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Journal of the New Zealand Medical Association, 03-April-2009, Vol 122 No 1292

What gets in the way of clinical contact? Student perceptions of barriers to patient contact

Fiona Mathieson, Tracey Barnfield, Greg Young

Abstract

Aims Students clearly need to have direct clinical contact with patients during their training. However, students complain that the opportunities for this are inadequate. This study aims to describe students’ perceptions of internal and external factors that may impede clinical contact.

Methods A questionnaire was developed from a literature review and a focus group discussion. Participants were medical students who had just completed their fourth year at Otago University, Wellington, where the curriculum is integrated with clinical contact. Questionnaire responses included Likert scale scores and written responses to open questions.

Results Sixty-four percent of the year group participated (45/70). Likert scale responses were categorised into high scoring (three or more; with a maximum of five) and low scoring (two or less) and into “internal” (13) and “external” (12) factors. Sixty-nine percent of respondents endorsed six or more high-scoring items. No significant differences were found between internal and external barriers, but female students were significantly more likely to endorse internal factors. Forty-nine percent of students commented in response to the open questions that direction to appropriate patients by a supervisor would help.

Conclusions Students identified a number of barriers to clinical contact with patients. This research suggests that access to clinical contact could be improved.

Clinical contact is seen as a critically important component of medical education.1 There are no previous studies exploring students’ perceptions of barriers to contact although the broader literature on medical education raises both internal and external factors that may play a part.

A New Zealand study found that students spend substantially less time than stipulated in the curriculum, with a considerable variation in the amount of time individual students have with patients (range 39–299 minutes per week, mean 128.2 minutes, SD 84.76).2 The authors suggested a number of possible reasons for the low level of contact. Some students may have seen no great need for patient contact, given the pressures of other commitments and low reinforcement for patient contact (no direct contribution to grades). The allocation system via notice boards may have caused problems or allowed avoidance due to its indirect nature. Students may have lacked confidence and felt uncomfortable with ill-defined roles.

The current study arose out of frequently expressed concerns by fourth year medical students that they were not seeing enough patients.

Method

Study development—In order to develop a questionnaire, 12 fifth-year medical students were selected randomly and invited to participate in a focus group, facilitated by two of the researchers. Consent was obtained from the students and from the Curriculum Committee, which has oversight of curriculum management and development. This was a single meeting lasting 90 minutes. The students were informed that we had come up with 27 possible factors in the literature that ‘may get in the way’ of contact with patients during attachments. The students were asked to comment on their own experiences of gaining clinical contact and were then given the list of factors and asked to comment on their relevance. Students were assured of the confidentiality of their responses and no identifying information was made available to anyone other than the authors of the study.

The students were enthusiastic about the research and commented that they felt it needed to be done. All students invited to the focus group attended. On the basis of the students’ feedback, the questionnaire was refined down to 25 possible factors (see Appendix 1).

Students entering their fifth year of study were contacted by email during the orientation period, before the start of the formal academic year. They were asked to remain in a lecture theatre (following a lecture), for about 15 minutes to complete a confidential questionnaire regarding their experience of fourth year attachments, focussing particularly on patient contact.

Data collection and analysis—The questionnaire (see Appendix 1) listed 25 possible ‘barriers’ to contact and asked students to rate these on 6-point Likert scales, from ‘never’ to ‘always’. The students’ responses were scored by the investigators from 0 (never) to 5 (always).

Two open-ended questions asked students whether achieving clinical contact became any easier as the year progressed and what Medical School staff organisation could do to help students overcome any barriers to clinical contact. Returned questionnaires were anonymous, but did ask for gender and ethnicity.

For the purposes of the data analysis, the researchers divided the questionnaire items into 13 ‘internal’ factors and 12 ‘external’ factors. Internal factors were items relating to how students thought and felt about themselves and their skills. External factors were situational or systemic factors related to the clinical placement such as availability of supervision. High scoring items were defined as scores of three or more (out of a maximum of five) while Low scoring items were defined as two or less (out of five).

Results

There were 70 students in the fifth-year class and 45 (64%) chose to complete the questionnaire about their experiences of the fourth-year clinical placements. Some students were not present when asked to complete the questionnaire, while others chose not to participate.

Twelve of the participating students were male and 30 were female; three students declined to respond to the gender question. Thirty-one students identified as Pakeha (New Zealand European), one as New Zealand Māori, three as Pacific Nations (e.g. originating from Samoa, Tonga, Cook Islands), and five identified as being from other ethnic groups; five declined to respond to the ethnicity question.

High and low scoring items, the associated mean scores, and the percentage of students endorsing these items as a barrier (i.e. percentage rating the item above zero), are summarised in the Table 1 and Table 2 respectively. High scoring responses as summarised in Table 1, suggested many students were concerned about the level of patient illness; were uncertain about which patients (and how many) it was appropriate for them to see and they had concerns about seeming incompetent or failing to grasp the significance of clinical symptoms. They also expressed difficulties with being assertive and with supervisor availability.

Table 1. High scoring student responses to patient contact survey

High scoring questions	Mean	Percentage endorsed
I am concerned that the patient is too ill/has too much going on to see me	3.6	80
The person who supervised me was too busy	3.5	82
I find it hard to be assertive in arranging to see patients	3.3	76
I worry about seeming incompetent/getting the clinical significance of symptoms wrong	3.2	71
I am not sure how many patients I need to see to learn clinical skills	3.2	80
I am not sure which patients are appropriate for me to see	3.1	69

Responses measured on Likert scale: 0 (never) to 5 (always).

Low scoring responses, as depicted in Table 2, suggested that there was little concern about: patient refusal; patients denying examinations on the basis of student gender or patient consent being requested in a way that encouraged refusal. Similarly, concerns about: causing cultural offence; about managing emotional responses to patients; about discussing patients’ personal or emotional matters; and worries about aggressive behaviour by patients were not strongly or frequently endorsed by students.

Table 2. Low scoring student responses to patient contact survey

Low scoring questions	Mean	Percentage endorsed
Patient or staff deny examination due to my gender	0.6	5
I find that a lot of patients refuse to be seen by a student	1.3	16
Patient consent is requested in a way that encourages refusal	1.4	22
I worry about offending patients from other cultures	1.5	18
I am concerned about my ability to manage my emotional reactions (e.g. getting upset or laughing)	1.6	27
I worry about aggressive behaviour from drunk/psychotic patients	1.6	24
I don’t feel comfortable discussing patients’ personal or emotional matters with them	1.8	27

Responses measured on Likert scale: 0 (never) to 5 (always).

Table 3 shows that female students endorsed a number of questionnaire items more strongly than male students. Females reported being more worried about seeming incompetent, being humiliated by senior staff, and lacking confidence in their basic clinical skills. It was not possible to assess statistically whether there were any cultural differences in student responses due to small numbers.

Table 3. Male and female student responses to questionnaire items

Item	Male (mean)	Female (mean)
I worry about seeming incompetent/getting the clinical significance of symptoms wrong	2.1	3.5
I had to learn clinical skills from a textbook, rather than a demonstration	1.9	3.0
I worry about being humiliated by senior staff if I make a mistake	2.0	3.2
I have difficulty justifying the role (don’t think I am helping the patient)	1.5	2.3
I lack confidence in basic clinical examination skills	2.4	3.1

Responses measured on Likert scale: 0 (never) to 5 (always).

A t-test was conducted to evaluate the relative impact of internal and external barriers. No statistically significant difference was found between internal factors (M=30.43, SD=9.34) and external factors (M=27.77, SD=7.15), t (42)=1.97, p=0.055).

A t-test was conducted to compare scores on external factors for males and females. There was no significant difference in scores for males (M=26.17, SD=7.02) and females (M=29.38, SD=6.78, t (41)=1.37, p=0.18).

A t-test was conducted to compare scores on internal barriers for males and females. These was a significant difference in scores for males (M=23.58, SD=8.21), and females (M=32.66, SD= 9.32, t (41)=2.93, p=0.006).

The magnitude of the differences in the means was very small (eta squared=0.011). Students were asked if they found it easier to get clinical contact as the year passed. Responses from this open-ended question were grouped into themes. Students who endorsed ‘yes’, reported an increase of confidence in themselves, in approaching patients directly or asking for help from others (n=22, 49 %). Others reported being more assertive or proactive (n=5, 11%), or becoming less concerned about bothering patients or receiving a negative reaction (n=4, 8 %).

Not all students found initiating clinical contact became easier over time. Nine percent (n=4) reported the level of clinical contact depended on the attachment, the doctors taking an interest and / or the organisation of the attachment. Other responses included students continuing to feel they were imposing on patients for their own benefit, worrying they were bothering or intruding on the patients, that initiating clinical contact became harder over time as their sense of inadequacy increased, they became lazy, or the incentives seemed inadequate.

Students were asked what the Medical School could do to help them overcome any barriers to clinical contact. Suggestions included assigning students to a clinical team on attachment (n=4, 9 %), and to organise lots of early clinical contact/bedside teaching to build up confidence (n=4, 9%). Other students favoured teaching more clinical skills in the orientation course and ensuring that all basic examination skills are covered (n=6, 13%).

Some students suggested making the number of expected patient contacts clear or making a set number compulsory (n=6, 13 %). Finally, some suggested more one to one or small group teaching would be helpful, increasing the number of tutorials, and encouraging house surgeons to do more one to one teaching (n=3, 7 %).

Discussion

The results of this study suggest that the students surveyed perceived both internal and external barriers to clinical contact with patients, with no significant difference between internal and external barriers. Some gender difference was found in terms of females endorsing internal barriers slightly more. Patients being too ill; insufficient supervision; difficulties with being assertive; worries about seeming incompetent; uncertainty about how many patients they are required to see; and who may be appropriate were endorsed most frequently as barriers—while gender discrimination; patient refusal; and cultural issues were not strongly endorsed as barriers.

Having a helpful supervisor, doctor, or nurse to indicate whom it is appropriate to see was seen by many as helpful in assisting them to see patients and most students reported that they found it easier to get clinical contact as the year progressed. High scoring external factors such as the supervisor being too busy, may be amenable to systemic changes such as delegation to others in the team to assist with appropriate patient selection. The high rating by students of uncertainty as to how many patients it is appropriate for them to see during attachments, suggests that giving students clear expectations regarding the amount of clinical contact would be helpful.

This study has some limitations. Firstly, the results need to be interpreted with caution. They reflect the views of only 45 students out of 70 in 1 year. The result may have been biased due to the possibility that students who chose to complete the questionnaire may have been those who felt the most strongly about patient contact or had the most difficulty seeing patients.

‘Patient contact’ was not specifically defined because in this context it is widely accepted that this means face-to-face contact with patients. The questionnaire used was developed for the study and no reliability/validity data is available. It is possible that some items in the questionnaire may not actually be related to ease of patient contact. For example, students may worry about becoming infected, but this may have no bearing on the likelihood of them having contact with the patient.

The researchers’ method of dividing scores into ‘high’ and ‘low’ scores is arbitrary. Further, the division of items into ‘internal’ and ‘external’ by the researchers is also arbitrary. For example ‘I lack confidence in basic clinical skills’, could be seen as an internal factor relating to that students’ low self-confidence or as an external factor in terms of inadequate training and practice.

While there was no significant difference between ‘internal’ and ‘external’ factors, this may be misleading: with a larger sample, significant differences may have emerged. It is difficult to draw firm conclusions from the open questions, as there were almost as many different responses as students.

Too little supervision and worries about causing discomfort were identified as barriers, consistent with O’Sullivan, Martin and Murray (2000).3 Worries about seeming incompetent or getting the clinical significance of symptoms wrong were also identified as barriers, consistent with Moss and McManus (1992)4 who found that interaction with senior staff on ward round was anxiety provoking, particularly related to getting diagnoses wrong or admitting ignorance.

Concern about patients being too ill was highly rated by a barrier in this study and is consistent with Hajek, Najberg, and Cushing’s (2000)5 identification of concerns about communication with patients who are in pain or experiencing negative emotions. Further, concern that patients may have too much going on is consistent with Seabrook’s (2004)6 finding that students often perceived that they were ‘in the way’.

While there are several studies in the medical education literature which suggest that perceived verbal abuse by senior staff is common,7–9 for the students surveyed in this study worries about being humiliated by senior staff if they made a mistake did not seem to be a common issue.

High workload has been identified as a major stress in medical school,10,11 however students did not rate high workload as an important barrier to patient contact. Fears of infection, anxiety about performing basic clinical tasks, and dealing with drunk or abusive patients, (identified by one study),4 also did not stand out as barriers to contact in the group surveyed.

Students have been described as feeling daunted due to feeling ill prepared for clinical attachments, in terms of knowledge or style of learning required.6 However, the students in this study did not identify concerns about interviewing or clinical skills as being important barriers to patient contact. This suggests they came to their attachments feeling adequately prepared.

It would be interesting to replicate this study in other medical schools in order to ascertain the extent to which the barriers we identified are similar to other medical schools. This study raises the question as to whether an intervention can be designed to improve the level of student access to patients for learning purposes.

One idea may be to try to target the problem group of students for intervention once the year has progressed. This study found that most got better at accessing contact, but 9% found that (for various reasons) barriers persisted or even increased. It may be possible to those students and design remedial interventions that are tailored to the individual student.

Patient contact is a valuable resource in medical education. It is important that students have access to this, and that they make full use of that access. Medical doctors have a duty to patients to ensure that the best use is made of their generosity. This research suggests that there may be ways in which this resource can be used better.

Competing interests: None known.

Correspondence: Fiona Mathieson, Department of Psychological Medicine, Otago University, Wellington, PO Box 7343, Wellington South, New Zealand. Email: Fiona.mathieson@otago.ac.nz

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