 (61.7%) of the participants
had attended 4 or more previous appointments in the outpatient unit, and only 73 (15.7%)
were attending an appointment for the first time.
A total of 384 (81.9%) participants reported having previous consultation experiences
with a medical student. Among them, more than 396 (96%) agreed (formally and/or strongly)
that they had observed 5 of the 6 aspects that compose the student-doctor demeanor
during an earlier appointment. However, 74 (18.1%) of those women did not agree with
the statement: ‘The student (she or he) requested the patient's permission to participate
in the consultation.’ Additionally, only 227 (48.4%) of the 469 patients asserted
that they could refuse student participation in their gynecological care if they wanted
to.
Most patients (n = 331, 70.6%) felt at ease with the prospect of students, male or female, attending
their gynecological consultation. A lower proportion (n = 86, 18.3%) only felt at ease with females, while a minority (n = 51, 10.9%) felt uneasy with students of any gender, and the single remaining patient
was only comfortable with the presence of male students. We reclassified this case
into the first group during further analyses. This grouping regarding the level of
comfort (three groups: no student, female only, and any gender) was significantly
related to the patients' previous consultation experience (no = 0; yes= 1) with a
student in attendance (Cramér V = 0.155; p = 0.003; N = 469). The third group (any gender) had six times more experience than the novice
participants.
The grouping according to the level of comfort showed a strong association (Cramér
V = 0.671; p < 0.001; N = 469) with the number of students that the patients allowed to attend the consultation,
as reported in [Table 1]. Greater acceptance of student involvement was linked to lack of gender bias, as
37.7% (177/469) of the participants were at ease with either male or female students,
and were tolerant of 3 (or more) students being in the consultation room.
Table 1
Association of the patients' comfort level with the prospect of student presence in
the consultation and the number of students that they allowed to attend (n = 469)
|
Comfort level
|
Acceptable number of students
|
Total
|
|
None (%)
|
One or two (%)
|
Three or more (%)
|
|
At ease with a male or female student
|
0 (0.0)
|
155 (46.7)
|
177 (53.3)
|
332
|
|
At ease only with female students
|
0 (0.0)
|
59 (68.6)
|
27 (31.4)
|
86
|
|
Uneasy either with male or female students
|
45 (88.2)
|
4 (7.8)
|
2 (3.9)
|
51
|
|
Total
|
45
|
218
|
206
|
469
|
Note: Measure of association: Cramér V = 0.671; p < 0.001.
Moreover, the relationship between the grouping by level of comfort and the patients'
acceptance or refusal to undergo a pelvic examination performed by a student was significantly
linked to gender (Cramér V = 0.276; p < 0.001; N = 468). Although most participants (275, 58.8%) said they would be at ease with students
and would consent to be examined by either male or female students, 40 patients (8.5%)
only allowed female attendance and examination. The patients' stance on pelvic examination
performed by a student was also significantly related to the number of students that
they allowed in the consultation room (Cramér V = 0.191; p < 0.001). The significant interrelationships among the three facets of student acceptance
supported the creation of a composite variable index of receptivity, as described
in the Methods section of the present paper.
The grouping by level of comfort also showed a significant association with the patients'
gender preference (male, female, or either one) for Ob-Gyn physician (Cramér V = 0.262;
p < 0.001; N = 469). Notably, 294 patients (62.7%) had no gender preference regarding the Ob-Gyn
physician or the student involved in the appointment. In contrast, 38 patients (8.1%)
had a preference for a female Ob-Gyn physician and only felt at ease with female students
during their consultations.
Most participants agreed with the four reasons to consent to student attendance during
their consultation. [Table 2] shows their responses (dichotomized between agreement or disagreement). The first
reason (students helping in the consultation) was the most discriminant in the relationships
between the consenting responses and the patients' stance on the acceptance of a pelvic
examination performed by a student.
Table 2
Relationships between the patients' agreement with the reasons to consent to student
attendance at a consultation and their ordered stance on the acceptance of a pelvic
examination performed by a student (n = 468)
|
Reasons for consent (percentage of agreement)
|
Acceptance of pelvic examination
|
Cramér V
|
p-value
|
|
Neither by male or female students, n (%)
|
Only by female students, n (%)
|
Either by male or female students, n (%)
|
|
Students' help in the consultation,
412 (88.0%)
|
23 (67.6)
|
75 (79.8)
|
314 (92.4)
|
0.233
|
< 0.001
|
|
Expecting students attendance,
432 (92.3%)
|
28 (82.4)
|
81 (86.2)
|
323 (95.0)
|
0.168
|
0.001
|
|
Learning about her own health,
421 (90.0%)
|
26 (76.5)
|
81 (86.2)
|
314 (97.9)
|
0.150
|
0.005
|
|
Wishing to help in student education,
452 (96.6%)
|
33 (97.1)
|
86 (91.5)
|
333 (97.9)
|
0.141
|
0.010
|
Note: Within each stance group on the examination by a student, the rows show the
number and percentage of participants who did agree (formally and/or strongly) with
the given reason on each stance regarding the pelvic examination.
Furthermore, the participants mostly disagreed with the six reasons to refuse student
attendance. The reasons for refusal (dichotomized between disagreement or not) and
their percentages of agreement are shown in [Table 3]. Shame or fear of the pelvic examination was the most discriminant in the relationships
between the reasons for refusal and the patients' stance regarding acceptance of a
pelvic examination performed by a student.
Table 3
Relationships between the patients' agreement with a reason to refuse student attendance
at a consultation and their ordered stance on the acceptance of a pelvic examination
performed by a student (n = 468)
|
Reasons for refusal (percentage of agreement)
|
Acceptance of pelvic examination
|
Cramér V
|
p-value
|
|
Neither by male or female students,
n (%)
|
Only by female students,
n (%)
|
Either by male or female students,
n (%)
|
|
Feeling shame in examination by a male student,
182 (38.9%)
|
22 (64.7)
|
79 (84.0)
|
81 (23.8)
|
0.512
|
< 0.001
|
|
Privacy during pelvic examination by an Ob-Gyn physician, 212 (45.3%)
|
25 (73.5)
|
71 (75.5)
|
116 (34.1)
|
0.366
|
< 0.001
|
|
Feeling shame in examination by a female, student
71 (15.2%)
|
14 (41.2)
|
26 (27.7)
|
31 (9.1)
|
0.288
|
< 0.001
|
|
Students' lack of expertise, 160 (34.2%)
|
22 (64.7)
|
45 (47.9)
|
93 (27.4)
|
0.249
|
< 0.001
|
|
Privacy during dialogue with an Ob-Gyn physician,
190 (40.6%)
|
23 (67.6)
|
50 (52.2)
|
117 (34.4)
|
0.216
|
< 0.001
|
|
Lingering of consultation because of student attendance,
139 (29.7%)
|
16 (47.1)
|
34 (36.2)
|
89 (26.2)
|
0.137
|
0.012
|
Note: Within each stance group on the examination by a student, the rows show the
number and percentage of participants who did agree with the given reason to refuse
students attendance at the consultation.
Based on the patients' dichotomized opinions on three ways of acceptance (as reported
in the Methods section), we generated the following four-level index of receptivity
to student engagement among the 469 participants. The levels of receptivity were either
0 (no-way; n = 63; 13.4%), 1 (one-way; n = 89; 19.0%), 2 (two-way; n = 162; 34.5%), or 3 (three-way; n = 155; 33.0%). The receptivity index correlated positively with the index of reasons
for consent (ρ= 0.314; p < 0.001; N = 469), negatively with the index of motives for refusal (ρ= -0.453; p < 0.001; N = 469), and again positively with the measure of inclination to consent to student
attendance (ρ= 0.482; p < 0.001; N = 469). Additionally, receptivity had a significant relationship with previous experience
with (Cramér V = 0.235; p < 0.001) and previous knowledge of (Cramér V = 0.217; p < 0.001) student attendance.
Consistently, the participants' index of receptivity to student involvement related
to their stance regarding the gender of the Ob-Gyn physician 10 (2.1%) of male preference,
81 (17.3%) of female preference and 378 (80.6%) of no gender preference; N = 469). The relationship between three ways of acceptance and gender bias regarding
the Ob-Gyn physician (dichotomized as bias or no bias) was quite strong (Cramer’s
V = 0.388; p < 0.001; N = 469). These data are presented in [Table 4].
Table 4
Relationship of the patients' gender bias regarding the Ob-Gyn physician with the
index of receptivity to student participation in the gynecological consultation
|
Three ways of acceptance index
(ways of acceptance)
|
Ob-Gyn gender bias
|
Total
|
|
Bias, n (%)
|
No bias, n (%)
|
|
0. No-way
|
33 (52.4)
|
30 (47.6)
|
63
|
|
1. One-way
|
27 (30.3)
|
62 (69.7)
|
89
|
|
2. Two-way
|
20 (12.3)
|
142 (87.7)
|
162
|
|
3. Three-way
|
11 (7.1)
|
144 (92.9)
|
155
|
|
Total
|
91
|
378
|
469
|
Note: Measure of association: Cramér V= 0.388; p < 0.001.
Notably, the measure of inclination to consent correlated positively with the score
for student-doctor demeanor (ρ= 0.253; p < 0.001; N = 408); namely, a stronger difference in motivation for consent was significantly
related to a better appraisal of the students' demeanor during the consultation in
previous outpatient appointments. Finally, the indexes of inclination to consent and
receptivity displayed distinct relationships with the demographic features. Inclination
to consent correlated positively with schooling (ρ= 0.158; p = 0.001; N = 469) and with family income (ρ= 0.175; p < .001; N = 460). Receptivity showed weak associations with age (ρ= 0.135; p = 0.003; N = 469) and parity (ρ= 0.114; p = 0.027; N = 469).
Discussion
A crucial part of the education of medical students is learning through interaction
and direct contact with the patients. Over the years, this involvement has been viewed
positively[5] both by students and patients. However, as the intimacy level increases, the patients'
willingness decreases,[5] which is particularly true for a gynecological clinical history and physical examination
and may lead women to refuse student attendance.
From this point of view, our finding of a greater acceptance of student participation
in gynecological consultations (as shown by the relationship between the stances regarding
the possible level of comfort and the number of students that are allowed to attend)
is noteworthy and seems consistent with the findings of other studies.[1]
[4]
[12]
[13]
[14]
The level of acceptance could derive from situational and sociocultural factors. We
suggest that in the context of outpatient gynecological care, the patients' combined
affective and cognitive reasons for refusal or consent to student attendance drive
the components of receptivity to student participation. The patients' levels of informed
experience, gender bias, and socioeconomic background moderate these relationships.
Our results indicate the positive influence of background familiarity: ill-advised
and inexperienced women were less receptive to the students than informed and seasoned
women, which is in agreement with other studies.[1]
[3]
[5]
[15]
[16] We observed a higher rate of acceptance of student presence among patients who knew
in advance that students may attend, as described in other reports.[3]
[17] Other authors noticed that, in addition to a greater level of acceptance, the patients
also allowed a higher level of student participation in subsequent visits.[5]
Additionally, the amount of previous experience with students, regardless of gender,
seemed to matter. Reciprocal altruism could be at work in the patient-student relationship.
We found that most women valued the students' help with the consultation and wished
to contribute to the learning of futures doctors, which is in agreement with other
studies.[1]
[2]
[3]
[13]
[14]
The specific context of outpatient care as a public service in a teaching hospital
also seems to be influential. The patients may feel obligated to give their consent
and show willingness, and even expect student involvement, in return for the free-of-charge
care provided by the staff and students. However, in a study by Berry et al,[13] fewer than half of the patients anticipated that students would be involved in the
medical consultations or were aware that their physician could be a professor, despite
being in a teaching hospital. Moreover, Ching et al[4] demonstrated a high acceptance rate of student involvement in private schools.
In addition, the health staff could probably help set up a favorable environment for
student participation in a healthcare unit by providing patients with information
and by introducing the student. Mavis et al[5] observed that the likelihood of a patient agreeing with student involvement was
higher when the request came from the doctors themselves, a finding that further emphasizes
the importance of the doctor-patient relationship on the student's education, which
includes more than the acquisition of specific skills. Despite this, other authors
have suggested that a non-physician should request permission so that the patient
did not feel pressured to accept.[13]
In the context of the present study, we viewed receptivity as a combination of affective
states that resulted from the patients' different opinions regarding student attendance.
A patients' inexperience with trainees attending a consultation could lower their
receptivity to student involvement, especially male students in gynecological care.
Nonetheless, findings from the literature show that most women agree (even those that
refuse student involvement) that the best way for the students to develop clinical
skills is the effective participation in consultations with real patients, that is,
the “hands-on” approach.[2]
[14]
[16]
The subjective feeling of many patients that males (students or physicians) have a
lower understanding of the needs of women could also be at work. In the literature,
the women's preference for female Ob-Gyn physicians has been associated with a negative
stereotype about male Ob-Gyn physicians, hinging on the patients' expectations of
their desired gynecologic care.[10] The negative gender-role stereotype could be related to the supposed differences
in empathy regarding men and women.[18]
However, regardless of the reason, studies have shown that male students have greater
difficulty in acquiring experience in gynecological clinical practice.[19]
[20] The higher proportion of refusals and the greater difficulty in obtaining consent
compared with female students could lead to greater anxiety among male students, which
could negatively affect their interactions with patients.[20] Additionally, the quality of the clerkship experience could influence the students'
choice of Ob-Gyn as a career.[7]
We surmise that some patients' uneasiness at the prospect of student attendance and
the consequent refusal of an examination were associated with a fluid sense of being
unprotected; this feeling was linked to personal beliefs (such as a need for privacy)
and emotions (such as shame or fear), especially concerning male student involvement.
However, we argue that physicians of any gender, if they have the proper training,
can address such conditions to encourage the interaction between patients and students
without gender bias.
Additionally, attention should be given to the differences in the level of comfort
regarding gender of students and Ob-Gyn among the patients; in our sample, the distribution
was as follows: no gender preference (62.7%), and preference for females (8.1%). The
frequency of gender bias regarding the the student and Ob-Gyn physician (preference
for females) was higher among younger patients (12–26 years old) than among older
patients, but it is not clear whether such opinions are subject to change. In a study
by Fortier et al,[21] the patients who changed their minds about accepting students were on average 10.2
years younger than those who didn’t change their minds.
The results have been inconsistent regarding the association between demographic characteristics
and acceptance of student attendance. Like other studies,[14]
[19]
[22] we found a positive association with older age, while two studies[1]
[3] found that the association was not significant[3] or that it was with younger patients.[1] We also found a significant relationship between acceptance and parity, which is
in agreement with other authors,[14]
[19] but not between acceptance and the patients' marital status, which is in disagreement
with other studies.[3]
[22]
However, we cannot forget that 48.4% of the patients in our study felt that they could
refuse the student if they wanted to, which was a better result than those reported
by other authors,[12]
[23] and 18.1% of the patients did not hear a request for permission from the student
in attendance. These issues are of critical importance due to the clear need to demonstrate
ethical values, to humanize medical education, and for the empowerment of women concerning
their rights and choices.
It seems that there still is a misguided belief among physicians that they should
not ask patients for permission out of a fear that they could refuse it,[1]
[5] which appears to be based more on prejudice than on empirical evidence.[17] It is vital for everyone involved in the educational process that this belief does
not spread further.
The present study had some limitations. The cross-sectional design and the use of
a closed-question survey, which prevented the causal interpretation of the data, restricted
its scope. Additionally, the use of a single-site report with patients using a public
medical care service hinders the generalization of the findings. Moreover, as suggested
by a recent report,[24] there are many aspects to the interactions between patients and students, and we
recognize that student engagement in outpatient care involves consent, care, and safety
for the women involved, which are issues that were not framed in the survey.
We suggest that it is essential that medical staff and professors explain to patients
the importance of their cooperation to the education of future physicians and request
their cooperation in this process, without assuming that they are obliged to consent
to it without asking for their permission, because in the end, amid so many variables,
it seems that the decision to accept student participation involves a balance between
altruistic intentions to contribute to the training of future physicians and the private
nature of gynecological issues (clinical history and physical examination), as some
authors have noted.[4]
[21] The performance of the medical staff and the absence of biased attitudes are crucial
for the teaching of skills and abilities and for the transmission of ethical values,
such as observing the autonomy of the patients and showing respect for them.
Conclusion
Greater receptivity to student participation related significantly to five conditions,
in decreasing order of strength of association: lack of gender bias regarding the
Ob-Gyn physician, previous experience with student involvement, previous information
about student presence, older age, and multiparity. We also found that a more positive
inclination to consent (that is, a higher motivation to consent and lower motivation
do refuse) to student attendance correlated positively with a greater receptivity
to student participation and suitable student-doctor demeanor.
