INTRODUCTION

In recent years, medical schools have engaged in curricular reforms aimed at fostering patient- and learner-centeredness^1,2,3. Such curricular transformations are thought to counterbalance the erosion of humanistic and professional values⁴ and the loss of idealism⁵ of recently-graduated physicians. Innovations usually involve faculty, students and institutions acting as the modeling process of relationship-centered professional values^6,1.

Despite attempts for curricular change, desirable outcomes towards patient-centered care have not been fully analyzed^7,8,3. Most studies have assessed punctual interventions in the medical curriculum, addressing longitudinal integrated clerkship^2,9 and integrated communication skills activities^10,11. However, previous results of the real effects of curricular designs on medical students’ attitudes are controversial^12,5.

In line with this trend, Brazilian medical schools are facing the challenge of redesigning medical curricula towards more learner-centered and patient-centered approaches, stimulated by recent national medical education guidelines¹³. Since the publication of these educational guidelines, Brazilian schools have been involved in different stages of curricular changes. This multicenter cross-sectional study aims at assessing medical students’ attitudes and predictors of patient-centered relationship among different curricular designs (traditional, innovative and advanced).

METHODS

RESULTS

Medical students’ mean age was 22.3 years (SD = 3.3), most of them being female (n = 867; 59.3%). Table 1 shows students’ sociodemographic and curricular characteristics.

Brazilian medical student scored higher for caring than for sharing (p < 0.001; d = 0.599). Caring scores related to the psychosocial context were significantly higher than scores related to the patient’s perspective (p < 0.001; d = 0.797). Sharing power and responsibility scores were significantly higher than sharing understanding (p < 0.001, d = 0.455) (Table 2).

There was no statistical difference among total, sharing and caring scores according to curricular designs (p > 0.05) (Table 2).

In the regression analysis (Table 3), we observed a positive association between total B-PPOS scores with public schools, female gender, year of medical training, preference for future medical practice in public services, extracurricular activities, as well as a negative association between total B-PPOS scores with the father’s educational level and choice to study surgical specialties (p < 0.05).

For caring scores, we found a positive association with public schools, female gender, year of medical training, preference for future medical practice in public services and negative association with the father’s educational level (p < 0.05). Sharing B-PPOS scores showed a positive association with public schools, female gender, preference for future medical practice in public services, extracurricular activities, and a negative association with the father’s educational level and choice to study surgical specialties (p < 0.05) (Table 3).

DISCUSSION

This cross-sectional study demonstrates that Brazilian medical students are moderately patient-centered. We know that holistic care and sharing decision-making varies among cultures and social norms⁷. Brazilian cultural and societal values reinforce medical students’ attitude in caring more than sharing in the doctor-patient relationship²⁰. Furthermore, our students consider the patients’ psychosocial context far more than the patients’ perspective. For a more person-centered care, beyond the psychosocial context, individual patient’s goals and preferences must be at the center of the doctor-patient relationship, which requires a great change in the culture of health care and medical education^21,22. Understanding care from the patient’s perspective can be fostered by educational strategies that value contact with the patients’ narratives²³.

Our results show that students share more power and responsibility than understanding. Doctors and students tend to underestimate patients’ preference to be fully informed²⁴, giving partial information about a diagnosis and limiting the patients’ opportunity for reflection²⁵. Furthermore, physicians may consider shared decision making a simple philosophical principle or value, and may not necessarily adopt or use it to communicate with patients²⁶. Since patients’ attitudes and behaviors influence physicians’ behavior²⁷, patients should be encouraged by physicians to assume an active role as agents for change²², acquiring the knowledge, skills and confidence to manage their healthcare^28,29. A truly shared decision approach requires both doctors and patients to be involved in information exchange and treatment decisions^30,31.

Gender is one of the factors that influence the doctor-patient relationship³², and the strongest predictor of patient-centered attitudes in our study. Pre-medical school entry factors such as family background and personality have a remarkable influence on the identification of the professional role of women and patient-centeredness³³.

We know that both male and female medical students have the capacity to improve their patient-centeredness, but evidence shows a gender-dependent communication style influenced by stereotypes. Female physicians and students report more interest in the doctor-patient communication and the patients’ psychosocial context, sharing more information with their patients^34,35. Women also report to be more empathetic, receptive, helpful and sociable than men, whereas men see themselves as robust, overbearing and inhibited. Men tend to establish a relationship of power over the patient, concerned more with medical history and less interested in voluntarily improving their communication skills and attitudes³⁵. In view of these gender-differences, effective strategies to implement gender-sensitive communication skills teaching is crucial to enhance the quality of medical training and care, especially among male students^32,35.

Surprisingly, students from advanced curricular designs did not show more patient-centered attitudes in all domains of the B-PPOS. This could be attributed to the low offer of communication skills activities during medical training. Studies show most medical schools concentrate communication skills activities during preclinical years³⁶. It is common knowledge that communication training improves rapport building, shared decision making³⁷ and understanding patients’ perspectives³⁸. Nevertheless, communication-skills learned at the beginning of medical training can be easily forgotten if not reinforced longitudinally throughout medical education^39,40,11. This might explain the lack of association between patient-centered attitudes among students and the presence of communication-skills activities in their curricula.

Despite expectations of medical schools to develop humanistic and patient-centered relationships, medical training does not guarantee these desirable learning outcomes^7,3. Except for the caring domain, we did not observe an influence of the number of years of training among students’ attitudes. We believe that informal aspects of medical training such as role models and the hidden curriculum contribute to these results.

Medical schools have traditionally depended on role modeling as part of the informal curriculum, in which physicians’ values, attitudes and behaviors influence students’ attitudes and career choice^41,42. Depending on the clinical attributes, teaching skills and personal qualities of the faculty⁴³, there may be a negative role model, that resists changes in medical education⁴⁴ and threatens the acquisition and nourishing of humanistic skills and attitudes in future physicians¹². During medical clerkship, much of the doctor-student socialization occurs outside formal places, where informal experiences become more influential, creating a cascade of events that precludes real changes in medical students’ attitude, despite curricular reforms^45,3.

Additionally, the hidden curriculum also shapes values, roles and identity of medical trainees, at the level of the organizational culture and structure^46,47,48, creating important barriers to effective and positive role modeling. Emotional neutralization, loss of idealism, acceptance of the hierarchical structure and the adoption of a ritualized professional identity may influence enculturation in medical training^46,47,49. At the same time, lack of institutional support for faculty development, career development and formal training in teaching methods and reflective practice, associated with work overload^50,41 lead to a less effective role modeling, especially in clerkship years.

Extracurricular activities are associated with more patient-centered attitudes. Participation in these activities develops empathy, allows reflection and self-development⁵¹, improves interaction with peers and people of different realities, makes students more engaged in the teaching-learning process⁵² and in the diversity of care⁵³. These experiences may contribute to students’ interest in the patient’s psychosocial, cultural and environmental factors⁵¹.

The father’s higher educational level is a predictor of less patient-centered attitudes. A higher educational level is linked to higher socioeconomic conditions and higher engagement in parental education⁵⁴. Previous studies have also associated physicians who have a high socioeconomic status with more difficulty in sharing information and decision-making with patients⁵⁵.

Our results indicate that the choice to study surgical specialties may predict doctor-centered attitudes. Personal characteristics and personality traits may be related to the choice of medical specialty⁵⁶ and can predict cognitive and clinical performance of medical students⁵⁷. Students who intend to choose a surgical specialty demonstrate less social orientations, preference for acute patients, technology-oriented activities and prestige, and are more hospital-oriented than clinical-oriented students^58,59. These findings suggest that students prone to surgical specialties should receive special support to foster their patient-centered attitudes towards the doctor-patient relationship.

Our study has some limitations. Since we chose an online-based questionnaire to assess students from 21 medical schools of different regions in Brazil, there were difficulties concerning response rates. Despite these issues, we achieved a representative sample of respondents. Although the use of self-reported validated scales facilitates assessing a larger sample of participants, social desirability bias inherent to such instruments may have influenced responses. Another limitation may be related to the fact that PPOS measures attitudes rather than real behavior towards patient-centeredness. Nevertheless, we know that attitudes can predict future physicians’ skills and competences⁶⁰. Inferences of causality and temporality are limited by our study design. Despite such limitations, to the best of our knowledge, our study was the first to assess attitudes of students enrolled in different curricular designs, in a multicenter approach.

CONCLUSIONS

Curricular designs did not predict medical students’ attitudes. Being female and attending a public medical school were important predictors of patient-centered attitudes among medical students. Further research should investigate the direct influence of faculty professionalism development programs on patient centered-attitudes among students. Such programs should foster relationship-centered values, in order to establish a proper and safe learning environment.