Journal of Osteopathic Medicine, 2002; 5(1):8-15 © 2002 Research Media

Original Article

Student and patient perspectives on the interaction between supervisors, students and patients during the clinical teaching experience at a university out-patient clinic: a descriptive pilot study

A Robertson, P Gibbons, A Carter School of Health Sciences, Victoria University

Abstract

Study objective: To determine student and patient perspectives orl clinical teaching in an out- patient setting. Design: Questionnaire using fixed-response, 5-point Likert scales, yes/no response and open comments. Setting: The Osteopathic Medicine Clinic, Victoria University, Australia.

Participants: 100 patients and 152 senior clinical students and graduates.

Measurements and main results: 96% of students found out-patient teaching to be a valuable way of gaining professional skills. 92% strongly agreed or agreed that out-patient teaching is an effective way to develop skills in history taking, conducting physical examinations (87%), enhancing communication skills (85%), and to develop record keeping (72%) and time-management skills (60%). The preferred location for the presentation of patient cases was in the tutorial room away from the patient. 100% of patients indicated that they were comfortable with the history taking in the out-patient setting with 84% of patients indicating that their experience of out-patient teaching would make them more likely to refer other patients. 96% of patients indicated that out-patient teaching did not make them anxious with 84% reporting that the clinical discussion of their case increased their knowledge of their clinical problem. 27% of patients suggested that there were some aspects of the clinical discussion that they didn't understand with 4% of patients finding that some discussion was inappropriate. Conclusions: Clinical teaching is a significant aspect of any medically focussed program of study. The clinical teaching environment should be a positive learning experience for the student while also providing for quality care of the patient. Reviews of student and patient perspectives regarding the out-patient teaching environment can be effective tools to inform curriculum development and clinic management. Key Words: clinical teaching, out-patient teaching student perspectives, patient perspectives, osteopathy, medical education, patient-practitioner interaction

INTRODUCTION

Clinical teaching is an integral component of the syllabus in most medically oriented university courses. Amongst the medical and health science professions this type of teaching occurs in out-patient clinics, hospital wards, operating theatres and other consulting rooms. Clinical teaching is defined as 'teaching that involves the presence of the patient, the student/s, and the qualified supervisor.'

Andrea Robertson, BSc, MHSc; Peter Gibbons, MBBS, DO, DMS- Med; Annie Carter, MBBS, GradDipOccHlth, BA(Hons), School of Health Sciences, Victoria University, Melbourne Australia

Address correspondence to: Associate Professor Peter Gibbons, School of Health Sciences, City Campus, Victoria University, PO Box 14428 MCMC VIC 8001 Australia. peter.gibbons @ vu.edu.au

As so much importance is placed upon clinical teaching and the patient/student interaction in a 'real world' setting it is important to ensure that the learning potential of that interaction is maximised for the benefit of the student and ultimately their patients. Patient and student perspectives regarding clinical teaching have the potential to inform course designers and co-ordinators as to the perceived effectiveness of this type of learning interaction and the environment in which it occurs.

A number of studies exploring the perspectives of both patients and students on clinical teaching have been conducted. Most of this research has been undertaken in the hospital setting with ward patients and medical students as participants. Some studies investigated the patient's perspectives on the experience of clinical teaching ~-7 others

© 2002 Research Media Robertson A, et al. Student and patient perspectives on clinical teaching within a university out-patient clinic.

investigated the student's perspectives, 8,9 and some inves- tigated both. 1°'11

Nair et al. 1° investigated student's perspectives on clinical teaching and did not fred any differences between year levels, nor any differences between undergraduates and graduates. This same study found that most students feel that clinical teaching is beneficial, and is the most effective way of learning professional skills. Students, however, do not always agree that they have received enough clinical teaching during their undergraduate training.

The presentation of patient cases is an important component of clinical teaching with previous studies reporting student preference to hold case-history discussions away from the patientJ °,11 Patients may prefer the discussion to occur in their presence as this can increase their knowledge of their disease or illness, 2,5 however, the converse can be true for some patients as this carries the potential for them to find out things about their clinical problem which they would rather not have discovered. 7

Patients can enjoy clinical teaching and it does not make them anxious, 2,1° however, this is not always the case as some patients report discomfort after students have taken their case history, 3 and some report embarrassment during the consultation. 6 Another important consideration in the clinical teaching environment is the maintenance of patient confidentiality. 1°,12

An effective clinical teaching environment is one that can accommodate the differing learning styles and approaches of students while meeting the expectations of patient care and communica t ion expected by a diverse pat ient population. Most previous research has been undertaken in hospitals and in the ward setting. While there are certain generalisations that can be made about clinical teaching no studies exist that took specifically at student and patient perspectives on out-patient teaching (OPT) in an Australian university osteopathic medicine program. The patient population generally presents with musculoskeletal dysfunction within teaching clinics that are not publicly funded. Patients are required to pay a fee for service despite the clinics being housed within the university setting. Are there similarities in patient and student perspectives to clinical teaching that cross discipline boundaries and clinical settings?

The purpose of this study was to determine student and patient perspectives on clinical teaching within a university out-patient clinic.

M E T H O D

Participants

The Human Research Ethics Commit tee of Victoria University approved this study. Participants were informed of the nature and purpose of this study prior to giving their consent.

Patients

One hundred new and return patients who attended the Osteopathic Medicine Clinic at Victoria University between November 1999, and March 2000, were invited to participate in the study.

Students and Graduates

All third, fourth and fifth year students and graduates from the osteopathic medicine program at Victoria University were invited to participate in the study.

Measures

Two questionnaires were used which were modified and expanded versions of the questionnaires used by Nair, Coughlan & Hensley. 1° They were adapted to reflect an out- patient teaching (OPT) environment. Questionnaires used fixed-response, 5-point Likert scales, yes/no response and open comments.

Patient Questionnaire

A two-page , twenty quest ion, se l f -admin is te red questionnaire asked the participant's their age, gender, and whether they were a new or a return patient. The participants were also asked questions regarding comfort, awareness of OPT, anxiety, confidentiality, future referral, and quality of care.

Student Questionnaire

A two-page, ten question, self-administered questionnaire asked the participant's their age, gender, current educational status and whether OPT was valuable in the development of specific professional skills. Additional questions sought perspectives upon the most appropriate site for case discussion/presentation to occur.

RESULTS

Patient Results

The response rate for the patient questionnaire was 51%. The mean age was 43 (age range 21-73 years) comprising 52% male and 48 % female patients. Patient responses are shown in Table 1.

Student and Graduate Results

A total of 152 questionnaires were distributed of which 52% were completed and returned. 29% of respondents were graduates, 44% were 5 'h year, 46% were 4 ~ year and 73% were 3 rd year. Of all respondents, 44% were male and 56% were female which represents the gender distribution within this population of students and graduates. The mean age was 25 (age range 20-47 years). Student and graduate responses relating to development of specific professional skills are shown in Table 2.

The questionnaire sought to explore student and graduate perceptions on the most appropriate site for students and

Journal of Osteopathic Medicine, 2002; 5(1):8-15 @2002 Research Media

Table 1. Patient responses (n=51)

Yes % (n) No % (n) No Response % (n)

Have you been a patient at the Osteopathic Medicine Clinic at Victoria University prior to today? 68.6 (35) Did you experience clinical teaching during your last treatment at the Osteopathic Medicine Clinic? 80.4 (41) Were you comfortable during the:

History? 100 (51) Examination? 100 (51) Discussion of diagnosis? 98.0 (50)

Did you have any concerns with the: History? 2.0 (1) Examination? 2.0 (1) Discussion of diagnosis? 2.0 (1)

Were you aware of what was involved within the clinical teaching environment? 72.5 (37) Were you aware of the number of students who would be present? 58.8 (30) Did the practitioner and student act as if you were not there? 5.9 (3) Did you feel excluded from the discussion? 7.8 (4) Was there anything that you didn't understand about the discussion? 27.4 (14) Did you feel you could ask for clarification if you didn't understand something? 98.0 (50) Was any discussion inappropriate? 3.9 (2) Did the discussion increase your knowledge of your illness or disease? 84.3 (43) Did you find out things about your illness or disease which you would rather have not found out? 7.8 (4) Did the clinical teaching make you anxious? 2.0 (1)

31.4 (16) 0 (0)

15.7 (8) 3.9 (2)

0 (0) 0 (0) 0 (0) 0 (0) 2.0 (1) 0 (0)

98.0 (50) 0 (0) 98.0 (50) 0 (0) 98.0 (50) 0 (0)

25.5 (13) 2.0 (1)

39.2 (20) 2.0 (1) 92.1 (47) 2,0 (1) 88.2 (45) 4.0 (2)

72.6 (37) 0 (0)

2.0 (1) 0 (0) 96.1 (49) 0 (0)

15.7 (8) 0 (0)

90.2 (46) 2.0 (1) 96.0 (49) 2.0 (1)

Yes % (n) No % (n) Unsure % (n) No Response % (n)

Do you think that clinical teaching breaches confidentiality? 3.9 (2) 86.3 (44) 5.9 (3) 3.9 (2) Do you think that the level of fees are appropriate for a student clinic which utilizes clinical teaching? 86.3 (44) 2.0 (1) 7.8 (4) 3.9 (2)

More Likely % (n) Less Likely % (n) No Response % (n)

Does clinical teaching make it more likely or less likely for you to refer other people to participate in clinical teaching? 84.3 (43) 2.0 (1) 13.7 (7)

Better % (n) Worse % (n) No Response % (n)

If you have previously been elsewhere, would you consider that the quality of treatment and care in the following areas was better or worse at the Osteopathic Medicine Clinic?

Examination Diagnosis Treatment

62.7 (32) 2.0 (1) 35.3 (18) 56.8 (29) 2.0 (1) 41.2 (21) 60.7 (31) 4.0 (2) 35.3 (18)

clinicians to discuss patient cases and the reasons for the responses (Table 3).

D I S C U S S I O N

Professional Skills

Students and graduates of the osteopathic medicine program at Victoria University regard OPT as a valuable way to gain professional skills (96%). This is consistent with the results for medical students found by Nair et al.10

Nair et al. reported no important differences in responses from students, interns and residents with respect to opinions about the effectiveness of bedside teaching. 1° Amongst the student and graduate population surveyed in this study there

were differing perspectives between year levels and gradu- ates for some areas of professional skill development.

Students and graduates believe that OFF is an effective way to develop communicat ion skills (85%). This result is consistent across all student year levels and graduates, however, there is a stronger level of agreement amongst the 3 rd year students and graduates. A possible reason for this is that senior (masters degree - 4 ~ & 5 ~ year) students assume the 'p rac t i t ioner ' role in the student-pat ient relationship, whereas in clinical consultations 3 rd year students act as observers or take less responsibility within the patient consultation. It is possible that some senior students may lack confidence in their ability to communicate with patients and consequently doubt the role of OPT in developing their communication skills. Overall the results

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© 2002 Research Media Robertson A, et al. Student and patient perspectives on clinical teaching within a university out-patient clinic.

Table 2. Student and graduate responses to questions relating to the development of specific professional skills. (n = 79)

Strongly Agree Neither Disagree Strongly Agree % (n) % (n) Agree or % (n) Disagree

Disagree % (n) % (n)

No Response % (n)

Do you agree that clinical teaching in the Osteopathic Medicine Clinic is an effective way to develop these skills?

Communicating with patients 3 r~ Year 64.7 (11) 29.4 (5) 5.9 (1) 0 (0) 0 (0) 0 (0) 4 ~ Year 42.9 (15) 37.1 (13) 5.7 (2) 11.4 (4) 0 (0) 0 (0) 5 th Year 53.3 (14) 33.3 (5) 6.7 (1) 0 (0) 6.7 (1) 0 (0) Graduates 45.5 (5) 45.5 (5) 9.1 (1) 0 (0) 0 (0) 0 (0)

Obtaining medical histories 3 'd Year 70.6 (12) 29.4 (5) 0 (1) 0 (0) 0 (0) 0 (0) 4 'h Year 45.7 (16) 40.0 (14) 5.7 (2) 5.7 (2) 0 (0) 2.9 (1) 5 th Year 73.3 (11) 26.7 (4) 0 (0) 0 (0) 0 (0) 0 (0) Graduates 72.7 (8) 27.3 (3) 0 (0) 0 (0) 0 (0) 0 (0)

Conducting physical examinations 3 r~ Year 47.1 (8) 47.1 (8) 5.8 (2) 0 (0) 0 (0) 0 (0) 4 ~h Year 40.0 (14) 51.4 (18) 5.7 (2) 2.9 (1) 0 (0) 0 (0) 5 th Year 53.3 (8) 26.3 (4) 13.3 (2) 6.7 (1) 0 (0) 0 (0) Graduates 54.6 (6) 27.3 (3) 9.1 (1) 9.1 (1) 0 (0) 0 (0)

Applying basic scientific knowledge 3 rd Year 23.5 (4) 64.7 (11) 11.8 (2) 0 (0) 0 (0) 0 (0) 4 • Year 14.3 (5) 45,7 (16) 22.9 (8) 17.1 (6) 0 (0) 0 (0) 5 th Year 13.3 (2) 46.7 (7) 13,3 (2) 13.3 (2) 13.3 (2) 0 (0) Graduates 27.3 (3) 54,6 (6) 18.2 (2) 0 (0) 0 (0) 0 (0)

Record keeping 3 re Year 17.7 (3) 52.9 (9) 23.5 (4) 0 (0) 0 (0) 5.9 (1) 4~ Year 31.4(11) 37.1 (13) 17.1 (6) 8.6(3) 2.9(1) 2.9(1) 5 th Year 40.0 (6) 33.3 (5) 13.3 (2) 13.3 (2) 0 (0) 0 (0) Graduates 54.6 (6) 36.4 (4) 9.1 (1) 0 (0) 0 (0) 0 (0)

Evidence-based medicine 3 re Year 17.7 (3) 41.2 (7) 23,5 (4) 5.9 (1) 5.9 (1) 5.9 (1) 4 th Year 11.4 (4) 28.6 (10) 40.0 (14) 14.3 (5) 5.7 (3) 0 (0) 5 ~' Year 13.3 (2) 6.7 (1) 26,7 (4) 46.7 (7) 6.7 (1) 0 (0) Graduates 18.2 (2) 27.3 (3) 54.6 (6) 0 (0) 0 (0) 0 (0)

Self-directed learning 3 re Year 41.2 (7) 47.1 (8) 11.8 (2) 0 (0) 0 (0) 0 (0) 4 th Year 25.7 (9) 42.9 (15) 20.0 (7) 8.6 (3) 2.9 (1) 0 (0) 5 t~ Year 26.7 (4) 33.3 (5) 20.0 (3) 6.7 (1) 0 (0) 13.3 (2) Graduates 9.1 (1) 54.6 (6) 9.1 (1) 18.2 (2) 9.1 (1) 0 (0)

Time-management 3 r~ Year 17.7 (3) 52.9 (9) 23.5 (4) 5.9 (1) 0 (0) 0 (0) 4 ~ Year 25.7 (9) 34.3 (12) 20.0 (7) 14.3 (5) 5.7 (2) 0 (0) 5 th Year 33.3 (5) 33.3 (5) 6.7 (1) 6.7 (1) 13.3 (2) 6.7 (1) Graduates 18.2 (2) 36.4 (4) 18.2 (2) 18.2 (2) 9.1 (1) 0 (0)

Yes °/o (n) No % (n) No Response % (n)

Did you receive enough clinical teaching in these skills? Communicating with patients

3 'd Year 41.2 (7) 47.1 (8) 11.8 (2) 4 th Year 40.0 (14) 57.1 (20) 2.9 (1) 5 ~ Year 33.3 (5) 60.0 (9) 6.7 (1) Graduates 63.6 (7) 36.4 (4) 0 (0)

Obtaining medical histories 3 'd Year 82.4 (14) 11.8 (2) 5.9 (1) 4 ~ Year 71.4 (25) 28.6 (10) 0 (0) 5 th Year 86.7 (13) 6.7 (1) 6,7 (1) Graduates 90.9 (10) 9.1 (1) 0 (0)

Conducting physical examinations 3 ra Year 70.6 (12) 23.5 (4) 5.9 (1) 4 th Year 68.6 (24) 31.4 (11) 0 (0) 5 th Year 73.3 (11) 13.3 (2) 13.3 (2) Graduates 72.7 (8) 18,2 (2) 9.1 (1)

Applying basic scientific knowledge 3 ra Year 70.6 (12) 23.5 (4) 5.9 (1) 4 ~ Year 45.7 (16) 54.3 (19) 0 (0) 5 t~ Year 73.3 (11) 20 (3) 6.7 (1) Graduates 72.7 (8) 27.3 (3) 0 (0)

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Journal of Osteopathic Medicine, 2002; 5(1):8-15 © 2002 Research Media

Table 2. Continued

Yes % (n) No % (n) No Response % (n)

Record keeping 3 rd Year 70.6 (12) 23.5 (4) 5.9 (1) 4 ~ Year 60 (21) 40 (14) 0 (0) 5 th Year 33.3 (5) 60 (9) 6.7 (1) Graduates 90.9 (10) 9.1 (1) 0 (0)

Evidence-based medicine 3 r~ Year 47.1 (8) 35.3 (6) 17.7 (3) 4" Year 37.1 (13) 57.1 (20) 5.7 (2) 5 th Year 60 (9) 33.3 (5) 6.7 (1) Graduates 63.6 (7) 36.4 (4) O (0)

Self-directed learning 3 'a Year 58.8 (10) 35.3 (6) 5.9 (1) 4 t" Year 54.3 (19) 40 (14) 5.7 (2) 5 ~ Year 73.3 (11) 13.3 (2) 13.3 (2) Graduates 54.6 (6) 36.4 (4) 9.1 (1)

Time-management 3 ~ Year 41.2 (7) 52.9 (9) 5.9 (1) 4 ~ Year 28.6 (10) 71.4 (25) 0 (0) 5 ~ Year 53.3 (8) 40 (6) 6.7 (1)

Graduates 45.5 (5) 45.5 (5) 9.1 (1)

Table 3. Student and graduate responses to questions relating to case presentation. (n = 79)

Yes % (n) No % (n) Unsure % (n) No Response % (n)

Do you consider clinical teaching to be a valuable way to gain professional skills? Do you think that patients enjoy clinical teaching? Do you consider clinical teaching to be a valuable way to gain professional skills?

H

96.2 (76) 0 (0) 2.5 (2) 392 (31) 3.8 (3) 55.7 (44)

96.2 (76) 0 (0) 2.5 (2)

Agree % (n) Do not agree % (n)

1.3 (1) 1.3(1)

1,3 (t)

Where do you consider new patient case presentations are best conducted?

In the consultation room with the patient present In the tutorial room separate from the patient In the clinic corridors separate from the patient A combination of being in the consultation room with the patient present and in the tutorial room separate from the patient Other

Where do you consider return patient case presentations are best conducted?

In the consultation room with the patient present In the tutorial room separate from the patient In the clinic corridors separate from the patient A combination of being in the consultation room with the patient present and in the tutorial room separate from the patient Other

If you consider that new patient case presentations are best conducted away from the patient, for what reasons?

Don't want to hurt the patient's feelings Don't want to confuse the patient Don't want to make the patient anxious Don't want possible lack of knowledge displayed in front of the patient Other

If you consider that return patient case presentations are best conducted away from the patient, for what reasons?

Don't want to hurt the patient's feelings Don't want to confuse the patient Don't want to make the patient anxious Don't want possible lack of knowledge displayed in front of the patient Other

o (o) lO0 (79) 67.1 (53) 32.9 (26) 2.5 (2) 97.5 (77)

27.9 (22) 72.1 (57) 2.5 (2) 97.5 (77)

6.3 (5) 93.7 (74) 55.7 (44) 44.3 (35) 1.3 (1) 98.7 (78)

34.2 (27) 65.8 (52) 2.5 (2) 97.5 (77)

24.1 (19) 75.9 (60) 51.9 (41) 48.1 (38) 72.2 (57) 27.8 (22)

41.8 (33) 58.2 (46) 25.3 (20) 74.7 (59)

16.5 (13) 83.5 (66) 40.5 (32) 59.5 (47) 64.6 (51) 35.4 (28)

32.9 (26) 67.1 (53) 12.7 (lO) 87.3 (69)

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© 2002 Research Media Robertson A, et al. Student and patient perspectives on clinical teaching within a university out-patient clinic.

of this study are comparable with Nair et al.l° who reported that 90% of students felt that bedside teaching was an effective way to develop communication skills.

96% of students believe that OPT is an effective way to develop medical history taking which is consistent with the findings of previous studies. 8,1° This is not surprising as history-taking skills are taught before OPT begins and reinforced with every patient interaction during the clinical years.

The overall response that OPT is an effective way to develop physical examination skills (87%) is similar to the findings of Walker et al. (80%), 8 yet not as positive as the findings of Nair et al. (99%). l° Over the different year levels there is less agreement, with the 5 th year students and graduates being less positive compared to the 3 ra and 4 ~ year students. The classroom curriculum teaches the same physical examination skills to all students in the early years of the osteopathic medicine at Victoria University. The difference between year levels may be because the reinforcement of physical examination skills in the clinical setting is subject to high levels of variability as a result of individual practice style of supervisors and the unpredictable nature of the clinical environment. 10

Overall, OPT is regarded as a less effective way to apply basic scientific knowledge. This differs from reports by other authors who argue that the bedside can be an appropriate site for reinforcing the teaching of basic sciences. 9,1° Results from this study show low agreement levels for 4 th and 5 ~ year students at 60%. It is possible that these results reflect the variability in teaching style and content received from different clinical supervisors. Masters students (4 t~ & 5 th year) are also expected to take responsibility for their own learning and may not be utilising the clinical environment to integrate basic science knowledge. It is also possible that these students receive greater integration of the basic and clinical sciences within their classroom settings and therefore do not value the clinical environment as highly for the development of this skill.

72% percent of students and graduates agree that OPT is an effective way to develop record keeping skills. This is a much higher value than Nair et al. who found only 55% agreement? ° This is likely to reflect the fact that students within the osteopathic medicine clinic are required to record the full historical and examination findings for each patient as the patient's permanent record of attendance whereas in many medical schools students are not permitted to record information within the patients notes.

One might expect that the clinical environment would provoke critical reflection upon case presentations and clinical findings and that this would be an impetus for student development of skills in self-directed learning. Despite that expectation, Nair et al. found only 63% of respondents believed that clinical teaching was an effective way to develop self-directed learning skills. ~° Comparable results were identified in this study (70%) and may reflect an accurate response to the question relating to clinical teaching

13

more than views as to the nature of the clinical environ- ment stimulating skill development in self-directed learn- ing. Perhaps the question would have been better phrased "does the clinical environment (or access to real patients) encourage development of self-directed learning skills".

Students are not confident that OPT is an effective way to develop time-management skills (agree = 62%; disagree -- 18%). There are increasing levels of disagreement with increasing year level (3 rd yr -- 6%; 4 a yr -- 20%; 5 ~ yr -- 20%; graduates = 27%). It is possible that because 3 ra year students act as observers during clinical consultations and are not in charge of consultation time, they are not aware of time-management as an important clinical skill. In the 4 th and 5 th year the students take responsibil i ty for maintenance of appointment schedules. A possible reason that they may disagree with OPT as an effective means for the development of time-management skills is that clinical supervisors place emphasis upon clinical education rather than adhering to scheduled consultation times.

Overall students and graduates felt that they received sufficient OPT in medical history taking and conducting physical examinations. Respondents reported less agreement that OPT provided sufficient teaching in the application of basic scientific knowledge (60%), in self- directed learning (58%), evidence-based medicine (47%) and in time-management skills (38%).

Location of case presentations

Students and graduates felt the best location for OPT patient case presentations is in the tutorial room away from the patient. This finding applies to both new and return patients. Nair et al. and Wang-Cheng et al. also found that students prefer to present cases away from the bedside. ~°,11 Wang- Cheng et al. suggested that the reason students preferred to discuss case presentations away from the patient was because they had concerns for the patient's feelings, they didn't want to confuse the patient and they didn't want to make the patient anxious.11 Similarly, Nair et al. found the reasons g iven by students were pat ient comfor t , confidentiality and a desire to be polite.I°

In the OPT setting students and graduates preferred to present cases away from the patient primarily because they didn't want to make the patient anxious, however, they also didn't want to confuse the patient nor want their lack of knowledge displayed in front of the patient. Allowing students to present patient cases away from the patient gives them more freedom for discussion with their clinical tutor as well as other classmates, and allows them to explore different issues relevant to the patient's injury or disease. Nair et al. states that presenting cases in front of the patient 'places the student more formally at the centre of attention and requires a firm knowledge base and well developed communication skills to avoid patient confusion, to involve the patient in the process and to impart the right information in the right manner'.1° In the OPT setting a combination of the consultation room and the tutorial room may be the best answer as this facilitates a free ranging discussion as to the nature of possible differential diagnoses away from

of Osteopathic Medicine, 2002; 5(1):8-15 © 2002 Research Media

the patient and a more temperate explanation, without stu- dent concern of causing the patient undue anxiety, being given on return to the consultation room.

Patient perspectives

Generally, students are unsure if patients enjoy being participants in OPT. The majority of 3 rd year students felt that patients did enjoy the interaction while 4 ~ and 52 year students and graduates mostly answered 'unsure'. This differs to Nair et al. who found that students generally think that most patients enjoy the experience of clinical teaching.I° Do student perspectives reflect patient attitudes and experiences of the OPT setting?

Linfors & Neelon reported that 95% of patients found clinical teaching to be a positive experience, 2 while Nair et al. reported that 77 % of patients enjoyed bed-side teaching.I° Similarly 84% of patients responses on the OPT setting at Victoria University indicated that OPT would make it more likely for them to refer other people to the clinic. Patients reported high levels of comfort with the history taking, examination and discussion of diagnosis. In the hospital setting only 37% of patients felt they were properly forewarned about the nature of bedside teaching. 1° In the OPT setting 73% of patients indicated that they were aware of what was involved. An ideal outcome from a patient's perspective would be that all patients were adequately informed as to the nature of the clinical encounter.

6% of patients in this study felt that the practitioner and student acted as if they were not there. 27% of patients felt there were aspects of the discussion that they didn't understand but this was qualified by 97% stating that they felt they could ask for clarification if they didn't understand something. Only 4% felt that some discussion was inappropriate and 8% felt that they found out things about their illness or disease that they would rather not have discovered. For 84% of the patients discussion increased their knowledge of their clinical problem with only 4% reporting that OPT made them anxious. These results are comparable to previous s tud ie s . 2'6'7'1° Despite general patient comfort with the OPT setting students could be encouraged to focus upon their clinical teaching consultations to ensure that the patient is made the subject rather than the object of the process.

Comment

Questionnaires can be used to assess the value of courses and to modify course activities and objectives. 13 Although clinical competency may be the 'gold standard' by which students are assessed, their perceptions of educational experiences may assist the faculty to develop a better understanding of the process of clinical skill development.14 This study, while reporting upon student and patient perceptions of OPT, has also highlighted areas for future investigation that could be incorporated into the quality assurance/audit cycle. Is there an explanation for the differences exhibited between year levels and are these important markers for attention? Do they result from

variability between different clinical teachers, the extent of supervisor experience and knowledge, changes in curriculum structure and design, differing class sizes, demographics and availability of patients? This study looked only at perceptions of OPT and did not enquire as to the quality of clinical teaching experienced in the out-patient clinical setting.

CONCLUSION

Educationists cannot know which processes implemented to improve educational outcomes are effective unless they are rigorously tested. All educational initiatives must be constantly reviewed, refined and improved on the basis of ongoing curriculum evaluation. Where clinical teaching is such an important focus it is essential that both student and patient perspectives inform the process of review.

Students value highly many aspects of the clinical interaction that involve real patients in the out-patient setting. Patients appear to accept the nature of the educational environment and respond also in a generally favourable manner. It would seem that the benefits of bedside teaching are transferable f rom the bedside of in-pat ients to the out-pat ient consultation room. It also appears that the opinions of students on clinical teaching cross discipline boundaries with both medical and osteopathic students' perceptions on clinical teaching being remarkably similar. It is likely that the key aspect of the clinical learning experience is the interaction between a student and patient rather than the discipline area.

Contributors

Andrea Robertson contributed the original idea for the study which was then developed as a collaborative project involving all authors in the study design, development of the questionnaire, overall supervision and conduct of the study and data analysis and production of the final draft. Andrea Robertson carried out data collection and generated the first draft of the paper in collaboration with Peter Gibbons and Annie Carter.

Acknowledgements

The authors would like to thank the students, graduates and patients who kindly donated their time to participate in this study.

Funding: No funding was obtained.

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