Undergraduate education

Directing student response to early patient contact by questionnaire

rio Joaquim Edson Vieira, Maria do Patrocnio Teno Nunes & Milton de Arruda Martins

Context First year medical students experienced early patient contact by observing outpatient consultations. Objectives To evaluate a questionnaire designed to examine emerging attitudes during the development of a doctor)patient relationship. Methods First year medical students participated in medical outpatient consultations as observers. These consultations represented a total of 295 registered clinical appointments. After each observation, the students completed a questionnaire surveying themes related to the doctor)patient encounter. An instructor met the students at the end of the appointments to discuss the questions raised. The Dundee Ready Education Environment Measure was used to assess the course environment. Results Students found the activity useful and enjoyable. They reported increased self-esteem and enhanced enthusiasm for the study of medicine. They completed write-ups describing and evaluating the questionnaire data. The questionnaire notes showed

homogeneity among the students. The Dundee Measure indicated the students regarded the learning environment positively (622%); social and ambient conditions were rated highly (646% and 647%, respectively). Conclusion The teaching of humanitarian attitudes by observation of the doctor)patient relationship in practice was welcomed by students. The environment in which this educational programme was carried out was considered adequate. The outpatient service schedule and the limited time available for student instruction on the part of staff doctors made this activity productive. The programme motivated students towards higher achievement and the pursuit of medical responsibility as well as more developed humanitarian behaviour patterns. Keywords education medical, undergraduate *methods; physician patient relations; outpatient clinics; communication; attitude; questionnaires. Medical Education 2003;37:119125

Introduction
The ability of medical students to meaningfully consider the social history of patients appears to decline during their medical training. Because of this, the teaching of clinical communication skills has become an increasingly necessary component of medical school curricula, representing a subject which ought to be taught during the early stages of medical education.1 During the doctor)patient encounter, the doctor should seek to establish a partnership which encourages the individuality of the patient and facilitates the emergence of ideas about what might be wrong with the patients health.

Internal Medicine Department and Center for Development of Medical Education (CEDEM), University of Sao Paulo School of Medicine, Brazil Correspondence: Joaquim Edson Vieira MD, PhD, Av. Dr Arnaldo, 455 salsa 1216, Sao Paulo, SP 01246-903, Brazil. Tel: 00 55 11 3066 7317; Fax: 00 55 11 3085 0992; E-mail: joaquimev@hotmail.com

The interaction between a doctor and a patient occurs by means of various techniques and through their personal relationship. While the techniques depend on the application of medical knowledge, the personal relationship is more complex. Patients have their own social conventions, attitudes, expectations and needs, which are not necessarily similar to those of their doctors, and nor are they always evident.2 The emphasis on learning from patients is not new. At Guys and St Thomass Hospitals this practice has been developed in such a way to allow clinical students to play more active roles and take greater responsibility. Here, students have welcomed opportunities to see patients, to deal with undifferentiated problems and to test themselves as clinicians.3 Interestingly, the programme is also reported to allow students to gain in condence and to begin to develop the human qualities the public expects to see in doctors.3 In a previous study, undergraduate medical students stationed at an ambulatory clinic used a questionnaire
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Key learning points

Observation of appointments in an outpatient clinic by first year medical students represents a unique opportunity to bring to life subjects the students sometimes consider dry or remote. A questionnaire directed the students participation and acquainted them with the main aspects of the doctor)patient encounter and the psychosocial care involved. Cultural and social values, rights, obligations and responsibility were brought to the undergraduates attention to demonstrate that medicine should always consider the patients interests first. Medical students as observers in outpatient clinics may use questionnaires, the support of a practitioner and the usual facilities from medical services as part of their early exposure to patient contact.

as an instrument to orient their notes and to identify the attitudes of in-training doctors. The students, after observing a clinical appointment and making a short round with a staff doctor, reported an increasing interest in better study of hard biomedical subjects, such as biochemistry.4 It is reasonable to suppose that not all students are aware of exactly what they need to master in order to practise medicine. Opportunities to observe outpatient appointments have been shown to be successful in motivating preclinical students to study basic science subjects more thoroughly.5 This report aims to describe a questionnaire and its use as a facilitator during a teaching programme concerned with attitudes in the doctor)patient relationship. The investigation also reports on the methodology employed, indicating that general medical practice has a key role to play in providing early experience of patient contact.

Methods
The programme took place at the outpatient clinic of the General Medicine Service, Hospital das Clnicas of the University of Sao Paulo Medical School (HCFMUSP). A total of 41 rst year medical students were enrolled on the programme. They were split into groups of 1012 students, which were later allotted to either morning or afternoon sessions. The programme was scheduled to take place in eight 4-hour sessions,

the last two of which were reserved for the presentation of a nal report. Students were allowed direct interaction with patients by means of a short interview and they observed medical appointments on an individual basis. The HCFMUSP has a capacity of 2000 ward beds and undertakes 75 000 ambulatory appointments per month in all medical specialties. The General Medicine Service deals with approximately 4000 of these appointments. Patient interviews were carried out in the waiting room. The patients main self-described demographic characteristics were recorded, along with their own impressions about their conditions of health. Immediately after this, the students attended the outpatient consulting rooms, where patients were informed of their presence. A student could be asked to withdraw from a consultation if a patient, medical resident or staff doctor considered this appropriate. A total of 13 in-training doctors responsible for outpatient clinical training were involved in this study, but students did not always sit in on consultations with the same doctor. The students used a questionnaire to guide their observations (Table 1) and were required to complete one questionnaire for each doctor)patient encounter they observed. The questionnaire used a Likert scale (where 1 very poor, 2 poor, 3 acceptable, 4 good, 5 excellent) designed to capture a range of levels of patient satisfaction.6 In the consulting room, the student assumed the role of observer. The last hour of each 4-hour session was reserved for discussion between the group of students and their instructor about the consultations and the clinical ndings. Emphasis was placed on particular aspects of the encounter, such as the patients rights, the doctors obligations towards the patient, cultural values in medical practice and social responsibility. Pathophysiology was also considered in response to student requests, but to a limited degree. The Dundee Ready Education Environment Measure (DREEM) was used to assess the programmes educational environment and climate.7 This consists of a 50-item questionnaire, with a potential total score of 200 points, and considers ve domains of perception: teaching, teachers, academic achievement, learning atmosphere and students social relationships. The higher the score attained, the better these conditions are held to be.

Results
A total of 295 doctor)patient encounters were registered with completed questionnaires by the 41

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Table 1 The questionnaire Identication: Gender: Age: Education level: illiterate elementary high school graduate Appointment: Beginning (hh:mm): End (hh:mm): Physicians behaviour 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Yes No Yes No 12345 12345 12345 12345 12345 12345 No PE 12345 12345 12345 No tests 12345 No prescription 12345 12345 12345 Yes No Only prescription Does Does Does Does Does Does Does Does the the the the the the the the doctor doctor doctor doctor doctor doctor doctor doctor greet the patient? introduce him herself to the patient? show interest in the patients daily activities? use open questions? ask questions with yes or no replies? allow the patient to interpret his her own problem? give attention to the main concerns of the patient? invite the patient to undergo a physical examination (PE)?

Does the doctor keep up a dialogue with the patient during the PE? Does the doctor provide information about the ndings of the PE? Does the doctor explain the necessity and nature of laboratory tests? Does the doctor explain about the medicines prescribed? Does the doctor Does the doctor Does the doctor needed? Does the doctor use vocabulary compatible with the patients understanding? ensure that the patient understands his her own problem? ensure that the patient understands the prescription or test give a written orientation?

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Patients behaviour 17 18 19 20 21 22 Students name Group Date Scale: 1 very poor; 5 excellent. 123 Yes Yes 123 123 123 45 No No 45 45 45 Is the patient apparently interested in describing his her symptoms to the doctor? Is the patient concerned about receiving a prescription? Is the patient concerned about getting lab tests? Is the patient interested in receiving explanations regarding his her condition? Is the patient apparently enthusiastic or happy? How does the patient appear? (shy)talkative)

students. The students collated the data and prepared oral and written presentations. The activity was welcomed by the students, who reported increased selfesteem and enhanced enthusiasm for the study of medicine. The questionnaire notes showed homogeneity. The Dundee Questionnaire was completed by all 41 students and results indicated that the students considered both their learning environment and their social climate to be positive. The programme nished with the groups reports. These were qualitatively evaluated by the instructor to

generate a course grade. An open form (without identication) allowed the students to criticise the programme. Students said that they had learned a variety of things from the activity; mainly these involved developing an awareness of the importance of a patients individuality and the necessity of showing interest in the patients life, outwith their health or illness. The doctors role as an educator, the use of adequate vocabulary and the quality of information given were considered by students to be critical to the doctor)patient relationship.

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Table 2 Questionnaire with mean grades achieved during appointments (n 295) Order 3 4 5 6 7 8 9 10 11 12 13 14 15 17 20 21 22 Question Does the doctor show interest in the patients daily activities? Does the doctor use open questions? Does the doctor ask questions with yes or no replies? Does the doctor allow the patient to interpret his her own problem? Does the doctor give attention to the main concerns of the patient? Does the doctor invite the patient to undergo a physical examination? Does the doctor keep up a dialogue with the patient during the physical examination? Does the doctor provide information about the ndings of the physical examination? Does the doctor explain the necessity and nature of laboratory tests? Does the doctor explain about the medicines prescribed? Does the doctor use vocabulary compatible with the patients understanding? Does the doctor ensure that the patient understands his her own problem? Does the doctor ensure that the patient understands the prescription or test needed? Is the patient apparently interested in describing his her symptoms to the doctor? Is the patient interested in receiving explanations regarding his her condition? Is the patient apparently enthusiastic or happy? How does the patient appear? (shy)talkative) Mean 39 39 38 32 44 36 36 36 40 41 44 38 40 40 38 30 35 SD 04 02 03 03 03 03 04 06 02 02 03 02 02 04 04 03 04

The DREEM resulted in an overall evaluation of 1244 out of 200 possible points (622%), indicating a positive student response to the learning environment. In order to classify rates as high or low, any mean result to a DREEM question of lower than 20 was considered inadequate and indicative of an area to be improved. The students weak perception of the teaching domain (289603%) has been attributed to the questions related to the short time spent on teaching (12), unfocused teaching (1.6) and the emphasis on memorising facts (18). The section concerned with teachers attitudes (274624%) registered generated no responses lower than 20. In the section concerned with academic achievements (189590%), the question related to learning strategies that had worked before, altered to refer to a condition of discussion rather than of listening (14), and the question related to the capacity to memorise (18) were indicated as hindering learning conditions. While the learning environment won a high level of approval (310646%), student perceptions highlighted important issues, including a lack of precision regarding time-keeping (07), a readiness to cheat in tests (15) and a lack of condence in asking questions (18). Finally, students graded social relationships on the programme highly (181647%) but perceived a low level of interest on the part of teachers in dealing with students difculties during stressful conditions (18). The 295 encounters were recorded by individual questionnaires. A few questionnaires with insufcient data were omitted from the students nal report and

have likewise been omitted from the results of this study. Each student participated in between six and eight appointments. Use of the questionnaire was fairly uniform, despite differing conditions of observation (Table 2). The standard deviation for all questions with gradations of 1)5 was less than 06. Students felt comfortable lling in the questionnaire.

Discussion
The results suggest that the programme was conducted in an environment suitable for learning and that the questionnaire can be considered an adequate instrument for the independent following of outpatient consultations by students early in their education. The waiting room interviews helped the students to understand the patients views of their own health conditions and to gain initial impressions of their social status. This context represents an interesting opportunity for dealing with communication skills, taking into account the patients own views of health and illness. It is worth suggesting that social history taking should be made a short but integrated part of the overall rst assessment of a patient in order to improve students and doctors skills in this important area. Placing rst year medical students in a general medical outpatient clinic provides a unique opportunity to enliven themes previously considered dry or remote by the students. Not only are students able to observe special moments in the doctor)patient relationship,

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but the signicance of biochemistry in terms of its relationship with pathophysiology and physical diagnosis begins to make sense as a component of medicine as a whole. At this stage, medical students might be considered to be closer in understanding to the patients they observe than to doctors, given their identication as laypeople. For this reason, there is no conict between the interests of in-training residents and those of undergraduate students during consultations. The interest of the resident in-training is directed towards therapy and the outcome of the clinical situations encountered. The student, however, through the use of the questionnaire, can focus on the doctor)patient relationship while retaining a natural degree of curiosity about the diagnosis. The questionnaire seems to be able to direct the students attention and preserve their interest in the patient as a person with a particular culture, while enthusing them for the knowledge they will acquire from the consulting session. This complex situation certainly supports the hypothesis that the doctor)patient relationship represents a partnership rather than an isolated professional encounter. This course considered the use of a questionnaire to direct student participation during a patient contact experience, supported by qualied practitioners, at an early stage of training. It has proved able to acquaint students with the main aspects of the doctor)patient encounter and the psychosocial care involving a subject and his or her family. However, this type of participation in observing outpatient appointments may deserve further investigation in areas such as paediatrics or gynaecology, where some difculties may arise. The mean results from the groups indicate that the students perceived the doctors under observation as being highly interested in their patients: the overall grades given by students were close to 4. The use of adequate vocabulary attained a higher grade (44). The attending physicians in this study were doctorsin-training as residents, which may explain the prompt attention they offered. This may fuel the consideration of relationships and communication skills during training, thereby steering undergraduates away from undesirable situations where doctors regard their patients as disease puzzles rather than as people to whom they should listen and pay attention.8 Students perceived the patients levels of satisfaction as fair (30). Kiyohara et al. showed patients in similar settings to have higher degrees of satisfaction with their consultations, although not necessarily at the time of the consultation.4 Our questionnaire did not record the patients impressions outside the clinic,

where they may have felt more comfortable. It is also interesting to note that this discomfort might be occasioned by patients illiteracy, which can cause embarrassment and compromise the doctor)patient relationship.9 The suggestion that clinicians should not assume their patients know how to read should not be interpreted as an invitation to avoid listening to them. Promptness to listen results in better understanding of patients difculties and offers opportunities to deal with psychological issues. Cantwell and Ramirez cited inadequacy of skills and a willingness to avoid awkward questions, as well as lack of time, as reasons for avoiding psychological issues.10 These may suggest a lack of condence that might be addressed through the provision of more opportunities for training and counselling from the early stages of medical school. The time reserved for group discussion after the clinical encounters represented an opportunity to deal with the students wish to understand the interrelated aspects of medical practice. It is important to emphasise that the students demand for some pathophysiology was briey considered in order to illuminate some situations and to appraise the disease in question by taking biological and molecular science issues into account. At the group discussions, the students were rst asked to identify their patients given names. While this practice might be seen as routine, it represents a simple way of directing the students attention to the patient as a person rather than as a subject of medical attention only. From here, even the most interesting clinical diagnosis was discussed in terms of how the care of doctors and health professionals might lead to better understanding and control of the disease according to the patients own interpretation. Cultural and social values, rights, obligations, social responsibility and other issues were brought to the undergraduates attention in an effort to underline their value at an early stage in the students medical education. This practice adheres to a tenet that ought to be underlined by all medical educators: that medical practice should always consider the interest of the patient rst. Practitioners who comply with this rule allow their humanitarian impulses to serve not only as a means of perfecting their own practice of medicine but also as an end purpose of medical practice. In other words, one ought not to learn medicine from patients, but with persons who can become partners in the search for some kind of mutual well-being. The programmes strategy is based on the SPICES model (student-centred, problem-based, integrated, community-based, elective and systematic). It is student-centred in that questions are discussed with

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an instructor, and problem-based in that clinical appointments foster the themes for discussion, although, as indicated by DREEM, there is an emphasis on memorising facts. The course lacks integration with any other medical discipline and is not community-based. It is an elective discipline but it is hard to distinguish as systematic or apprenticeship-based. However, although there is a systematic approach to the themes proposed, the opportunities are random, which, in some senses, makes the course apprenticeship-based.11 It is interesting to note that DREEM detected the main weaknesses in the course: namely, unfocused teaching (perhaps related to the practices of the General Medicine Service) and the short time spent on teaching (very likely related to schedule pressure). The students hesitation in discussion was reinforced by their lack of memorising skills, conicting with their interest in some clinical conditions and undermining their incipient capacity for clinical reasoning. In addition, these two results, relating to discussion and memory, may indicate conict in a previous situation where students were challenged to memorise facts instead of reasoning. The lack of precision in timekeeping is denitely a negative factor and must be challenged seriously. It risks undermining the importance of time-keeping and its signicance to the doctor)patient relationship. The 41 students completed the 295 questionnaires, collated them and presented the results as a nal report, from which this paper originated. However, the groups may have shown differences in the number of encounters they observed, as the morning programme had a higher number of appointments scheduled. Moreover, there was no instructor control over the ways in which students chose to complete their questionnaires. Although this technical difculty seemed not to interfere with the main results presented, a stricter system of control might be proposed to the students. The students responses noted as low standard deviations for the mean grades suggested the questionnaire generated fairly homogenous observations. Considering that the students had lled in their notes individually and collated them for the nal report only at the end of the programme, the low deviation may suggest the instrument is sensitive to the attitudes investigated. A similar instrument cited in an earlier report showed almost the same prole for correlated questions, although not in terms of means.4 In conclusion, early exposure to patients of medical students as observers in outpatient departments should be encouraged. Students should receive guidelines to be

followed and ndings should be discussed at the end of the period. The writing up of a report stimulates the use of the written word for the organisation and presentation of data and ideas. The model can be adapted for use in different kinds of medical schools, and requires the same or usual number of hospital or primary care attending physicians, and the usual facilities from medical services. Further investigation should address achievements throughout the medical course within the context of the themes discussed here.

Contributors
JEV and MdPTN directed the students practice, designed the questionnaire and prepared the manuscript. MdAM reviewed the text, discussed the results and supervised the statistics.

Acknowledgements
We would like to thank the students and instructors who participated in this study and Professor Moacyr Roberto Cuce Nobre for his support and advice.

Funding
JEV, MdPTN and MdAM are staff members of the Laboratory of Experimental Therapeutics I, Faculty of Medicine, University of Sao Paulo, Brazil. This work was supported by the Fundacao Faculdade de Medi cina, a non prot-making organisation that provides wage supplementing to laboratory staff.

References
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8 Lieberman JA III. Medical education and patients psychosocial needs. J Family Prac 1999;48:6756. 9 Kefalides PT. Illiteracy: the silent barrier to health care. Ann Intern Med 1999;130:3336. 10 Cantwell BM, Ramirez AJ. Doctor)patient communication: a study of junior house officers. Med Educ 1997;31:1721.

11 Harden RM, Sowden S, Dunn WR. Some educational strategies in curriculum development: the SPICES model. Med Educ 1984;18:28497. Received 16 January 2002; editorial comments to authors 17 April 2002, 14 June 2002; accepted for publication 30 August 2002

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