Gynecological patients differ from prenatal patients in appraisals of medical student participation in outpatient clinics

Abstract Introduction: The participation of students in clinical consultations is essential for their medical education. This experience allows for the acquisition of technical skills and the transmission of ethical and professional values. Objective: To evaluate how differences in outpatient conditions (gynecological or prenatal care), appraisal of previous experience, and sociodemographic profiles influence women’s willingness to accept student participation in their consultations. Methods: We selected 743 cases (45.1% prenatal) with previous experience in student participation of 893 women attending outpatient gynecological (52.6%) or prenatal (47.4%) clinics at Brasilia University Hospital from 2016 to 2019. Scales were adopted for women’s appraisal of student interpersonal communication, willingness to accept, and unwillingness to accept student participation. We used t tests to assess differences, chi-square statistics to compare proportions between outpatient groups, correlations between key variables, and linear regression to estimate variables predicting the willingness outcome. Results: Odds ratios over 1 (p< 0.01) emerged for age older than 35 years, not married, less than higher education, multiparity, discomfort with students, and lower acceptance of gender equality in relation to the Ob-Gyn gender for the gynecological group. Women in the gynecological group offered a better appraisal (from one to five) of interpersonal communication (4.75 vs. 4.43, effect size g= 0.605), showed more willingness (4.58 vs. 4.26, g= 0.625), and conveyed less unwillingness to accept student participation (2.35 vs. 2.47, g= 0.143) than women in the prenatal group. In the linear regression analysis (N= 743), a higher willingness to accept student participation was significantly related (in decreasing impact) to better appraisal of student interpersonal communication (p< 0.001), lower unwillingness (p< 0.001), gynecological group (p< 0.001), tolerance to pelvic examination by a student (p= 0.017), and age older than 35 years (p= 0.016). Conclusions: The experience of supportive interpersonal communication, especially regarding the gynecological group, had a predominant impact on the patient’s willingness to accept the participation of students in consultations. Overall, the willingness to accept this participation differs depending on the patient’s (reason for consultation, lower unwillingness, age) and student’s (communication, gender) factors. Hopefully, the findings can contribute to fostering student-patient partnerships from the perspective of the articulation between service and teaching in medicine.


INTRODUCTION
The participation of students in patient consultations is essential for their medical education.Among other reasons, students can learn clinical skills, refine interpersonal communication, and develop critical professionalism to ensure a robust physician-patient partnership in their future careers.However, within the clinical education framework, student participation depends on patient self-determination to decide whether to accept the student's presence at appointments and to allow learners to participate in clinical history-taking and physical examination.
Given the singularities of private and personal clinical history and sensitive pelvic examination, women in obstetricsgynecology care appear to be more stringent in determining the amount and level of student participation compared to patients in some other specialties 1 .Thus, in leading studies of obstetric-gynecological consultations, most women showed higher acceptance of student participation if attended by a female student, examined less intimately, and previously experienced student involvement in consultations [2][3][4][5][6][7] .
Nevertheless, the relationships of patient acceptance with their clinical conditions, demographics, and sociocultural factors are more uncertain.For example, Ching et al. found no significant differences between the gynecological and obstetric groups 8 .Rizk et al. found greater acceptance in obstetric consultations and.observed that participation acceptance was inversely related to the patient's perception and knowledge of the student's task and responsibility 3 .In contrast, Subki et al. observed that gynecological patients, compared to obstetric ones, were more accepting of medical students' presence 9 .
In a two-phase study, we evaluated women's comfort status during gynecological or prenatal care regarding medical students' involvement in consultations and assessed how the comfort levels were related to the women's demographics, sensitivity to the students' gender, and previous experience with student presence 10,11 .This study, conducted in the same public-hospital outpatient clinics for 4 years, involved women of equivalent social strata, either for gynecological or prenatal care.Wide receptiveness to students' participation in outpatient care appointments was a common finding of the two-phase study 10,11 .We also clarified the positive relationship between patients' appraisals of students' interpersonal communication in previous consultations and their willingness to accept learners' participation in upcoming appointments 12 .
The current secondary investigation aimed to evaluate how differences in outpatient conditions (gynecological or prenatal care), appraisal of previous experience, and sociodemographic profiles influence women's willingness to accept student participation in their consultations.We analyze the following research questions to assess the attributes of the outpatient groups regarding the outcome of willingness.
1. How did the selected demographic and attitudinal conditions differ between women receiving gynecological and prenatal outpatient care? 2. How did women in gynecological care differ from women in prenatal care in their appraisals of students' interpersonal communication, willingness, or unwillingness to accept medical students' attendance at outpatient consultations? 3. What were the antecedent or concomitant factors (attitudinal, demographic, or outpatient conditions) related to the women's willingness to accept student attendance at their consultations?

Context
We conducted the study in a public university hospital connected to the Brazilian Unified Health System.The Brasília University Hospital (HUB) outpatient unit provides well-diversified health care to any woman with a medical appointment.Informed consent was obtained from all women involved in the study.All women agreed to participate: those aged < 18 signed an assent form, as did their parents, and

Participants
The original two-phase observational study involved 893 women selected by casual sampling while attending gynecological (52.6%) or prenatal (47.4%) outpatient services at HUB from 2016 to 2019.Two cases from the gynecological group and one from the obstetrical group were excluded because of crucial omissions in the data.In the current reanalysis, 743 patients (335 prenatal) with previous student participation experience constituted the study sample.This sample was adequate based on the t test difference between two independent means: alpha = 0.05, power = 0.90, and effect size = 0.25.Five demographic factors were identified and recorded (for the analyses) in the binary classification: age (1= 36 years or older; 0= up to 35 years), parity (0= nulliparous), marital status (1= married, 0= not married: divorced, single, or widowed), schooling (1= higher education (partial or completed); 0= less than higher education), and family income (1= three minimum wages or more; 0= less than three).Furthermore, three attributes were recorded: level of comfort with (the prospect) of student (male or female) presence in the consultation (1= comfortable; 0= uncomfortable), performance of a pelvic exam by a student (1= acceptance; 0= restriction), and gender preference for Ob-Gyn physician (1= gender equity; 0 = bias to male or female).

Procedures
Using a questionnaire, trained medical students conducted face-to-face interviews with women who had a medical appointment for any gynecological condition and pregnant women who complied with a scheduled prenatal consultation at any gestational age.Interviews were conducted in 2016−17 for the gynecological participants and in 2018−19 for the prenatal participants.We describe the used questionnaire elsewhere 10 .

Analysis
As reported, performing dimension and reliability analyses helped validate the rating scales 12 .The first measure was the willingness scale, based on four items on motives for accepting student participation.The second was the unwillingness scale, based on six items on motives for disagreeing with student involvement.Based on six elements, the scale for patients' appraisal of student interpersonal communication in the consultation was the third measure.
Internal consistency measures (Cronbach's alpha) were 0.68, 0.71, and 0.90, respectively, which are acceptable 13 .The items for the three rating scales are read as follows.
Willingness scale (motives to consent): Students helping with the consultation; Expecting the student to be present; Wishing to help the students' education; Learning about one's health.Asked permission to attend the consultation.
We report the scores as weighted means using the 1-to-5 response scale.Correlations (Spearman's rho) and chisquare statistics (Fisher exact tests) measured relationships and compared proportions between the indicator (attitudinal, demographic, and group) variables; t tests explored differences between the gynecological and prenatal groups.We used linear regression analysis (automatic linear modeling, best subsets model) to assess independent indicators that explain variances in the willingness outcome 14 .SPSS software, version 20, was used for the analyses with bootstrapping (a method robust to violations of assumptions of normality and outliers), as needed 13 .The BCA (bias corrected and accelerated) method improved the accuracy of the confidence intervals.The abbreviations used are M (mean), SD (standard deviation), CI (confidence interval), and g (Hedges' g for the effect size of the standardized difference between two group means).A larger g indicates larger differences between the groups.

RESULTS
All participants shared previous experiences with student attendance at outpatient consultations.Table 1 shows the demographic differences between the gynecological and prenatal groups.Women in the gynecological group (compared to those in the prenatal group) were older, delivered more live births, had less schooling, and had a higher proportion of unmarried status.The strongest association appeared for the age indicator, as evidenced by the odds ratio.Compared to younger women, older women had higher proportions of less schooling (59.7 vs. 40.3%)and unmarried status (53.9 vs. 46.1%) among the 743 participants.To evaluate the relative importance of predictors for the measure of willingness as an outcome variable, we performed multiple linear regression (as reported in Methods).Table 4 shows that five indicators represent 27.2% of the variance in the outcome of willingness.The appraisal of (previous) student interpersonal communication was the most critical antecedent, (current) gynecological status was the third most important antecedent, and older age had the least impact.

DISCUSSION
Studies have identified many factors that affect women's comfort with student participation during their gynecological or obstetric care [2][3][4][5][6][7] .Our investigation provides information on the relative importance of key influences, including whether a gynecological condition or a prenatal check-up motivated outpatient appointments.
The results of the multiple regression model provided information on the relative contribution of the selected indicator variables to the willingness outcome.As portrayed by interpersonal communication scores, a better experience of student-patient interaction was the main predictor of willingness, accounting for 45% of the overall importance.
Other studies have already revealed that previous experiences with student involvement contribute to greater acceptance of students in subsequent consultations 4,5,7,15 .Our data indicate that the patient's assessment of experienced interpersonal communication definitively matters 4,16 .Additionally, the patients' appraisals suggest a positive effect of communication training in medical school 17 .Of note, a French study remarked that students showing higher interpersonal skills during consultations were more prone to be female 18 .Overall, the findings remind us of the relevance of broader communication training (including staff, students, and patients) 19 .
The second important factor (expressed in the unwillingness score) implies the women's reasons for disagreement with student attendance, negatively affecting their potential willingness.As previously reported, the unwillingness scale represents women's concerns about privacy, self-assurance, student intervention, ability, and gender 9,10 .Women in either outpatient group shared those concerns.However, those in prenatal care were more sensitive, perhaps due to their higher level of schooling (Table 1), as claimed by other authors 20 .
Furthermore, a negative attitude towards student participation is more prevalent with male than female students, especially regarding breast and pelvic exams and talking about sexual issues, as reported in more or less recent studies 3,4,7,15,21,22 .Notably, feelings about the pelvic exam by a student appeared to be an independent, nonoverlapping factor, accounting for 5.2% of the impact on the level of willingness.
Although not targeted in this study, gender differences in women's compliance with student participation hint at limitations on experiential skills, affecting male learners' clinical competence and career interests 23 .Among the 327 medical school graduates from 2016 to 2019, 34 (six men) chose a medical residency in gynecology and obstetrics (unpublished data).A scoping review explored the perceived bias felt by male students, the influences, probable reasons, and potential effects of women's choice to consent to or disagree with student attendance 24 .
Of note, the gynecological group was a positive factor in explaining the variability in willingness.Congruently, women in the gynecological group appraised interpersonal Because lack of practice lowers the standards of medical education, it is crucial to support students in developing clinical skills without compromising patient autonomy.Most women seem to be willing to contribute to medical education by consenting to student attendance at Ob-Gyn appointments.However, patient consent should not be taken for granted or subordinated to teaching purposes 19,30,31 .For the ultimate benefit of women's health, the ethics of patient autonomy requires a constructive, evidence-based approach to clinical education that addresses their rights and learners' needs.

CONCLUSIONS
We highlight three findings as follows.First, compared to women in prenatal care, women in gynecological care showed a greater willingness to accept medical students during consultations in an outpatient public hospital setting.Second, willingness was closely related to the appraisal of student interpersonal communication, which was more positive among women in gynecological care.Third, women's privacy, gynecological condition, age, and student interpersonal communication emerged as independent factors for the relationship to willingness as an outcome.
Briefly, greater tolerance or benevolence (including towards the male student's presence) was associated with better appraisal of student interpersonal communication and less reluctance about student participation (including a pelvic exam) in outpatient consultations, gynecological status, and older age.The results indicate that factors related to the patient (privacy, gynecological status, age) and the student (communication skills, gender) affect the willingness to accept the learner's participation in outpatient health clinics.
Hopefully, knowledge of interpersonal communication can help to adjust and optimize student learning opportunities, improve the context of outpatient services, and foster studentpatient partnerships, thus allowing a higher proportion of patients to feel more comfortable and willing to cooperate even more with medical teaching.
those aged > 18 signed an informed consent form.The Ethics Committee for Human Research of the Faculty of Medicine of the University of Brasilia approved the study (approval n. 1.126.648;CAAE 45773315.3.0000.5558).Notably, across the 4-year study period, 327 students (45.6% women, 74.3% younger than 27 years at graduation) learned and contributed to outpatient care, under supervision, during two semesters of their clinical education in gynecology-obstetrics and graduated from the University of Brasilia Faculty of Medicine.
Unwillingness scale (motives to disagree): Need for privacy during a pelvic examination by an Ob-Gyn; Need for privacy during a dialogue with an Ob-Gyn; Feeling ashamed during an examination by a male student; Feeling ashamed during an examination by a female student; Students' lack of (medical) expertise; Lingering consultation in the student's presence.Interpersonal communication scale (student's attitudes): Revealed concern for my health; Acted professionally during the consultation; Communicated well throughout the appointment; Was respectful and caring; Had good looks and manners, which helped with the consultation;

Table 2
shows the differences in the rates of attitudinal attributes between the outpatient groups.The strongest association emerged for the comfort factor, as indicated by the odds ratio.Compared with gynecological cases, women in prenatal care depicted higher rates of comfort with the prospect of students' presence in consultations and acceptance of gender equality concerning the gender of an attending Ob-Gyn but similar tolerance to the pelvic exam by a student.

Table 3
shows significant differences between the gynecological and prenatal cases in the patients' appraisals of three measures related to student attendance in outpatient appointments.Women in the gynecological care group, compared to those in the prenatal group, showed less unwillingness (2.35 vs. 2.47, g= 0.14), were more willing to

Table 1 .
Differences in percentages of dichotomized demographic attributes between women in prenatal (n=335) or gynecological (n=408) outpatient care at the Brasilia University Hospital.
*Three or more minimum wages.**Less than three minimum wages.Source: prepared by the authors.

Table 2 .
Differences in the percentages of dichotomized attitudinal characteristics between women in prenatal care (n = 335) or gynecological (n = 408) care in the outpatient clinics of the Brasília University Hospital.Source: prepared by the authors.

Table 3 .
Differences between women in gynecological (n= 408) or prenatal (n=335) care regarding scores of appraisals of student participation in outpatient consultations at the Brasilia University Hospital.
Weighted mean (M) in the response scale metric (1-5) with standard deviation (SD).*Bias corrected and accelerated; 2000 samples (an accurate measure of CI= confidence interval).Source: prepared by the authors.

Table 4 .
14sults of linear regression (automatic modeling) highlighting predictors for the outcome (patients' willingness to accept student participation in outpatient consultations) among gynecological and prenatal patients with prior experience of student involvement (N = 743).Modeling excluded degree of comfort, level of schooling, marital status, and income as independent nonoverlapping variables.*Theimportancevalues assess the individual contribution of each predictor variable (e.g., age) to the overall prediction model14.Source: prepared by the authors.