Adherence to a national consensus statement on informed consent: medical students' experience of obtaining informed consent from patients for sensitive examinations.

AIM: To determine whether the guidance from the New Zealand medical programmes' national consensus statement on obtaining informed consent from patients for sensitive examinations are being met, and to explore medical students' experience of obtaining consent. METHOD: A self-reported, online, anonymous questionnaire was developed. Data were collected in the period just after graduation from final year medical students at The University of Auckland in 2019. RESULTS: The response rate was 35% (93/265). Most students reported that they were "not always compliant" with the national consensus statement for obtaining informed consent for almost all sensitive examinations. The main exception was for the female pelvic examination (not in labour) under anaesthesia, where most students reported being "always compliant". We identified factors related to students, supervisors, institution, and the learning context as reasons for lack of compliance. CONCLUSION: Adherence to the national consensus statement on obtaining informed consent for sensitive examinations is unsatisfactory. The medical programme needs to review the reasons for lapses in implementing the policy in practice, to ensure a safe learning environment for patients and our students.

Medical students' attitudes towards peer physical examination: findings from an international cross-sectional and longitudinal study.

Although studies have begun to shed light on medical students' attitudes towards peer physical examination (PPE), they have been conducted at single sites, and have generally not examined changes in medical students' attitudes over time. Employing both cross-sectional and longitudinal designs, the current study examines medical students' attitudes towards PPE at schools from different geographical and cultural regions and assess changes in their attitudes over their first year of medical study. Students at six schools (Peninsula, UK; Durham, UK; Auckland, New Zealand; Flinders, Australia; Sapporo, Japan and Li Ka Shing, Hong Kong) completed the Examining Fellow Students (EFS) questionnaire near the start of their academic year (T1), and students at four schools (Peninsula, Durham, Auckland and Flinders) completed the EFS for a second time, around the end of their academic year (T2). Univariate and multivariate analyses revealed a high level of acceptance for PPE of non-intimate body regions amongst medical students from all schools (greater than 83%, hips, at T1 and 94.5%, hips and upper body, at T2). At T1 and T2, students' willingness to engage in PPE was associated with their gender, ethnicity, religiosity and school. Typically, students least comfortable with PPE at T1 and T2 were female, non-white, religious and studying at Auckland. Although students' attitudes towards PPE were reasonably stable over their first year of study, and after exposure to PPE, we did find some statistically significant differences in attitudes between T1 and T2. Interestingly, attitude changes were consistently predicted by gender, even when controlling for school. While male students' attitudes towards PPE were relatively stable over time, females' attitudes were changeable. In this paper, we discuss our findings in light of existing research and theory, and discuss their implications for educational practice and further research.

Don't want to show fellow students my naughty bits: medical students' anxieties about peer examination of intimate body regions at six schools across UK, Australasia and Far-East Asia.

BACKGROUND: Although recent quantitative research suggests that medical students are reluctant to engage in peer physical examination (PPE) of intimate body regions, we do not know why. AIM: This article explores first-year medical students' anxieties about PPE of intimate body regions at six schools. METHODS: Using the Examining Fellow Students (EFS) questionnaire, we collected qualitative data from students in five countries (UK; Australia; New Zealand; Japan; Hong Kong) between 2005 and 2007. RESULTS: Our framework analysis of 617 (78.7%) students' qualitative comments yielded three themes: present and future benefits of PPE; possible barriers to PPE; and student stipulations for successful PPE. This article focuses on several sub-themes relating to students' anxieties about PPE of intimate body regions and their associated sexual, gender, cultural and religious concerns. By exploring students' euphemisms about intimate areas, our findings reveal further insights into the relationship between students' anxieties, gender and culture. CONCLUSION: First-year students are anxious about examining intimate body regions, so a staged approach starting with manikins is recommended. Further qualitative research is needed employing interviews to explore in depth students' anxieties about examinations of intimate body regions and how their views are shaped by interactions with peers, patients and doctors.

Medical students' attitudes to complementary and alternative medicine: further validation of the IMAQ and findings from an international longitudinal study.

BACKGROUND: Current research mainly employs cross-sectional designs to examine changes in medical students' attitudes towards complementary and alternative medicine (CAM). AIMS: This paper reports the findings of a longitudinal study to further validate the Integrative Medicine Attitude Questionnaire (IMAQ) and examine changes in medical students' attitudes over 3 years. METHODS: A total of 154 medical students from four schools in three countries completed a modified version of the IMAQ during their first (T1) and fourth year (T2). RESULTS: We established the validity of a three-factor model for the IMAQ: (1) attitudes towards holism; (2) attitudes towards the effectiveness of CAM therapies, and (3) attitudes towards introspection and the doctor-patient relationship. We found that IMAQ factor scores did not differ significantly from T1 to T2, emphasizing the relative stability in attitudes across time. Various student characteristics were significantly associated with IMAQ factor scores at T2: age, gender, CAM use, CAM education and school; and two variables (gender and CAM use) predicted changes in medical students' attitudes between T1 and T2. CONCLUSIONS: We urge medical educators to continue exploring medical students' attitude changes towards CAM and we provide examples of what further research is needed.

Understanding student concerns about peer physical examination using an activity theory framework.

CONTEXT: Peer physical examination (PPE) has been employed for several decades as part of the formal curriculum for learning clinical skills. Most of the existing studies exploring students' attitudes towards PPE are single-site and use quantitative methods. Currently, there is a lack of theoretical underpinning to PPE as a learning method. METHODS: Using an adaptation of the Examining Fellow Students questionnaire, we captured qualitative data from Year 1 medical students about their views and concerns around learning using PPE. The study was set in six schools across five countries (the UK, Australia, New Zealand, Japan and Hong Kong). Students provided free text comments that were later transcribed and analysed using framework analysis. RESULTS: A total of 617 students provided comments for analysis. This paper focuses on several related themes about the complexities of students' relationships within the context of PPE and their reflections on peer examination in comparison with genuine patient examination. Students drew parallels and differences between the peer examiner-examinee relationship and the doctor-patient relationship. They explained how these two types of relationship differed in nature and in terms of their levels of interaction. DISCUSSION: Our findings illuminate the interactional and complex nature of PPE, drawing out concerns and ambiguities around relationships, community and rules. We discuss our results in light of Engeström's model of activity theory (AT) and provide recommendations for educational practice and further research based on the principles of AT.

Multischool, international survey of medical students' attitudes toward "holism".

PURPOSE: Core and optional courses of study in complementary and alternative medicine (CAM) are being incorporated into medical curricula. The authors carried out this study to validate a tool to examine students' attitudes toward holism and CAM and explore the relationships between their attitudes and other demographic and education-related characteristics in a large, multischool, international sample of medical students. METHOD: In 2003 the authors used a modified version of the Integrated Medicine Attitude Questionnaire (IMAQ) to survey students at a total of six medical schools in the United Kingdom, New Zealand, Canada, the United States, and Hong Kong, China. A three-factor model was tested using confirmatory factor analysis, and the internal consistency of the factors were identified using Cronbach's alpha coefficients. A multiple-indicator multiple-cause (MIMIC) analysis was carried out to determine the relationship between IMAQ factors and student characteristics. RESULTS: The authors validated a three-factor model for the IMAQ: (1) attitudes toward holism, (2) attitudes toward the effectiveness of CAM, and (3) attitudes toward introspection and the doctor-patient relationship. Cronbach's alpha coefficients ranged from .41 to .71. The MIMIC model indicated that various background variables were associated with IMAQ factors (gender, race/ethnicity, and school), depending on whether students had previously visited a CAM practitioner and whether students were willing to undertake a special study module in CAM. CONCLUSIONS: Further development work on the IMAQ is required and qualitative research to verify and examine the reasons behind the relationships found in this study between students' attitudes to holism and their demographic and education-related characteristics.

A concordance-based study of metaphoric expressions used by general practitioners and patients in consultation.

BACKGROUND: All languages use metaphoric expressions; some deliberately chosen, some (for example, 'digesting information') not usually perceived as metaphoric. Increasingly, it is suggested metaphoric expressions constrain the way we conceptualise the world, as well as being a means of achieving stylistic effect. AIM: To study metaphoric expressions used by doctors and patients in general practice. DESIGN OF STUDY: Concordance-based language analysis of spoken data. METHOD: A database containing transcriptions of 373 consultations with 40 doctors in a UK general practice setting was scrutinised for metaphoric expressions, using 'concordancing' software. Concordancing enables identification of strings of text with similar lexical properties. Comparators (for example, 'like'), selected verb-types (for example, of feeling), and the verb 'to be' were used as starting points for systematically exploring the data. Quantitative and qualitative thematic methods were used in analysis. RESULTS: Doctors and patients use different metaphors. Doctors use mechanical metaphors to explain disease and speak of themselves as problem-solvers' and 'controllers of disease'. Patients employ a range of vivid metaphors, but fewer metaphors of machines and problem/solution. Patients use metaphors to describe symptoms and are more likely to use metaphoric language at the interface of physical and psychological symptoms ('tension, 'stress'). CONCLUSION: The different patterns of metaphoric expression suggest that doctors make limited attempts to enter the patients' conceptual world. This may not be a bad thing. One function of the consultation may be to reinterpret vivid and unique descriptions as accounts of the familiar and systemically comprehensible. Doctors may use different conceptual metaphors as a reassuring signal of expertise.

Exploration of the attitudes of nursing students to peer physical examination and physical examination of patients.

BACKGROUND: The use of peer physical examination (PPE) in early clinical skills has been studied amongst medical students. The majority of students are comfortable with using peer physical examination, when sensitive areas are excluded. Students' attitudes are related to their personal characteristics: gender, age, religious faith, and ethnicity. There is no data on nursing students' attitudes to peer physical examination. OBJECTIVES: Identify and explore: DESIGN: Dual cohort, cross-sectional, anonymous survey. SETTING: Three-year undergraduate nursing programme, skills centre and service clinical learning. METHODS: All first and third year nursing students were asked to complete a modified Examining Fellow Students questionnaire at the end of 2008. The questionnaire asked students to indicate which of 12 body areas they would not be willing to examine/have examined by a peer of the same/opposite gender. This study also asked students which of the 12 body areas they felt uncomfortable examining on patients. RESULTS: The response rate was 76% (128/168). The students were predominantly female (93% female; 7% male). Most students were comfortable with examining non-sensitive body regions of peers (78.2%-100% willing) and patients (92.3-100% willing). Male gender was significantly associated with willingness to examine and be examined by peers (p=0.001); Asian students were significantly less willing to engage in peer physical examination with opposite gender (p<0.007). Year 3 students were significantly more comfortable than Year 1 in examining patients of either gender (p<0.001). DISCUSSION AND CONCLUSIONS: In spite of the male gender findings, this predominantly female population expresses similar attitudes to the gender-balanced medical student studies - high acceptability for non-sensitive areas. The role of characteristics and attitudes to peer physical examination shows similarities and differences to other studies. Student characteristics were not related to patient examination attitudes.

Programmatic research in medical education: a national collaboration.

AIM: We aimed to identify areas that are a high priority for medical education research in New Zealand and that would benefit from a coordinated collaborative approach as an initial step in developing a coordinated research strategy. METHODS: A modified Delphi technique was used to reach consensus, among medical education researchers in New Zealand, on the optimal areas of activity. RESULTS: The programme of research fits under an overarching theme of "Growing a professional workforce". Seven key areas of activity have been identified: engaging in community and clinical learning environments; improving recruitment and retention; improving phases of transition; assessing professional behaviours; promoting quality feedback; engaging clinical teachers and educational and clinical leadership. CONCLUSION This programme of medical education research projects is in the national interest, assists in theory building, helps develop research groups with similar interests, helps avoid duplications, ensures efficient use of funding opportunities, and makes effective use of existing expertise.

Medical student selection in New Zealand: looking to the future.

AIMS: To review whether current New Zealand (NZ) medical student selection policies are likely to result in specialists prepared to work in areas of greatest health need in the future. METHOD: This paper describes approaches used to select medical students, with some details about NZ medical student cohorts. It then discusses the evidence linking selection and career choice. RESULTS AND CONCLUSIONS: Selection processes have to serve multiple purposes and no tools are ideal. The NZ medical student population is more diverse than previously with more females than males, and higher proportions of students who are Maori, Pacific, rural, Asian or born overseas. Tracking projects are already underway to obtain data to better understand the effect of student factors on career choice. The Maori and Pacific Admission Scheme and Rural Origin Medical Preferential Entry affirmative action pathways have been successful, but to increase the number of doctors who identify as Maori or Pacific will require a larger pool of students with strong educational backgrounds from which to select. The strongest evidence between selection and future practice exists for students from rural backgrounds - they are more likely to practice in rural areas and to enter general practice. Therefore, increasing the numbers or rural students, or broadening the definition of 'rural', should be considered.

Receiving bad news: patients with haematological cancer reflect upon their experience.

The literature on breaking bad news (BBN) tends to focus on professional consensus rather than empirical patient evidence--the 'giver' rather than the 'receiver'. Using semi-structured interviews, this study explores the experiences of patients with haematological cancer as they reflect on the process and content of receiving bad news. Fifteen patients with a diagnosis of leukaemia or lymphoma were recruited through a haematology service during a routine clinical visit, with the decision to participate being made later. Interviews were audiotaped, transcribed and analysed using thematic content analysis. Patients place importance on not being rushed during the bad news consultation and the doctor's manner. Receiving bad news was the first step on a journey, not an isolated incident. Doctors were regarded as the best judge of their information needs, with leaflets and written summaries as supplements. Patients had strong preferences about continuity and language use. Displays of empathy were important, but must be genuine. Patients wanted to know about likely emotional reactions and future support. Where patients brought a companion, they found this valuable. Patients concur with much of the content of the guidelines, but place more emphasis on their illness journey, the doctor's ability to adapt to their emotional needs, language used, information leaflets, having a companion and genuinely personalizing the approach. Reflection on these patient-derived factors may help health professionals better serve patients with serious illness.

"I" and "we": a concordancing analysis of how doctors and patients use first person pronouns in primary care consultations.

BACKGROUND: It is widely accepted that "partnership" with patients is desirable, and that patients should be enabled to participate in decisions, but it is not clear to what extent doctor-patient interactions represent partnership in action. OBJECTIVE: Our aim was to measure aspects of doctor-patient interaction through the deployment of the first person pronouns "I", "me", "we" and "us" in general practice consultations. METHODS: The study design was a concordance-based language analysis of spoken data. Concordancing software was used to interrogate a database of 373 consultations with 40 doctors in UK general practice. The frequency and function of first person pronouns used in these consultations were scrutinized. Concordancing enables identification of strings of text with similar lexical properties and uses specialized statistics to assess relationships between words and phrases ("collocates" being words commonly found together) as well as their patterns of use (MI, mutual information, describes the likelihood of two words or phrases being associated). Analysis is therefore quantitative and qualitative. RESULTS: Doctors use the word "we" far more often than patients or companions do (doctors 23.5% and patients 2.9% of all personal pronoun occurrences). Doctors are far less likely to use "I", after which a verb of thinking is usually selected (38 collocates with MI >3). However, after 'we', doctors select verbs of physical activity or auxiliary verbs. Three types of doctor use of "we" were distinguished: to include patients ("you and I"), exclude them ("we doctors" or "we as a practice") or to mean "all of us as human beings". CONCLUSIONS: The findings suggest a prototypical pattern of interaction in primary care: PATIENT: I suffer. Doctor: I think. We will act. This, within the current paradigm which values partnership between doctor and patient, might seem encouraging; but there is evidence to suggest that power relationships in the consultation may still be unequal.