INTRODUCTION
Medical students’ involvement in gynecological consultations is of the essence for a useful educational experience in women’s medical care. An essential feature of that experience is the students’ clinical skills qualification through the interaction with the women going through gynecological care under the guiding supervision of the teaching staff. Thereby, as future physicians working in the country’s healthcare system, the students shall meet the health needs of women.
To reach such a desideratum, the willingness of women to accept student engagement in their consultations is crucial. Nevertheless, the intimate nature of a gynecological consultation requires an interpersonal context of confidence and privacy. Thus, a patient may not feel at ease with a student’s presence during her appointment, depending on a diversity of factors, such as the woman’s needs, expectations and experiences, the student’s attributes, and the context of care1)-(4. Obstacles to learners’ involvement could prevent not only adequate clinical training but also the choice of specialty training in Ob-Gyn, which is an unhelpful outcome in times of growing demands for the provision of women’s health services5. A current review summarizes the learners’ perceptions of the patients’ factors related to, and the potential reasons for the gender differences in clinical opportunities and outcomes6.
Among the patients’ factors, it is noteworthy the possible effect of an earlier experience with students in gynecological consultations on the women’s attitudes towards the learners. Several studies found a mostly facilitating influence of prior acquaintance on the patients’ willingness to accept and feel at ease with the learners’ presence1),(3),(7),(8. Two Brazilian studies revealed similar effects in the setting of women’s outpatient care at public hospitals9),(10. What features of a prior appointment experience would impact the patients’ intended attitudes? One study noted that patients assigned high ratings to interpersonal communication attributes in connection to the patients’ attitudes towards student involvement3. Another study revealed that experienced patients rated such (trainees’) professional skills even higher, according to the duration of contact8. However, those studies did not clarify the level and the nature of the relationship between the women’s perceptions of learners’ interpersonal communication attributes and the women’s acceptance of student involvement. Further analysis seems necessary to investigate the association of those perceptions with positive or negative motives regarding the students’ presence.
Accordingly, this exploratory study aimed at assessing the expectation that patients’ appraisal of students’ interpersonal communication attributes in prior appointments would correlate to the patients’ motives for consenting to or dissenting from student presence and, therefore, impact the patients’ ultimate receptivity regarding a learner’s involvement in coming consultations. We extended the data analyses from a recent cross-sectional survey10 by using several of the patients’ responses to a tested questionnaire to pursue the following research questions.
How did the scales - which indicate the patients’ appraisal of students’ interpersonal communication attributes and patients’ motives to consent to and dissent from a student’s presence at their consultation - fare in dimension and reliability?
How significant were the relationships between the measures of patients’ consenting and dissenting motives and an index of their receptivity to student participation in an impending consultation?
How meaningful were the differences between the measures of consenting and dissenting motives of patients who experienced a student’s presence at a prior appointment and those patients who did not experience a student’s presence at a prior appointment?
How significant were the relationships between the patients’ appraisal of students’ interpersonal communication attributes during earlier appointments and the measures of consenting and dissenting motives concerning a learner’s presence at a prospective consultation?
METHOD
Context. The study was conducted at a gynecological outpatient unit. This unit, belonging to the Brasília University Hospital (HUB), provides well-diversified gynecological care to any woman registered for a medical appointment. Supervised medical students (45% females) have attended outpatient consultations during two semesters of their clinical training for the last 25 years.
Participants. We used a consecutive sampling strategy for the women complaining from a wide variety of gynecological problems. No exclusion criteria were established based on demographics or nosological conditions, so a total of 471 patients were interviewed over 24 nonconsecutive weeks. The mean age of the participants was 43.06 years (SD=14.1, median=43, range=12-78). Of the total number of participants, 53.4% were married, 27.4% were unmarried, and the remaining 19.1% were divorced or widowed. Nulliparous women comprised 21.7% of the participants, and 78.3% of the participants had given birth one or more times. Only 23.9% of the participants had higher education, while 76.1% of the participants had a lower level of schooling. Only 9.8% earned five or more minimum wages per month, and the remainder earned less than that. A majority (61.7%) of the women recollected attending four or more previous appointments in the outpatient unit, but 15.7% were undergoing a consultation for the first time. All patients signed a consent form agreeing to participate in the study. The Committee of Ethics of the School of Medicine approved the study protocol (CAAE 45773315.3.0000.5558).
Instrument. Based on examples in the literature8),(11)-(13, we developed a 32-item closed-question questionnaire and pretested it with 29 outpatient volunteers. The tool contained 16 Likert-type questions (5 = strongly agree, 1 = strongly disagree); six questions addressed the patients’ motives to dissent from a student’s presence, four questions addressed their reasons to consent to a student’s presence, and six questions addressed their appraisal of a student’s interpersonal communication attributes in a preceding appointment. We adapted those last questions from two works3),(8.
Analysis. Incomplete answers to critical questions led to the exclusion of two participants. The SPSS software was used for the analyses. T-tests were included to define differences between groups, and correlations (Spearman’s rho) and crosstab statistics were used to measure relationships and compare proportions between the indicator variables. Performing dimension and reliability analyses helped to validate the scale measures. These measures included the 4-item questioning about motives for consenting to the students’ presence, the 6-item questioning about motives for dissenting from students’ presence (Tables 1 and 2), and the 6-item questioning about students’ interpersonal communication attributes (Table 3). Additionally, we defined a composite variable by dichotomizing and adding the responses related to three facets of receptiveness: being comfortable with the students’ presence (1 = accepting the presence of either a male or female student); the number of students allowed in the consultation (1 = three or more students); and pelvic examination by a student (1 = acceptance, either by a male or female student). Using this composite variable as a receptiveness index constituted a useful outcome measure of the patients’ level of acceptance of students’ participation in the consultation. Following the usual norms14, we reported the values for Spearman’s rho and Cramer’s V as effect sizes and accepted P-values < .05 as significant.
RESULTS
No significant differences emerged, when using chi-squared tests, between the proportions of five demographic factors in women with prior experience of students’ presence at gynecological appointments (n = 408) and those in women without this prior experience (n = 61). The respective P values were .92 (age bracket, family income), .79 (schooling, conjugal experience), and .52 (parity).
The Principal Component Analysis (PCA) of the results of the 4-item questioning about motives for consenting to the students’ presence at the consultation yielded a single component, which accounted for 47.3% of the total variance. The standardized Cronbach’s alpha for corresponding items (henceforth called the consenting motivation scale, CMS) was .62 (Table 1). Likewise, for the 6-item questioning about motives for dissenting from student attendance, PCA yielded a single component, which accounted for 40.8% of the total variance. The standardized Cronbach’s alpha for the corresponding items (henceforth called the dissenting motivation scale, DMS) was .70 (Table 2). Moreover, for the 6-item questioning about the students’ interpersonal communication in an earlier consultation, PCA yielded a single component, which accounted for 52.7% of the total variance. The standardized Cronbach’s alpha for the same items (henceforth called the students’ interpersonal communication skills scale, SIC) was .81 (Table 3).
Items: Motives for consenting | Consenting motivation component | |
Loadings | Commonalities | |
Students helping with the consultation | .751 | .564 |
Expecting the student to be present | .738 | .544 |
Wishing to help the students’ education | .682 | .465 |
Learning about one’s health | .566 | .321 |
Eigenvalue | 1.89 | |
Percentage of variance | 47.35 |
Items: Motives of dissenting | Dissenting motivation component | |
Loadings | Commonalities | |
Need for privacy in a pelvic examination by an Ob-Gyn | .764 | .583 |
Need for privacy in a dialogue with an Ob-Gyn | .695 | .482 |
Feeling ashamed during an examination by a male student | .683 | .466 |
Feeling ashamed during an examination by a female student | .640 | .410 |
Students’ lack of expertise | .541 | .293 |
Lingering consultation in the student’s presence | .496 | .246 |
Eigenvalue | 2.48 | |
Percentage of variance | 41.33 |
Interpersonal communication* She (he): | Interpersonal communication component | |
Loadings | Commonalities | |
3. Revealed concern for my health. | .807 | .652 |
4. Acted professionally during the consultation. | .801 | .642 |
5. Communicated well throughout the appointment. | .787 | .619 |
2. Was respectful and caring. | .732 | .536 |
6. Had good looks and manners, which helped with the consultation. | .692 | .478 |
1. Asked permission to attend the consultation. | .484 | .234 |
Eigenvalue | 3.16 | |
Percentage of variance | 52,68 |
*Numbered by their order in the study questionnaire.
Notably, patients who had experience with a student’s being present in prior appointments (SIC assessment) expressed greater acceptance of a learner’s participation in their coming consultations than those who did not have this experience in prior appointments. A chi-squared test of independence showed a significant association between the condition of familiarity and the outcome of receptiveness: chi-squared = 20.49 (df = 3), P< .001; Cramer’s V = 209, P < .001. These data show that the prior experience was associated with a greater proportion of patients expressing broader receptiveness to the students’ participation, with a medium-sized effect. Broader receptiveness equals rank 3 regarding the index of receptiveness and stands for gender fairness and openness to learners (see Methods). Table 4 depicts the data.
Receptiveness Index | Familiarity with student’ involvement | Total | |
Inexperienced | Experienced | ||
N (%) | N (%) | N (%) | |
0 (zero facets of acceptance) | 19 (31.1) | 44 (10.8) | 63 (13.4) |
1 (one facet of acceptance) | 10 (16.4) | 79 (19.4) | 89 (19.0) |
2 (two facets of acceptance) | 20 (32.8) | 142 (34.8) | 162 (34.5) |
3 (three facets of acceptance) | 12 (19.7) | 143 (35.0 | 155 (33.0) |
Total | 61 (100) | 408 (100) | 469 (100) |
Facets (yes or no): at ease with both female and male learners; allows a pelvic examination by students of both genders; welcomes some students in the consultation. Chi-square = 20.40, df = 3, P < .001. Cramer’s V = .209, P < .001
Additionally, significant correlations (P < .001) emerged between both the CMS and DMS and the outcome of receptiveness to students’ participation. For the CMS, the correlation with receptiveness was positive (rho = .314), while the correlation was negative for the DMS (rho = -.454). However, the CMS and DMS scores of experienced and inexperienced patients differed significantly. On average, the 408 experienced participants showed higher CMS scores (M = 4.58, SD = .55) than the 61 inexperienced participants (M = 4.31, SD = .68). The difference (.27, SE .08) was significant: t(468) = 3.54, P < .001. In contrast, on average, the experienced participants showed lower DMS scores (M = 2.35, SD = .94) than inexperienced participants (M = 2.70, SD = 1.02). The difference (-.35, SE = .13) was significant: t (468) = -2,70, P = .007. For both comparisons, the difference observed denoted a small-sized effect (d = .41 and d = .37, respectively).
Consistently, the experienced participants reported a mostly favorable appraisal of SIC in prior appointments (M = 4.75, SD = .47, 95% CI 4.71-4.80), and no significant differences in the scores emerged for any of the participants’ demographic features (age bracket, parity, conjugal experience, schooling, and family income). The most positive, prevalent appraisal was for She/he acted professionally during the consultation, while the least positive appraisal was for She/he asked permission to attend the consultation. Furthermore, weak correlations emerged between those patients’ appraisal of SIC in earlier appointments and both their CMS score (rho = .236, P < .001) and DMS score (rho = -.208, P < .001) for the students’ presence at their coming consultation. For each of the six SIC attributes, except for She/he was respectful and caring, the strength of the correlation was higher in the CMS score than in the DMS score. Table 5 reports the data.
Attributes* of students’ interpersonal communication (SIC) skills She (he): | Consenting motivation | Dissenting motivation |
Rho | Rho | |
4. Acted professionally during the consultation. | .255 | -.225 |
3.Showed concern for my health. | .218 | -.216 |
2. Was respectful and caring. | .214 | -.231 |
5. Communicated well throughout the appointment. | .197 | -.185 |
6. Had good looks and manners, which helped with the consultation. | .179 | -.103 |
1. Asked permission to attend the consultation. | .176 | -.149 |
SIC average score | .236 | -.208 |
*Numbered according to their order in the study questionnaire. P values for the correlations between the dissenting motivation scale and the SIC attribute 6 and 1 were .037 and .002, respectively; all other P values were <.001.
Finally, a weak correlation also emerged between the patients’ assessment of SIC and their index of receptiveness to the students’ involvement (rho = .147, P = .003). The strongest correlation was for She/he asked permission to attend the consultation (rho = .136, P = .006).
DISCUSSION
In summary, we have tested and confirmed the expectation that the positive effect of the patients’ prior familiarity with the students’ presence on their forward acceptance of trainee involvement is related to their appraisal of the learners’ interpersonal communication skills and its impact on the balance of motives that impact the level of receptiveness to the presence of trainees in consultations. Using standardized scales helped to establish significant differential relationships between the indicators (students’ interpersonal communication skills, patients’ consenting and dissenting motivations) and their associations with the outcome of receptiveness to students’ participation15. The main pieces of the argument are as follows.
First, the receptiveness to the students’ participation regarding women with the experience of students’ attendance at prior appointments differs from that of women without this experience, and the level of acceptance is related to the patients’ consenting and dissenting motives regarding future consultations. Compared with inexperienced women, experienced women showed about twice the receptiveness (denoting gender fairness and openness to learners) and just one-third of null responsiveness to trainee involvement. The patients’ level of receptiveness positively (and more strongly) correlated with their motives to consent and negatively (and less strongly) with their reasons to dissent. Indeed, experienced participants had higher scores for consenting and lower scores for dissenting motivations than inexperienced ones. The tendency to consent reflected both a positive view of the student’s role and a perceived or expected benefit of the trainee’s attendance for the patient’s understanding of her health condition. Thus, prior experience increases the willingness and decreases the unwillingness to accept, and the trends show that the balance between the patients’ consenting and dissenting motivations would predict a stronger or weaker tendency for their ultimate receptiveness.
Furthermore, the patients’ motives for consenting or dissenting are related to their appraisal of the students’ interpersonal communication attributes. Among the experienced participants, the recollection of the students’ attributes during the medical interview of earlier appointments was mostly approving, although a specific intervention should improve those skills16),(17. The expressions of interpersonal communication skills, such as showing respect and kindness, conveying concern, and acting professionally during the consultation, could contribute to the woman’s attitude regarding the welcoming of a student in a pending appointment. Although the relationship between the appraisal of SIC and the outcome of receptiveness was weak (albeit significant), the correlations were meaningfully stronger between that patient’s estimate assessment and both their CMS (positive correlation) and their DMS scores (negative correlation). We infer that the influence of the recollection of interpersonal communication attributes was an indirect one, through the moderation of the patients’ motives and feelings concerning prospective student attendance. Thus, a stronger appraisal of the prior interpersonal communication skills would reinforce the willingness to consent to the trainee’s attendance and attenuate the willingness to dissent from the trainee’s attendance.
Additionally, women’s factors and student attributes differ regarding the acceptance of the learners’ involvement. The factors related to women (needs, expectations, and preferences, as subsumed in the CMS and DMS levels) prevailed over the students’ attributes (subsumed in the SIC level) regarding the eventual acceptance of the learners’ participation. Nevertheless, the results above highlight the relevance of the patients’ appraisal of the trainees’ professional skills, thus confirming and extending earlier reports3),(8. From the patients’ viewpoint, the learners show abilities and help with the consultation through some means, while the women themselves want to help the students’ medical education. As remarked elsewhere, reciprocal altruism may underlie the student-patient relationship10.
Overall, the results confirm the positive influence of prior experience, as reported by many authors1),(3),(7),(8. The findings extend the argument by providing quantitative evidence and uncovering the potential role of the patients’ assessment of students’ interpersonal communication skills in their willingness to accept the trainee’s involvement. Without claiming causality, a sequential relationship between appraisal, motives, and receptiveness seems conceptually plausible and meaningful. Nevertheless, the study cross-sectional and exploratory nature, as well as the participants’ response context, rule out high certainty.
Hence, we proffer that the results display implications for both medical students’ clinical preparation and women’s healthcare from the viewpoint of the physician’s work construction. The results highlight the relevance of patients’ perceptions of trainees’ attributes in the medical interview and the importance of learners’ embodiment of professional behavior and compassionate approaches18, as incorporated into the students’ communication skills. We suggest that a stronger willingness to accept the students’ participation among the patients with prior experience of student attendance may reveal the perception of ethical stances of teaching and learning, in the outpatient health-task context. Indeed, the assertion that modifiable student-related characteristics influence women’s willingness to agree to a pelvic examination19) by a student concurs with our findings. Besides, the results underline the importance of revealing the framework and balance of the patients’ motives and expectations regarding their care in the gynecological outpatient setting.
The study has limitations regarding its survey design15. The single-site report about patients from a public medical care service hinders the generalizability of the findings. Using a closed-question questionnaire in a cross-sectional design restricts its scope and strength. A restricted scope prevents a deeper understanding of ethical profiles of teaching, learning, and partnership in health services. Nonetheless, the study shows strengths, including the participants’ sample size and excellent response rate. The study also upholds the credibility of the reported findings10, explains the positive influence of prior experience and hints at the potential usability of that explanation in grounding research from a qualitative outlook to the interest of patient-physician partnership in public health services20.
CONCLUSION
The results imply that the appraisal of students’ interpersonal communication skills in earlier appointments moderates the patients’ consenting and dissenting motivations regarding the students’ attendance and thereby their receptiveness to learner involvement in coming consultations. Notably, the results suggest that better assessment of interpersonal communication skills reinforces the willingness to consent to student attendance and attenuates the unwillingness to accept it. Furthermore, higher consenting scores and lower dissenting scores correlate (positively and negatively, respectively) with broader receptiveness, which stands for gender fairness and openness to learners. Overall, the results confirm the positive influence of the preceding experience, clarify its relationships with consenting and dissenting motives by providing quantitative evidence, and reveal the potential role of patients’ appraisal of students’ interpersonal communication skills in balancing the women’s motives and, hence, their ultimate receptiveness towards learners’ participation. The findings have implications for both the patients’ role in the gynecological education of medical students and the learners’ qualification in the clinical interview and, therefore, for the benefit of women’s healthcare.