Patients’ attitudes towards involvement of medical students in their care at university teaching hospitals of three public universities in Uganda: a cross sectional study | BMC Medical Education

We present insights from sub Saharan Africa regarding patients’ attitudes towards and comfort with medical students during clinical consultations and care. In our knowledge, this is the first study from Uganda since the inception of the first medical school at Makerere University in 1923 that has assessed patients’ comfort with the involvement of medical students in their care in three university teaching hospitals. We found that most patients could recognize and differentiate medical students from doctors. Majority of the participants had had previous experiences with medical students, and do not mind the involvement of medical students in their care nor are they bothered with the increased consultation time because the physicians are teaching medical students during consultations. Participants prefer to attend care in the university teaching hospitals where medical students are trained than in equivalent level hospitals where students are not. The sex of the medical student was not an important consideration in deciding whether or not a medical student should be involved in a patient’s care. The patients’ level of comfort with medical students did not significantly vary between patients attending care at the medical and obstetrics-gynecology departments. Highly educated patients from the medical department were less likely to be comfortable with the involvement of medical students in their care. The few participants who were uncomfortable with involvement of medical students in patients’ care were concern with invasion of privacy by the unqualified medical students. The patients from Makerere University teaching hospitals situated in the capital city were significantly more likely to be uncomfortable with involvement of medical students in patients’ care.

In this study, majority of participants were young (aged less than 40 years), female, married and with some formal employments. The age distribution of participants in this study is similar to other studies in this field of research. For example, a study in Canada that involved 625 patients from various specialties had a mean age of 39 years, with the majority aged 30 – 65 years. Majority of the patients (62%) in that study were female [23]. In the US, a study in the Midwest involving 213 obstetric gynecology patients had a mean age of 34.9 years [20]. In this study, age of participants was not statistically associated with being comfortable with involvement of medical students in patient care. While it could be expected that older patients would be uncomfortable with involvement of medical students (most are young) in their care, our data do not show that. Earlier studies showed that both outpatients and older hospitalized patients have positive attitudes towards medical students’ involvement in their care [24]. Although more context specific data are needed, our finding that age of patients does not determine patients’ comfort and acceptance of medical students’ involvement in patient care means that the deployment of medical students shall therefore not be restricted by the age of the patients.

Most participants in this study were able to recognize and differentiate medical students from the qualified medical doctors. Majority of them had ever had medical students present in their previous consultations and healthcare. The participants who were married, with higher educational attainment and those formally employed were more likely to recognize medical students. Our finding coheres with most studies in which majority of patients recognize medical students. However, results from a few studies show that a varying proportion of patients don’t know how to differentiate qualified healthcare professionals from medical students [10, 13]. For example, in Tunisia, up to 78% of patients did not realize that medical students were involved in their care [13]. In Australia, a study among women attending antenatal care reported that more than half of the women (54%; N = 625) had challenges differentiating medical students from other health professionals cadres [25]. It is important that patients are told that medical students are involved in their care. The patients should consciously consent to involvement of medical students in their care. They should as well be told the roles of medical students in their care.

The majority of participants were comfortable with involvement of medical students in their care. They did not feel that presence of medical students would adversely affect the quality of care, nor were they concern with the longer duration of consultation when medical students are present. This positive finding regarding acceptance of medical students by patients in university teaching hospitals is quite encouraging. Our finding is similar to results from other studies from both the high-income countries (HIC) and low- and -middle income countries (LMIC) where patients across specialties have shown acceptance for medical and other healthcare students to be involved in patients’ care as part of the students’ training. Data from the high-income countries show that medical students are highly accepted (55 to 95% acceptance) in accident and emergency services but not as much among pregnant women, especially during intrapartum care [26,27,28,29]. Similarly, data from the LMIC also show high level of acceptance of medical students’ involvement in patients’ care. For example, in Ethiopia, 69.2% – 77.4% accepted medical students to participate in their care [13, 14]. High level of acceptance have been also reported from the Middle East; for example, in a study involving patients from various specialties in Saudi Arabia, patients were generally acceptable to students’ involvement in their care. Refusal rate was only 11% – 43%, mainly in the obstetrics—gynecology specialty [30]. Acceptance of medical students is higher for non-invasive contacts including reading patients’ files, observing doctors during ward rounds, and taking history than with intimate procedures including digital rectal exams, vaginal deliveries and episiotomy repairs, and pelvic examinations [13, 30]. Patients accept medical students to participate in their care because they want to contribute to the learning of the students and making of future doctors, companionship, and because they learn quite significantly about their own health states from the medical students who often give significant time to patients. Patients also feel that they learn more when the doctors are teaching medical students during consultations [16, 20, 23, 25, 28, 31]. Majority of patients concur that patients-medical students’ interactions is a critical factor in training of competent future doctors [23]. Participation of medical students in patients’ care was considered a worthwhile learning experience for the students [29]. Similar findings were reported from Australia, where 96% of patients (N = 248) acknowledged the importance of students’ involvement in patients’ care as part of their training [7]. Patients’ contact under different clinic settings is an invaluable and inseparable component of appropriate medical training to groom competent medical doctors and other healthcare professionals’ personnel. The patient-medical student interactions during training provides a firm irreplaceable platform for the development of clinical skills, patient-physicians communications, and ethical skills necessary for their practices in the future.

We found that participants with higher education standards were less comfortable with involvement of medical students in their care. However, demographic characteristics of participants including age, sex, marital and employment status were not significantly associated with attitudes and comfort with involvement of medical students in patients’ care. Our findings are different from that of a study from Tunisia, where it was found that higher acceptance and comfort with medical students’ involvement in care was among male patients, patients aged more than 40 years, and those employed compared to women, patient aged under 40 and unemployed patients [13]. Our findings also differs from that of Hartz et al. [20] which showed that patients’ education level did not influenced their decisions to allow involvement of medical students in their care in general. However, they reported that level of education significantly influenced acceptance and comfort level with medical students during intimate examinations including pelvic examinations and performance of Pap smear among women. Women with higher education achievement are more willing to accept medical students’ involvement than the less educated women [20]. Our findings also differ from results of a study in Australia, which showed that obstetrics and gynecology patients (n = 255) aged less than 40 years, and those who were inpatients were significantly more likely to be satisfied with involvement of medical students in their care. Satisfaction was higher among patients seen by female medical students (86%) compared with male students (74%) [7]. Majority of medical students maybe young. In our study, majority of our patients were also young, with median age 38 years (54% younger than 40 years). This could explain why age did not feature as a significant factor in determining patients’ comfort with medical students’ involvement. There was no significant difference by specialty regarding the level of acceptance and comfort with medical students except for education attainment. Passaperuma et al. [23] also found no inter-specialty differences regarding patients’ comfort and acceptance of medical students’ involvement in their care. However a large study involving 932 participants from 14 teaching hospitals in Kuwait showed significant inter-specialty difference in acceptance of medical students’ involvement in patients’ care. While acceptance was highest in the pediatrics specialty, refusal was highest in the obstetrics gynecology specialty [32]. We recommend more studies in sub Saharan Africa across various specialties to shine more light on the effects of subspecialties and patients’ comfort with medical studies.

In this study, majority of participants said they would put into considerations the sex of the medical student (78%) and the seriousness of the disease at the time of consultation. They would not decide based on their own religious and cultural beliefs, nor length of time of consultations. Majority of the participants also said they would not be influenced by the quality of their previous experiences with medical students. These findings make it easy to deploy medical students to interact with patients without the need to first sort patients on the basis of certain characteristics. Regarding sex of the students, it is important for medical educators and attending physicians to explain to the patients beforehand the need for both male and female medical students gaining the required skills. Our findings on sex of students, previous experiences with medical students and consultation time is similar to results from other studies. For example, York et al. found no significant differences between attitudes of patients who had previous experiences with medical students and those who had not [10].

Participants from the oldest university teaching hospitals located in the capital city were less likely to be comfortable with medical students when compared with participants from teaching hospitals of the other two universities which are younger and located away from the capital city. It is not clear why acceptance of students were relatively lower in Makerere University teaching hospitals. Findings from other studies show that previous positive students-patients interactions and experience tend to increase acceptance of medical students in future consultations [10]. On the other hand, negative previous experiences tend to reduce chance of the patients accepting participation of medical students in their care [33]. Although Makerere University medical school started way back in 1923, there is limited data on perceptions of patients on the manner in which students interact with them. The attitude of patients at Makerere University teaching hospitals could relate more to the location in the capital city center and the cosmopolitan nature of the population than an intrinsic factor within the university teaching hospitals themselves. Future studies need to categorize the patients based on their frequency of previous contacts with medical students in order to delineate the influence of the quality of previous interactions on current perception of comfort with medical students’ involvement in patients’ care. In the US, patients who had had fewer contacts with medical students during their care were more likely to decline medical students’ participation in their care [20]. In addition, qualitative studies exploring perceived quality of care in previous student involvement in care may elucidate the way in which previous students’ involvement influence future acceptance and comfort with medical students.

Our participants preferred to attend care where medical students are involved; they would not want the medical students to be trained in separate university teaching hospitals different from the tertiary public hospitals where patients seek care. Our finding is similar to the study by Passaperuma et al. where they showed that majority of patients preferred teaching hospitals to nonteaching hospitals [23]. Medical students’ training could continue in the large public hospitals. If some universities start separate designated university teaching hospitals, they should keep their gates open to patients who may want to attend care where medical students are trained. The fees in such university teaching hospitals should be subsidized to avoid discriminations against the financially less privileged patients who may want to attend care in university teaching hospitals.

Limitations

This study has some limitations inherent in the design. This was a cross sectional study; we can only appreciate associations between the socio-demographic and health systems’ factors with patients’ acceptance without asserting causality. Second, our results could be influenced by social desirability bias because data collection was conducted in the hospital setting and patients could have responded in a manner that would be socially desirable. We minimized this bias by not involving doctors and or medical students in the data collection process. Data were collected by masters of public health students and graduate research assistants who explained to the patients their status and encouraged them to provide appropriate responses without fear of any retributions. Thirdly, the tool used for data collection did not undergo psychometric testing to assess its validity and reliability. We also did not conduct exploratory factor analysis to provide insights into underlying psychological explanations for observed associations. However, we believe that the tool measured what we set out to evaluated because we adapted questions from previously validated questionnaires and piloted the tool in our local environment. We then fine-tuned the questions based on the findings from the pilot study, ensuring that the questions seek what they were designed to measure.