Receptiveness to students’ presence at gynecological consultations: patients’ motives and appraisal of learners’ interpersonal communication skills

Objective: To assess the expectation that the appraisal of students’ interpersonal communication skills in prior appointments affects women’s motives for consenting to or dissenting from the presence of a student and thereby their ultimate receptiveness regarding the learner’s involvement when participating in gynecological consultations. Methods: Face-to-face interviews were used to compile questionnaire data from 469 outpatients at the Brasília University Hospital. We used t-tests to evaluate the differences between the scores of the two motive-related scales of patients with prior experience of student involvement and those of patients without it, as well as contingency analyses to assess the association between the groups of women and an index of their receptiveness to students’ participation in the consultation. Moreover, we performed correlation analyses to verify the interrelationships between the scales and the levels of association of these measures with the index of receptiveness as an outcome. Results: Compared with inexperienced patients, experienced patients exhibited significantly broader receptiveness to students’ participation in consultations (chi-squared = 20.49, df = 3, P < .001; Cramer’s V = 209, P < .001). Broader receptiveness was positively correlated (rho = .314, P < .001) with their motivation to consent to and negatively (rho = -.454, P < .001) correlated with their motivation to dissent from students’ presence at coming consultations. The motivation to consent was significantly higher (P < .001) in experienced women (M = 4.58, SD = .55, n = 408) than in inexperienced ones (M = 4.31, SD = .68, n = 61). The opposite result was true for the motivation to dissent (M = 2.35, SD = .94 vs. M = 2.70, SD = 1.02; P = .007). Notably, for those 408 women, their appraisals of students’ interpersonal communication skills (in a prior consultation) positively correlated (rho = .236, P < .001) with their motivation to consent to and negatively with their motivation to dissent from students’ presence (rho = -.208, P < .001). Conclusion: The findings have implications for both the patients’ role in the gynecological education of medical students and the learners’ qualification in the clinical interview and, therefore, for the benefit of women’s healthcare.


INTRODUCTION
Medical students' involvement in gynecological consultations is of the essence for a useful educational experience in women's medical care. An essential feature of that experience is the students' clinical skills qualification through the interaction with the women going through gynecological care under the guiding supervision of the teaching staff. Thereby, as future physicians working in the country's healthcare system, the students shall meet the health needs of women.
To reach such a desideratum, the willingness of women to accept student engagement in their consultations is crucial. Nevertheless, the intimate nature of a gynecological consultation requires an interpersonal context of confidence and privacy. Thus, a patient may not feel at ease with a student's presence during her appointment, depending on a diversity of factors, such as the woman's needs, expectations and experiences, the student's attributes, and the context of care 1-4 . Obstacles to learners' involvement could prevent not only adequate clinical training but also the choice of specialty training in Ob-Gyn, which is an unhelpful outcome in times of growing demands for the provision of women's health services 5 . A current review summarizes the learners' perceptions of the patients' factors related to, and the potential reasons for the gender differences in clinical opportunities and outcomes 6 .
Among the patients' factors, it is noteworthy the possible effect of an earlier experience with students in gynecological consultations on the women's attitudes towards the learners. Several studies found a mostly facilitating influence of prior acquaintance on the patients' willingness to accept and feel at ease with the learners' presence 1, 3,7,8 . Two Brazilian studies revealed similar effects in the setting of women's outpatient care at public hospitals 9,10 . What features of a prior appointment experience would impact the patients' intended attitudes? One study noted that patients assigned high ratings to interpersonal communication attributes in connection to the patients' attitudes towards student involvement 3 . Another study revealed that experienced patients rated such (trainees') professional skills even higher, according to the duration of contact 8 . However, those studies did not clarify the level and the nature of the relationship between the women's perceptions of learners' interpersonal communication attributes and the women's acceptance of student involvement. Further analysis seems necessary to investigate the association of those perceptions with positive or negative motives regarding the students' presence.
Accordingly, this exploratory study aimed at assessing the expectation that patients' appraisal of students' interpersonal communication attributes in prior appointments would correlate to the patients' motives for consenting to or dissenting from student presence and, therefore, impact the patients' ultimate receptivity regarding a learner's involvement in coming consultations. We extended the data analyses from a recent crosssectional survey 10 by using several of the patients' responses to a tested questionnaire to pursue the following research questions.
1. How did the scales-which indicate the patients' appraisal of students' interpersonal communication attributes and patients' motives to consent to and dissent from a student's presence at their consultation -fare in dimension and reliability?
2. How significant were the relationships between the measures of patients' consenting and dissenting motives and an index of their receptivity to student participation in an impending consultation?
3. How meaningful were the differences between the measures of consenting and dissenting motives of patients who experienced a student's presence at a prior appointment and those patients who did not experience a student's presence at a prior appointment?
4. How significant were the relationships between the patients' appraisal of students' interpersonal communication attributes during earlier appointments and the measures of consenting and dissenting motives concerning a learner's presence at a prospective consultation?

METHOD
Context. The study was conducted at a gynecological outpatient unit. This unit, belonging to the Brasília University Hospital (HUB), provides well-diversified gynecological care to any woman registered for a medical appointment. Supervised medical students (45% females) have attended outpatient consultations during two semesters of their clinical training for the last 25 years.
Participants. We used a consecutive sampling strategy for the women complaining from a wide variety of gynecological problems. No exclusion criteria were established based on demographics or nosological conditions, so a total of 471 patients were interviewed over 24 nonconsecutive weeks. The mean age of the participants was 43.06 years (SD=14.1, median=43, range=12-78). Of the total number of participants, 53.4% were married, 27.4% were unmarried, and the remaining 19.1% were divorced or widowed. Nulliparous women comprised 21.7% of the participants, and 78.3% of the participants had given birth one or more times. Only 23.9% of the participants had higher education, while 76.1% of the participants had a lower level of schooling. Only 9.8% earned five or more minimum wages per month, and the remainder earned less than that. A majority (61.7%) of the women  (Tables 1   and 2), and the 6-item questioning about students' interpersonal communication attributes (Table 3). Additionally, we defined a composite variable by dichotomizing and adding the responses related to three facets of receptiveness: being comfortable with the students' presence (1 = accepting the presence of either a male or female student); the number of students allowed in the consultation (1 = three or more students); and pelvic examination by a student (1 = acceptance, either by a male or female student).
Using this composite variable as a receptiveness index constituted a useful outcome measure of the patients' level of acceptance of students' participation in the consultation. Following the usual norms 14 , we reported the values for Spearman's rho and Cramer's V as effect sizes and accepted P-values < .05 as significant.

RESULTS
No significant differences emerged, when using chisquared tests, between the proportions of five demographic factors in women with prior experience of students' presence at gynecological appointments (n = 408) and those in women without this prior experience (n = 61  (Table 3).      and DMS score (rho = -.208, P < .001) for the students' presence at their coming consultation. For each of the six SIC attributes, except for She/he was respectful and caring, the strength of the correlation was higher in the CMS score than in the DMS score. Table 5 reports the data.
Finally, a weak correlation also emerged between the patients' assessment of SIC and their index of receptiveness to the students' involvement (rho = .147, P = .003). The strongest correlation was for She/he asked permission to attend the consultation (rho = .136, P = .006).

DISCUSSION
In summary, we have tested and confirmed the  as subsumed in the CMS and DMS levels) prevailed over the students' attributes (subsumed in the SIC level) regarding the eventual acceptance of the learners' participation. Nevertheless, the results above highlight the relevance of the patients' appraisal of the trainees' professional skills, thus confirming and extending earlier reports 3,8 . From the patients' viewpoint, the learners show abilities and help with the consultation through some means, while the women themselves want to help the students' medical education. As remarked elsewhere, reciprocal altruism may underlie the student-patient relationship 10 .
Overall, the results confirm the positive influence of prior experience, as reported by many authors 1, 3,7,8 . The findings extend the argument by providing quantitative evidence and uncovering the potential role of the patients' assessment of students' interpersonal communication skills in their willingness to accept the trainee's involvement. Without claiming causality, a sequential relationship between appraisal, motives, and receptiveness seems conceptually plausible and meaningful.
Nevertheless, the study cross-sectional and exploratory nature, as well as the participants' response context, rule out high certainty.
Hence, we proffer that the results display implications for both medical students' clinical preparation and women's healthcare from the viewpoint of the physician's work construction. The results highlight the relevance of patients' perceptions of trainees' attributes in the medical interview and the importance of learners' embodiment of professional behavior and compassionate approaches 18 , as incorporated into the students' communication skills. We suggest that a stronger willingness to accept the students' participation among the patients with prior experience of student attendance may reveal the perception of ethical stances of teaching and learning, in the outpatient health-task context. Indeed, the assertion that modifiable student-related characteristics influence women's willingness to agree to a pelvic examination 19 by a student concurs with our findings. Besides, the results underline the importance of revealing the framework and balance of the patients' motives and expectations regarding their care in the gynecological outpatient setting.
The study has limitations regarding its survey design 15 .
The single-site report about patients from a public medical care service hinders the generalizability of the findings. Using a closed-question questionnaire in a cross-sectional design restricts its scope and strength. A restricted scope prevents a deeper understanding of ethical profiles of teaching, learning, and partnership in health services. Nonetheless, the study shows strengths, including the participants' sample size and excellent response rate. The study also upholds the credibility of the reported findings 10 , explains the positive influence of prior experience and hints at the potential usability of that explanation in grounding research from a qualitative outlook to the interest of patient-physician partnership in public health services 20 .

CONCLUSION
The results imply that the appraisal of students' interpersonal communication skills in earlier appointments moderates the patients' consenting and dissenting motivations regarding the students' attendance and thereby their receptiveness to learner involvement in coming consultations.
Notably, the results suggest that better assessment of interpersonal communication skills reinforces the willingness to consent to student attendance and attenuates the unwillingness to accept it. Furthermore, higher consenting scores and lower dissenting scores correlate (positively and negatively, respectively) with broader receptiveness, which stands for gender fairness and openness to learners. Overall, the results confirm the positive influence of the preceding experience, clarify its relationships with consenting and dissenting motives by providing quantitative evidence, and reveal the potential role of patients' appraisal of students' interpersonal communication skills in balancing the women's motives and, hence, their ultimate receptiveness towards learners' participation. The findings have implications for both the patients' role in the gynecological education of medical students and the learners' qualification in the clinical interview and, therefore, for the benefit of women's healthcare.