Impacto da “ Disciplina relação médico-Paciente ” sobre atitudes Centradas no Paciente The Impact of a “ Doctor-Patient relationship ” Discipline on Patient-Centred attitudes

– Educação Médica. RESUMO Vários estudos têm demonstrado que as atitudes centradas no paciente entre os estudantes de Medicina decaem ao longo do curso de graduação. A relação médico-paciente sofre influência profunda da contemporaneidade, e, cada vez mais, comunicar-se na prática clínica torna-se um desafio. O processo de educar em medicina deve encorajar os estudantes a compartilhar o processo de tomada de decisão com seus pacientes. Os estudantes devem compreender não somente o que preocupa seus pacientes, mas também o que os motiva no cuidado em saúde. No processo ensino-aprendizagem, a adoção de medidas eficazes direcionadas ao aprimoramento da escuta e das habilidades de comunicação torna-se a pedra angular na construção da relação médico-paciente de alta qualidade. O objetivo deste estudo foi avaliar o impacto da disciplina “relação médico-paciente” nas atitudes centradas no paciente entre os estudantes de Medicina. Também foi avaliada a influência de variáveis demográficas e do período do curso de Medicina nessas atitudes. Metodologia: Foram incluídos 279 estudantes de Medicina que responderam ao questionário Patient-Practitioner Orientation Scale (PPOS): 128 (45,9%) estudantes matriculados na disciplina “Relação médico-paciente” e 151 (54,1%) estudantes voluntários, que não cursaram a disciplina, pareados por sexo e idade aos que frequentaram a disciplina. Os dados foram analisados no software SPSS 17.0 (SPSS Inc., Chicago IL, EUA). Regressão linear múltipla foi realizada para determinar se variáveis demográficas e o período do curso de Medicina estavam independentemente associados aos escores do PPOS (escore total; dimensões sharing e caring). Modelos logísticos foram criados para avaliar associação entre a disciplina “Relação médico-paciente” e os escores das subescalas do PPOS. Resultados: Na análise de regressão linear, sexo feminino (p ≤ 0,01), idade mais avançada (p ≤ 0,02) e estar cursando os primeiros anos da faculdade de Medicina (p ≤ 0,02) estavam significativamente associados às atitudes mais centradas no paciente. Maior pontuação na subescala sharing estava independentemente associada à participação na disciplina “Relação médico-paciente” (4,50 ± 0,65 para aqueles que frequentaram vs. 4,33 ± 0,65 para aqueles não matriculados na disciplina, p = 0,03) em modelo logístico ajustado por sexo, idade e período do curso de Medicina. Educadores da área da saúde devem buscar estratégias inovadoras que estimulem atitudes humanísticas, melhorem as habilidades de comunicação e influenciem de forma decisiva as atitudes adotadas pelos estudantes de Medicina, que devem estar focadas no cuidado centrado no paciente/pessoa.


Impacto da "Disciplina relação médico-Paciente" sobre atitudes Centradas no Paciente
The Impact of a "Doctor-Patient relationship" Discipline on Patient-Centred attitudes Luciana Diniz Silva I Maria Mônica Freitas Ribeiro I Anelise Impelizieri Nogueira I Bruna Sodré Reis I Isabela Lopes Barbosa I Andreia Maria Camargos Rocha I Leonardo Maurício Diniz I

INTRODUCTION
Many efforts have been made by medical educators towards the training of medical students focused on the "patient-centred medicine" in opposition to "the disease-centred medicine".In 1969, the pioneer, Enid Balint 1 , who devoted much of her career to the study of the doctor-patient relationship, introduced the term "patient-centred medicine", which was related to the understanding of the patient as a unique human being 2,4 .Since then, various educational strategies have been adopted in the teaching-learning process aiming at the improvement of the doctor-patient relationship [5][6][7][8][9] .It should be highlighted that this contact is a special process of human interaction comprising significant dimensions of the clinical practice that includes technical, humanistic and ethical knowledge.Notably, high attention has been placed in the development of communication skills [10][11][12] .
In this way, several medical schools advocate the teaching of these skills and their evaluation as a fundamental factor in medical training [13][14][15][16] .Medical schools have not only an opportunity but also a responsibility to teach and evaluate the skills of communication and the effectiveness of the doctor-patient relationship of their students.
It is worth mentioning that, a formal discipline in this subject was not included in the great majority of the curriculum of medicine's schools.Actually, several attitudes regarding the doctor-patient relationship are transmitted to the students by professors, tutors and other staff's members 5,8,16 .Conversely, these attitudes are not analysed during the progress through medical school.The medical students must be stimulated to develop a critical own view toward the attitudes and communicative skills linked to the provision of patient care 6,16 .Educational strategies that encourage the examination of these attitudes and behaviours might result in the better understanding of the lapses of the doctor-patient relationship [5][6][7][8][9][10] .
In view of the relevance of the doctor-patient relationship in medical practice and the need to teach it, a group of medical teachers of the Faculdade de Medicina da Universidade Federal de Minas Gerais (UFMG) began offering in 2011 a discipline entitled "doctor-patient relationship".The discipline aimed to encourage the practice and reflection of this subject by the 285 students in an attempt to instruct physicians with humanistic profile, according to Brazilian curriculum guidelines for undergraduate course in medicine 17 .Until now, approximately 200 students have already concluded the discipline.Therefore, we aimed to evaluate the impact of the "doctor-patient relationship" discipline on medical students' attitudes towards patient-centred care, and to examine whether variables related to demographic characteristics and different stages of education are associated with undergraduate student's patient-centred attitudes.

Study setting
The Faculdade de Medicina da Universidade Federal de Minas Gerais (UFMG) is a traditional Brazilian medical school located in Brazilian southeast and a WHO collaborator centre that admits 320 new students yearly by public competition.The medical school has a 6-year curriculum, divided into pre--clinical (the first two years, mostly classroom and laboratory based) and clinical curricula (following four years, mostly patient care or ward-based).The clinical years emphasize ambulatory care at the university hospital, community health centres and at villages or small towns.The third and fourth years emphasize medical interviewing and physical examination at hospital and ambulatory sites.Paediatrics and internal medicine are taught in the fourth year at ambulatory sites, at the public health services and at the university hospital.The fifth year emphasizes specialty medicine at university hospital ambulatories.Students at the beginning of last year have already completed six months of emergency medicine, three months of ambulatory practice at small villages and three months of internal medicine, surgery or paediatrics at University Hospital wards.Three hundred and twenty students enter college per year and all of them experienced identical curricula because there were no important curricular changes at this institution in the period of this study 16 .

Participants
Attitudes towards patient-centeredness were assessed among students (n = 128) six to 24 months after completion of their 15 contact-hour discipline entitled "doctor-patient relationship".These students were enrolled via internet after providing consent for participation through a web-based survey.Student attitudes regarding the relationship between physicians and patients were measured using a previously validated instrument 2,3,15,16 .The Patient-Practitioner Orientation scale (PPOS) is an 18-item instrument originally designed to be administered to either doctor or patients.It measures an individual's attitudes toward the doctor-patient relationship along two dimensions termed 'sharing' and 'caring', respectively.The 'sharing' dimension consists of nine items that measure the degree to which the respondent believes that power and control should be shared between doctor and patient, and the degree to which doctors should share information with the patient.The 'caring' dimension consists of nine other items that measure the extent to which the respondent cares about the value of warmth and support in the relationship, and the degree to which the respondent thinks the doctor should inquire about psychosocial issues and employ a holistic approach to medical care.
Respondents were asked to rate their agreement or disagreement with individual items on a 6-point scale.The overall PPOS score was computed as the mean of the scores for the 18 items.'Sharing' and 'caring' scores were computed as the mean of the scores for the nine items in each dimension, respectively.
A control group of 151 medical student volunteers who do not attended the "doctor-patient relationship" discipline were also enrolled via internet after providing consent for participation through a web-based survey.These students were selected prospectively and tested at the same occasion of those who attended the discipline.

"Doctor-patient relationship" discipline
An interdisciplinary and multiprofessional group composed by clinicians, psychologists, psychoanalysts and preventive and social medicine specialists had fortnightly clinical meetings since the beginning of the study.The multiprofessional team discussed cautiously the strategies and interventions elected for teaching the "doctor-patient relationship" discipline.The theoretical basis was established on Michael Balint's studies 18 .The medical students were stimulated to explore psychological aspects of their consultations.The students were motivated to recognise emotional aspects of the relationship between clinician and patient.Communications skills were also discussed.Films, videos, books, papers and charges were used for this.

Statistical analysis
Data were entered into an access database, verified by double entry and analysed using the Statistical Package for Social Sciences, version 17.0 (SPSS Inc., Chicago, IL).For the comparison of the percentages and the median, Pearson's Chi-square test asymptotic and Mann-Whitney test was used, respectively.The Shapiro-Wilk test was used to evaluate if the data were normally distributed.Linear regression models were created for the PPOS total mean score and for each of the two dimensions 'sharing' and 'caring' (dependent variable).The independent variables were grouped into demographic (age, sex) and years in the graduation course.Variables with p-value < 0.25 in the univariate analysis were selected for the multivariate analysis.In each group of variables when more than one variable had p-value less than 0.25, hierarchical linear regression models were created for selection of variables truly associated with the reduction of scores in each domain.Variables with p < 0.05 were included in the final model of multivariate linear regression.
The R² (coefficient of determination adjusted) and the Anova test were used to assess the adequacy of the models.
Logistic models were created to quantify the independent association between the "doctor-patient relationship" discipline and PPOS and sub-scales scores, adjusting for age, gender and years in the medical course.All the variables with p ≤ 0.25 in the univariate analysis were included in the full models of logistic regression using the additive and subtractive step--wise approach.Odds ratio (OR) and 95% confidence interval (95% CI) were used as an estimate of the risk.The Hosmer-Lemeshow test was used to assess the adequacy of the models.
P values ≤ 0.05 were considered significant.

Characteristics of the students enrolled in the study
The demographic data of the study population are shown in the Table 1.Regarding the variables age, gender and years in medicine course, no significant differences were observed between the students who attended and those who do not attended the "doctor-patient relationship" discipline.

PPOS score
Among all students evaluated (n = 279), increased PPOS overall scores were associated with female gender (4.85 ± 0.40 for female vs. 4.69 ± 0.69 for male, p = 0.003) and with be attending the first years of medical school (4.84 ± 0.47 vs. 4.73 ± 0.43, p = 0.05), but not with student's age (p = 0.17).Because all the three  variables have a p-value < 0.25 in the univariate analysis they were selected for the multivariate analysis.In the linear regression analysis, age, female sex and year of medical school were independently associated with overall PPOS score (Table 2).

'Sharing' sub-scale score
In the univariate analysis, increased 'sharing' sub-scale scores were associated with female gender (4.50 ± 0.60 vs. 4.28 ± 0.69, p = 0.007).Neither the student's age (p = 0.10) nor the years in medicine course (p = 0.29) were associated with the scores of the 'sharing' sub-scale.As female gender and student's age have p-value < 0.25, they were selected for the multivariate analysis.'Sharing' scores were independently associated with age and female sex in the linear regression analysis (Table 2).

The influence of "doctor-patient relationship" discipline on medical students' attitudes towards patient-centred care
Regarding PPOS and sub-scales scores, higher 'sharing' scores were associated with attending the "doctor-patient relationship" discipline (Table 3).In the multivariate analysis, sharing (OR = 1.46; 95%CI = 1.01-2.13;p = 0.03) remained associated with attending the "doctor-patient relationship" discipline even after adjustment for age, gender and years in the medical course.Additional data: the medical students describe their own views toward the "Doctor-patient relationship" discipline At the end of the "doctor-patient relationship" discipline, medical students were encouraged to describe their own views toward this discipline.Among the various reports made by these students, some were selected and described below.
I believe that much more important than to discuss the professional relationship models in our career, it is to discuss our own perception about the patient.I think the most efficient way to ensure a noble conduct in the office is reconstructing the conceptions that each one brings about the place that the patient must occupy during the contact between him and his doctor. [

DISCUSSION
In the present study, medical students who attended the "doctor-patient relationship" discipline achieve higher 'sharing' scores than those who do not were enrolled in the discipline.
In addition, the students' reports revealed that they perceived the importance to understand the illness process through the patient's perspectives as an essential component in building a successful physician-patient relationship.
As previously described, the core elements of PPOS, an instrument that has been used to measure student's patient--centred beliefs, are based largely on two dimensions 'caring' and 'sharing' 2,3,15,16 .The last dimension might be defined as sharing the power, the control and the information about the patient's clinical condition.Conversely, in the daily clinical practice surrounded by high complexity of health care and high performance technologies, medical students have been felt poorly prepared to share decision-making process with their patients 14,19,20 .In the actual medical education scenario, listening and understanding the patient's life context including ideas, expectations, and feelings about the disease process have become a challenge.
The restructuring of the medical education focusing the patient-centredness is a current relevant issue worldwide [5][6][7][8][9][10]21,22 . Operaionally, our main goal in offering the "doctor--patient relationship" discipline was to maximize the learning and retention of fundamental humanistic and ethical knowledge and communication skills, particularly based on a reflective practice.
The strategies adopted by an interdisciplinary and multiprofessional team may be considered a remarkable characteristic of "doctor-patient relationship" discipline.Each week case-based small group tutorials were the key component of the didactic experiences.In this setting, the students were encouraged to reflect on their own and as a group about their real medical practice thorough an integrated approach.Each tutorial session was based on actual students' experiences during their consultations.Tutorials topics were selected based on the doctor-patient relationship's issues identified by the students.Altogether, the attitudes of the medical educators were focused in provoking the medical student to critically reflect on the doctor-patient interaction.The "doctor-patient relationship" discipline was designed to foster the closely connection between the students' actions and the values and beliefs of the patients, thereby enhancing the patient-centred attitudes.
Consistently with a previous study carried out in the medical school, using the PPOS instrument 16 , we found high 'caring' scores in all students that were enrolled in the current study, independently of attending the "doctor-patient relationship" discipline.'Caring' domain measures beliefs about attending to patient's emotions and lifestyle [2][3][4] .Similar findings were also observed in other two studies conducted in medical schools located in the same state 21,23 .Altogether, these results demonstrated that the effect of culture influences the 'caring' domain.Brazilian medical students achieve higher 'caring' scores than any other cultures in which these scores have been reported 16 .
Additionally, our results demonstrated that the progress through medical school was inversely associated with the scores of the subscale 'caring'.Apart from the divergences of the results revealed by several investigations [2][3][4]16,19 , our data are in accordance with previous studies, which found the decline of empathy in the later years in medical school 22,24 .
In agreement with previous studies, higher PPOS scores were identified among females' students and may be attributed to gender differences in communication skills among female and male doctors 3,4,16 .
The limitations of our study deserve to be discussed.This was a cross-sectional investigation of small sampling conducted in a single medical school.An additional limitation is the lack of the evaluation of the students in the beginning of the "doctor-patient relationship" discipline.Specifically, the students that opted to attend the discipline could be already concerned about issues addressing the interaction of doctors with their patients.
The data presented here should be taken into account in the understanding of medical students' attitudes towards patient-centred care and in the translation of the results into daily clinical practice.Altogether, these findings may improve the doctor-patient relationship and reassure the commitment of the future professional with a high quality of patient care.

Table 2 Effect of demographic characteristics and years in medicine course on Patient- Practitioner Orientation Scale (PPOS) summative and sub-scales (n = 279)
CI, Confidence interval; t, computed by dividing the estimated value of the β coefficient by its standard error.The linear regression models were appropriately adjusted according to the F-test of the ANOVA (P < 0.05).‡ P < 0.001.§ P =0.001.† P = 0.002.⃰ P =0.003.¥ P=0.02).

Table 3 Comparative analysis of Patient-Practitioner Orientation Scale (PPOS) and sub-scales (n = 279) between students who attended and those who do not attended the "doctor-patient relationship discipline"
n, number of subjects; SD, standard deviation.‡ P = 0.06; § P = 0.03; † P = 0.40 (Student's t-test for all).
...] the discipline clarified some concepts and allowed an ex-