Medical students in the perception of patients

The objective of this research was to identify the perceptions of patients when treated with student participation. The descriptive and crosscut research was carried out through a questionnaire applied to 200 patients of two Strategies for Family Health units and two outpatient medical specialties. As a result, 98% of patients reported satisfaction to be contributing to medical education, 90% reported receiving more explanations about their disease, 95% received polite, attentive and respectful treatment from students and 97.5% said that students introduced themselves and requested previous consent. It was concluded that most patients are pleased to contribute with teaching and receive further explanation in the presence of students. However, a small percentage reported inadequate approach and dissatisfaction, particularly in the specialties of gynecology and urology, implying the need for the supply of specific guidelines and greater emphasis in the teaching of disciplines concerning the relationship with patients, particularly of Bioethics, by the course coordination and health services.

Patients have contributed to medical teaching since the beginning of medicine.Great masters have transmitted their knowledge around the diseased or in outpatient clinics.The observation of the behavior of teachers during appointments and the direct contact with patients provides students essential opportunities for their scientific and humanistic development.
In their majority, patients usually take the presence of medical students naturally during their consultations.However, would there be a difference of perception between the service given by the physician alone and that with the participation of medical students?Moreover, in th perspective of patients, would the behavior of students be appropriate in these cases?
It is estimated that the presence of students during the consultation tends to reduce the privacy of the patient, possibly causing discomfort and embarrassment in the disclosure of information.On the other hand, the participation of students could mean the delivery of more detailed information to the patient, bringing additional benefits to the understanding of their disease and better orientation on the treatment.
Studies on this theme are not frequent in the literature.The present study sought to assess the perception of patients on the presence of medical students in ambulatory care of a medical school and of two units of the Estratégia de Saúde da Família (Family Health Strategy -ESF), as well as to identify occasional problems and to propose solutions.

Methods
This is a descriptive and crosscut study, performed during the course of Trabalho de Conclusão de Curso (TCC I, TCC II and TCC III, Graduation Project I, II and II), taught in the 8th , 9th and 10th semesters of the medical school course of the Universidade do Oeste de Santa Catarina (University of West Santa Catarina -Unoesc), in which 200 patients were randomly selected, being 50 of each of two units of ESF in the municipalities of Joaçaba and Herval d'Oeste, both located in in the State of Santa Catarina, Brazil, and 50 in each of the ambulatory care centers for gynecology and urology of the Ambulatório Médico Universitário (University Medical Ambulatory Clinic, AMU) of Joaçaba.
The selected ESF in both municipalities were the ones that regularly had medical students in heath care and both provide general, not specialized care.A inclusion of the AMU, which has specialized ambulatory clinics was due to the need to consider patients of two specialties that deal with the most private parts of the body, gynecology and urology, with the aim to investigate if their perceptions on the presence of students during medical care would show differences.The patients of the AMU had been forwarded by several institutions, including the ESF included in this study.
The survey was performed using a questionnaire with 3 social-demographic questions and 11 specific questions, structured and in the Likert scale.It was carried out between the months of February and August 2012.The perception variables indicated as answers to the questions were: "Definitely yes", "Probably yes", "Probably not" and "Definitely not"; or "Totally agree", "Agree", "Disagree", and "Totally disagree".For the reference of quantity the alternatives used were: "Usually", "Sometimes", "Rarely" and "Never".The topics of the questions were chosen with basis on the problems most frequently found in literature reviews.The structure of the questions for each type of perception was based on the guidelines presented in the book "How to design questionnaires" 1 .
The questionnaire was applied randomly by two of authors to patients in the research places, during routine ambulatory care, after explaining the objectives of the research, agreement to participate and signing of the term of free informed consent.The average time to answer the questionnaire was of approximately 12 minutes.
Answers were analyzed after the first week of data collection and, there being no problem as to the understanding of the questionnaire by the participants, the survey was carried out as planned.Data were stored in Microsoft Office Excel 2007.The test of analysis of variance (ANOVA), Tukey test and G test were performed through the software package BioEstat 5 .

Research article
Medical students in the perception of patients http://dx.doi.org/10.1590/1983-80422015233092school; 29 (14.5%) had finished elementary school; 21 (10.5%) had not completed high school; 35 (17.5%) had finished high school; 10 (5%) had incomplete college studies; 5 (2.5%) had completed college, and 3 (1.5%)had some type of post-college study.Through the analysis of variance and, later, by the application of the Tukey test, it was observed that the predominant schooling among surveyed patients was basic education with a history of incomplete elementary studies (p < 0.05).
It was found that 86 participants from the ESF (86%) answered they they received more explanations about their condition with the presence of students during the appointment, while 14 (14%) disagreed with the statement.In the AMU, 94 participants (94%) agreed and 6 (6%) disagreed.In total 180 (90%) agreed and 20 (10%) disagreed (Table 1).

Medical students in the perception of patients
http://dx.doi.org/10.1590/1983-80422015233092When asked if there was any episode of disrespect or impoliteness by students present in the appointment, 7 patients of the ESF (7%) and 4 of the AMU (4%) answered affirmatively, but the results did not show statistical difference in relation to the different health care units (p > 0.05).
In case the reason for the appointment were gynecological, urological or any other related to private parts of the body, half of the patients of the ESF units and 29 specialties of the AMU (29%) agreed that they would feel troubled by the presence of students.In total, 79 (39.5%) agreed that the presence of students can inhibit them, of which 24 (12%) answered "Definitely" and 50 (25%) answered "Probably"; however, 121 (60.5%) disagreed, of which 51 (25.5%) answered "Probably" and 70 (35%) answered "Definitely".
About the concern to disclose some private problem due to the possibility of secrecy breach by the students, 41 patients (20.5%) agreed and 158 (79.5%) disagreed.Of the total, 173 (86.5%) agreed that the medical students introduced themselves and asked for previous consent to perform the proceeding; however, 27 (13.5%)disagreed.
The feelings caused by the presence of students during appointments were also surveyed and the results were that 38 patients (19%) felt at ease; 103 (51%) felt tranquil, and 29 (14%) considered the appointment an opportunity to talk about personal problems.On the other hand, 17 participants (9%) felt not at ease; 4 (2%) felt untranquil; 6 (3%) felt embarrassed, and 1 (0.5%) felt troubled.Only 2 (1%) spontaneously reported another feeling during the consultation, one being contentment and the other was discomfort (in this for being a gynecological consultation).Statistically, there was no significant difference among the answers in relation to the health care units of the appointments (p > 0.05).

Discussion
The happiness of patients to contribute to the learning of medical students was almost unanimous (98%).This result is in accordance with what was found in other studies 2,3 , in which patients also felt

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Medical students in the perception of patients http://dx.doi.org/10.1590/1983-80422015233092 at ease in the presence of students and showed personal commitment with their training.
The interaction between students and patients is essential for medical training, and students must also be aware of the value of this relationship.According to a study 4 performed with 25 students in the 12 th semester of a medical school in the south of Brazil, 68% of them agreed that the practical learning takes place during appointments, extra-curricular internships and during the internship period, which shows the the recognition by the surveyed of the value of the patient for medical teaching.In the same study, 84% of the students declared that learning also takes place through observation of teachers, residents and classmates seen as role models.The technical learning obtained since the first years of medical school, with the inclusion of the patient in teaching, contributes effectively to the integration of the different disciplines, as well as to a better understanding of students concerning their studies 5 .
Most patients agreed that they get more information about their condition when there are students in the consultation.In the general context, the good interaction between students and patients make possible a more thoughtful assistance, providing more ease in identifying complaints, better adhesion to medical orientation, fewer complaints against the physician and higher satisfaction with the service 4 .It is inferred, thus, that this improvement in the quality of assistance to patients results in the following factors: higher availability of time for the examination; more thorough explanations during the discussion about the disease between the teacher and the students; the possibility for the patient to solve doubts and to get additional information from students about his/her disease.
Another factor that influences the acceptance of students by the patient during the consultation is the small number of appointments in the teaching environment, allowing for a longer time for examination.A study performed in the United States in 2003 3 found that only 28.9% of the patients reported not receiving more attention with the presence of medical students.In comparison, in the present study, this number was lower, ranging from 6% in the AMU to 15% in the ESF units, which evidences that, for the majority, this form of assistance is more thorough and thoughtful.This aspect shows the importance of improving information and attention to patients during routine appointments performed by physicians also without the presence of students.
Few patients of the AMU reported episodes of unthoughtfulness, disrespect or impoliteness by students; however, when asked about being troubled or embarrassed due to their presence during the consultation, 36% of the participants answered "Usually" or "Sometimes".This shows the need to provide specific orientation to students on the obligation to respect the patient's will and the need to obtain their consent at the beginning of the appointment, in order to fulfill the bioethical principles of autonomy and non-maleficence.Privacy, psychic--emotional well-being and comfort of the patient are rights stated in the Carta dos Direitos dos Usuários da Saúde ("Bill of rights of the users of health services) 6 in Brazil, calling for a reflexion on the convenience of limiting the presence of students during certain clinical proceedings.
The acceptance of medical students during the appointment vary according to the patient's age, social class and ethnic group 7 .Young, well-informed patients with few comorbidities tend to feel less embarrassed.On the other hand, the elder population, with less schooling and several comorbidities tends to be less receptive to consultations with the presence of students.The groups with the larger number of participants were above 50 years of age and incomplete elementary studies, and this aspect may have contributed for a relatively important fraction of these referred trouble or embarrassment.However, it is estimated that a respectful attitude along with prior clarification on the part of students from the start of their activities would fulfill the bioethical principles of autonomy and non-maleficence, as well as would contribute to the increase of confidence of patients.
Nearly all patients reported that the attitude of the students was appropriate, with 5% of the students of the ESF units and none at the AMU disagreeing with this.As to the behavior, 7% of the patients of the ESF units and 4% of the AMU reported disrespect, unthoughtfulness or impoliteness by students.Although the undesirable behavior happens in small number, as it is reported for a minority of students, an effort is necessary in order to totally eliminate it.
As to the possibility of the patient not communicating some complaint for fear of breach of secrecy by the student, 20% answered that this concern occurs "usually" or sometimes, with no statistically significant difference between the places studied.This lack of confidence must be solved through prior clarification which clearly assure the respect to the privacy of the patient.About this, a study of 2003 3 on the perception of patients of the dermatological clinic about the participation of medical students in

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Medical students in the perception of patients http://dx.doi.org/10.1590/1983-80422015233092consultations found a little lower values of lack of confidence, as 90% of the patients declared not to be troubled by disclosing personal information in the presence of students.This difference in results may arise from the place of the disease in the body of the patient, which is usually less private in dermatology, as well as from a more or less clarifying and respectful stance by students, especially in relation to the guarantee of secrecy.Such conjecture is corroborated by a recent study performed in Pará, in which only 37.4% of the students declare they received guidance on medical secrecy 8 .
When asked if the presence of students during the appointment would trouble them in the case of an urological or gynecological consultation, half of the patients of the ESF units answered affirmatively while in the AMU, which treats cases of gynecology and urology, these answers corresponded to 29%.This result, although apparently paradoxical for the lower discomfort shown by AMU patients, may be explained by the previous knowledge of patients about the nature of the service provided in that place, that is, specialized care with the participation of medical students.Since most ESF units do not have the participation of students and do not usually have the necessary infrastructure and gynecology and urology specialists, it is presumed that the introduction of students in these health care units may generate annoyance or discomfort.
In the Joaçaba ESF Unit and in the gynecology specialty of the AMU, there was significant statistical correlation (p < 0,05) showing that in these places the discomfort is more intense.To illustrate this result, a patient spontaneously referred her discomfort in having a gynecological consultation with the presence of students.In the cases when the patient has shown his/her discomfort, the responsible physician must consider the rights of this patient and the possibility of dismissing students during the appointment.This is because, even in a place also dedicated to teaching, the benefit to the patient is a fundamental ethical principle of the medical practice.
For 86.5% of the participants in this study, students presented themselves previously and asked for consent to perform the proceedings.However, 13.5% disagreed, meaning that there was no previous identification or request of consent by the students.A study performed at the hospital of the Universidade Federal da Paraíba (Federal University of Paraiba) 9 found a much less favorable result, as 50% of the interviewees answered they were not requested consent.By taking this politeness and truthful stance in the beginning of the appoint-ment, the student earns more easily the confidence of the patient.It is emphasized -repeatedly -that previous orientation to students on this aspect is indispensable by the ones responsible for teaching.
When asked about the possibility of having the appointment without th presence of students and if this would make the patient more at ease, 44.5% agreed with the statement, but the result did not show statistical significance among the places studied (p>0.05).According to a study performed at the "Hospital das Clínicas da Universidade Federal de Minas Gerais" (Clinical Hospital of the Federal University of Minas Gerais, HC-UFMG) 10 with 131 patients, 69.5% did not mind being treated by students and 49.2% considered their own participation in the learning of future physicians important, in consonance with the findings pf the present study.The study with dermatology patients mentioned above 3 found even more favorable results, as 94.2% of the patients valued the interaction with students and 99% did not demand exclusive service by the physician.In general, patients feel at ease to discuss their personal problems with medical students and are aware of the benefit of their personal contribution to the training of future physicians 11 .
Another aspect studied was the longer duration of appointments wit the participation of students, considering the time past from their arrival at the health care unit to their final release.Over half of the patients answered that the longer duration of the appointment troubles them.A study at the "Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo" (Clinical Hospital of theUniversity of São Paulo Medical School, HC--FMUSP) in 2001 12 estimated that the total time for the medical appointment in a service with the presence of medical students lasted, on average, 123 minutes, being a cause of complaints by the patients, in opposition of the positive aspects of the service.Such fact point to the need to adopt measures in order to rationalize the waiting time in services that count with students, mainly with the scheduling the arrival of the patient closer to the time of the appointment, greater agility in the consultation and the release right after the end of the procedures.
In order to expand this study, patients were asked about other feelings in relation to the presence of students in the appointments.The majority reported positive feelings of tranquility, comfort and the opportunity to talk.A portion, however, mentioned discomfort, untranquilness and embarrassment, showing the need of the course coordination and the responsible physician and/or preceptor to help Medical students in the perception of patients http://dx.doi.org/10.1590/1983-80422015233092improve the posture of students and, thus, reduce the negative feelings of patients.
Students get involved in embarrassing situations, either caused by the teacher or by the patients 13 .In the first case, the inadequate conduct of the physician responsible in post-abortion care, recriminating the patient, constitutes a negative example for the student.As to the second case, occasionally, the student, sensitive to the suffering of the patient, tries to solve problems beyond his competency or gets involved only because family members called his/her attention -examples that give a measure of the complexity of this interaction.As pointed by the literature 14 , the psycho-analytic theory of Balint may contribute to the development of emotional intelligence of the student and of competencies that favor the good student-patient relationship in medical school.
The way the teachers relate to the students, trying to treat them by their names is similar to the relationship they keep with their patients, which influences positively in the construction of the good student-patient interaction.The learning of medicine through observation and practice was already adopted by the lad Greek masters, as personally reported by the philosopher Plato 15 .However, the recent change in medical teaching, with the introduction of patient care from the beginning of the course has increased the need for teachers to be constructive examples for the scientific and humanistic training of students.
The practice performed by students in the health system as well as the incentive to th contact with patients and the inclusion of communicational abilities in the teaching of medicine converge to the improvement of the relationship with patients 16 .A fundamental aspect for the humanistic training of students was the insertion of bioethics in medical teaching.The good relationship with patients depends not only on the personal traits of students but also on the development of communication activities and the acquisition of knowledge about the rights of patients offered in the context of bioethics.Moreover, the consciousness of having a social role in the appointment leads students to identify with the community and contributes to the development of the very sense sense of citizenship 17 .
In this context, the recent appreciation of patient autonomy has encouraged shared decision making, which assumes a teaching focused on the needs of patients 18 .In turn, the acquisition of communicational abilities during medical school is increasing in medical training,with the introduction of new strategies 19 .Communication is fundamental in human relationships so that, in order to fulfill the curricular guidelines established by Resolution 4/2001 of the CNE/CES (Conselho Nacional de Educação, Câmara de Educação Superior -"National Council of Education, Higher Education Chamber") 20 , medical schools included subjects with the aim to develop and foster this ability in the student in their curricula.This way, it is estimated that the measure, besides contributing to the improvement of the communicative ability during medical school, will also improve the quality of the student-patient relationship.
Besides, students must be sensitized for the humanization of patient care, avoiding the fascination with technology 21 .Movies enshrined by the public, such as "The Doctor" 22 and "Wit" 23 , dramatized scenes that made some not recommended conducts of medical students during patient care in teaching environments widely known, signaling to the need of greater awareness of the ones responsible to the introduction of measures to prevent such behaviors.In the present study, the presence of flaws of conduct in students was evident.These, although rare, implied some difficulties in the student-patient-relationship, indicating the urgent need for orientation by the course coordination and/or by preceptor physicians.In this context, the convenience of preventive measures, through a broad approach of the theme in disciplines dealing with the relationship with patients in preparatory stages to ambulatory clinical practice -especially during the teaching of bioethics -, so that these conducts are not repeated with the future patients of the institution.In consonance with the recommendations of the present study, the AMU has recently approved a norm 24 with orientation to students about the need of attention and "extreme" respect in dealing with patients.

Final Considerations
Most patients reported to have received more information about their disease when medical students were present in the appointment and were pleased to contribute to medical teaching.
According to participants, most students behaved in a polite, respectful and thoughtful manner during appointments, and a small portion reported episodes of disrespect and impoliteness, as well as discomfort, untranquilness, embarrassment and and

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Medical students in the perception of patients http://dx.doi.org/10.1590/1983-80422015233092being troubled, which contributed to the omission of information on private matters in the presence of students.Moreover, part of the patients reported lack of prior identification and/or of request for consent by students during the approach.
We conclude that the perception of most patients relative to the behavior of students during health care service was broadly positive.However, the identification of some problems suggests the need to provide specific guidance on the patient-student relationship by the ones responsible for teaching and for the health services, and that of emphasizing this aspect in the teaching of related subjects, especially bioethics.

Table 1 .
Perception of patients as to receiving more explanations about their condition with the participation of medical students during the appointment

Table 2 .
Perception of patients as to the politeness, thoughtfulness and respect of medical students during the

Table 3 .
Discomfort, embarrassment and the lack of communication of symptoms due to the presence of medical students during appointment * p < 0,05.** p > 0,05.