medical students in ent outpatient clinics: appointment times, patient satisfaction and student...

Medical students in ENT outpatient clinics: appointment times,patient satisfaction and student satisfaction

Daniel Hajioff & Martin Birchall

Objectives Outpatient clinics are increasingly important

in medical education. The effect of students on clinic

times and patient satisfaction, as well as their own

satisfaction, were studied.

Design A prospective, non-randomized, controlled

study using adult patient questionnaires, medical stu-

dent questionnaires and clinic time sheets.

Setting Two teaching hospital ENT clinics.

Subjects Medical students and adult patients.

Results Three hundred and twenty-®ve patient ques-

tionnaires were collected (77% response), including

135 student encounters. Students did not affect ap-

pointment durations (19 min � 0á48 (standard error))

except at centre B (35 min � 1á1, P < 0á0001) where

patient numbers were cut for teaching. Patient satis-

faction, generally high, was not affected by students,

appointment duration or gender of doctor or patient. It

was slightly higher in the lower social classes

(rs � 0á20, P � 0á003) and older patients (rs � 0á17,

P � 0á002). Student acceptability scores were not af-

fected by student numbers (up to four), social class or

time spent alone with students. They were higher if

time was spent alone with the doctor (75á3% � 4á9)

than not (63á0% � 1á8, P � 0á024). Thirty-six per cent

of patients preferred to have a student present; only 9%

preferred not. Student satisfaction was higher at centre

B (73á7% � 2á3) where appointments were longer and

students spent more time alone with patients than

centre A (64á3% � 2á3, P � 0á0052).

Conclusions Clinic appointments are not necessarily

longer in the presence of students. When students have

the chance to see patients alone during longer consul-

tations, student satisfaction is higher. Patient satisfac-

tion, generally high, is not altered by the presence of

students, but patients given time alone with their doctor

are more accepting of students. These ®ndings have

resource implications for the planning of NHS clinics in

teaching hospitals.

Keywords Education, medical, undergraduate,

*methods; *job satisfaction; otolatyngology, *education;

out-patient clinics, hospital; *patient satisfaction; phy-

sician±patient relations; prospective studies; referral

and consultation.

Medical Education 1999;33:669±673

Introduction

The involvement of students in outpatients is increas-

ingly important. This re¯ects changes in both working

patterns and curricula. Much literature exists on the

two-way interaction of doctor and patient in the out-

patient setting and the factors affecting patient satis-

faction and compliance. Far less is known about the

more complex three-way interaction including the

medical student. Each party adopts dual, potentially

con¯icting roles. The student is both learner and pro-

vider; the patient is consumer and subject; the doctor is

provider and teacher.

Previous studies provide some information on the

demography of patient attitudes. Patients are, in gen-

eral, receptive to medical students who, they believe,

increase the attention given to the patient.1 The most

comprehensive study on students in a general medicine

clinic showed that half the patients `enjoyed' their in-

teraction with students but that one-third preferred not

to see a student.2 It found that older patients and men

were more receptive of students, but educational level

had little effect (within a group skewed towards higher

socio-economic status). Better-educated patients were

less tolerant of the involvement of residents in outpa-

tients.3 Other studies have shown that a signi®cant

minority of patients prefer to be seen by a doctor of the

same sex but this has not been assessed for students.4

In contrast, there is little information on how various

modi®able factors alter patients' experiences of medical

Southmead Hospital, Bristol, UK

Correspondence: Mr M A Birchall, Senior Lecturer/Consultant ENT

Surgeon, Southmead Hospital, Bristol BS10 5NB, UK

The patient in medical education

Ó Blackwell Science Ltd MEDICAL EDUCATION 1999;33:669±673 669

students. It has been noted that half the patients in a

general medical clinic expressed a desire for time alone

with their doctor2 and that patients say they ®nd more

than two to three students unacceptable.5 There is a

widely held belief that `students slow clinics down' but

this has not been measured to date.

The factors in¯uencing students' satisfaction have

been largely ignored. Students appeared to learn more

from orthopaedic outpatient clinics than ward rounds;

this appeared to be independent of the clinic workload.6

We aimed to address many of the above issues with a

prospective, controlled study of general otolaryngology

clinics in two teaching centres. One of these deliber-

ately provides longer appointments when students are

present; the other makes no special arrangements and

provides informal teaching only. The effect of students

on appointment duration was measured. Patient satis-

faction was correlated with age, sex (of patient and

doctor), social class, appointment duration, presence of

students and presence of a consultant. The patients'

receptiveness to students was correlated with these

factors, the number of students and time spent alone

with either the student or the doctor. We also examined

student satisfaction. The results have implications for

the organization of teaching clinics.

Methods

Two teaching hospital ENT clinics were studied for 2

weeks without students and 2 weeks with students. All

clinic staff were aware of the study and its aims but no

changes were made to routine clinic operation. Nurses

kept records of appointment durations (which included

time between patients), the number and type of doctors

and the number of students.

At the end of each appointment all patients over 18

were given a questionnaire (Appendix 1) by a nurse

who explained the purpose of the study. (They were

therefore not aware of the study during their consulta-

tion.) The questionnaires were completed and posted

anonymously before leaving the clinic. The patients

recorded their age, the occupation of their household's

principal wage earner (from which social classes I to V

were derived), their sex and the doctor's sex. The ®nal

item was recorded at only one of the two centres.

Agreement with seven statements of satisfaction was

rated on a ®ve-point Likert-type scale. Statements were

chosen on the basis of previous studies that suggested

they might be aspects of patient satisfaction particularly

sensitive to the presence of students. Positive state-

ments were used throughout, as it appears that asking

patients if they agree with negative statements may yield

arti®cially high levels of satisfaction.7 This was linearly

transformed to a `patient satisfaction' (PS) score on

which 100% corresponded to total satisfaction, 0% to

total dissatisfaction and 50% to neutrality. One state-

ment of overall satisfaction was included so that it could

be correlated with the total satisfaction score derived

from the other items for internal validation of the

questionnaire. A space for free comments was provided.

Those patients who met students completed a second

section (Appendix 1) to rate their receptiveness to

students or `student acceptability' (SA) score designed

in an identical manner to the PS scoring system. It

asked if they preferred to see the doctor alone. It also

included questions on the number of students en-

countered, their sex, and whether or not time was spent

alone with the student(s) or doctor. Patients in both

centres were routinely informed of their right not to

have a student present during the consultation though

this was rarely exercised. Such patients still completed

the ®rst section of the questionnaire.

Medical students were informed of the study at the

start of their attachment and completed one question-

naire anonymously after each occasion they attended

the clinic. This included information on the number of

students present and the student/doctor ratio, whether

they saw patients alone or just sat and watched, and

how much time they spent in the clinic. It asked if they

liked to see patients alone or sit in and watch. A student

satisfaction (SS) score was derived in the same manner

as the PS and SA scores. Again space was provided for

free comments.

Statistical analysis

Appointment durations were compared using the t-test

for independent samples. Where satisfaction scores

were compared between two groups the Mann±Whit-

ney U-test was used, but where a trend was suspected

between social classes or age groups Spearman's rank

correlation was used to assess statistical signi®cance.

Correction for multiple analyses was not applied.8

Results

Appointment durations

The time analysis covered 24 clinics at which 574 pa-

tients were seen. The proportions of new (36%) and

follow-up patients were the same between the two

centres with and without students. The distribution of

grades of doctors was also equivalent. At centre A the

mean appointment duration was 18á7 min � 0á48

(standard error), whether or not students were present.

At centre B in the absence of students the mean

Ó Blackwell Science Ltd MEDICAL EDUCATION 1999;33:669±673

Medical students in ENT outpatient clinics · D Hajioff & M Birchall670

appointment was 20á9 min � 0á34, which was signi®-

cantly longer than centre A (t-test, P < 0á001). How-

ever, in the presence of students the mean appointment

was 34á5 min � 1á1 (P < 0á0001). It should be noted

that centre B deliberately allowed longer appointments

for teaching clinics; no special arrangements were made

at centre A.

Patient satisfaction (PS)

Three hundred and twenty-®ve patient questionnaires

were received (response rate 77%) of which 97% were

completed correctly. (The latter ®gure excludes the

question relating to social class with which 29%

appeared to have dif®culty.) One hunderd and

thirty-®ve of these encountered students. Internal

validation was provided by the correlation between the

total PS score and the item relating to global satisfac-

tion (Spearman's rs � 0á715, P < 0á001).

Overall satisfaction was high at 76á7% � 14á5 (mean

� standard deviation) on a scale where 50% is neutral

and 100% total satisfaction. This was not dependent on

the presence or absence of students or the centre. It was

not in¯uenced by the sex of the doctor or patient (an-

alysed at centre A only). There was a mild positive

trend between social class and satisfaction (rs � 0á20,

P � 0á003). There was a similar trend between age and

satisfaction (rs � 0á17, P � 0á002); in other words,

the elderly and lower social classes were slightly more

satis®ed. Appointment duration did not correlate with

satisfaction. Satisfaction was slightly higher in the absence

of a consultant (79á4% � 1á56 (mean � standard error)

vs. 75á5 � 0á89, P� 0á036).

Student acceptability (SA)

Again internal validation was provided by a good cor-

relation between the total SA score and the global item

(rs � 0á836, P < 0á001). SA correlated moderately

with PS (rs � 0á387, P < 0á001). Overall SA was fair at

65á2% � 20á4 (mean � standard deviation, n � 135).

The mean number of students was 2á56 � 0á95

(standard deviation). The number of students did not

correlate with SA or PS. Social class had no discernable

effect on SA (unlike PS); however, SA was signi®cantly

higher in the older patients (rs � 0á308, P < 0á001). It

appeared that male patients were less accepting of

female than male students (59á1% � 4á6 (mean �

standard error) vs. 73á9% � 4á7, P � 0á034). SA was

not affected by time spent alone with the student but

appeared higher if time was spent alone with the doctor

(75á3% � 4á9 vs. 63á0% � 1á8, P � 0á024). Fourteen

per cent wanted time alone with the doctor; 36% pre-

ferred having a student present; 9% preferred not to

have a student present at all.

Student satisfaction (SS)

Forty-six completed questionnaires were received. (It is

not known how many clinics each of the 25 students

attended but the response rate is estimated to exceed

70%.) Internal validation (calculated as for PS and SA)

was reasonable (rs � 0á644, P < 0á001) and SS scores

were good (69á2% � 11á8 (mean � standard deviation)).

Ninety-two per cent stated that they liked to see

patients alone; 65% stated that they liked to sit in and

watch the doctor. SS was signi®cantly higher when

students saw patients alone (74á6% � 2á3 (mean �

standard error) vs. 64á2% � 2á2, P � 0á0021). It was

also higher at centre B (73á7% � 2á3 vs. 64á3 � 2á3,

P � 0á0052), which is where they were given the

chance to do this. SS correlated with appointment

durations, which were made longer at centre B when

students were present (rs � 0á575, P < 0á001). The

number of students per doctor did not correlate with

satisfaction (rs � ± 0á20, P � 0á19).

Discussion

Contrary to popular wisdom, students did not always

lengthen clinic appointments except at the centre where

patient numbers were reduced for teaching clinics. It is

clear that the effect students have on clinic times is

entirely dependent on how clinic doctors choose to

integrate students, so it is dif®cult to generalize from

these results.

The tools for assessing patient satisfaction (PS),

student acceptability (SA) and student satisfaction (SS)

were not tested for reliability, nor has their validity been

formally assessed. However, they have face validity

based on their common-sense content and the use of

similar questions in previous studies; internal correla-

tions provided some validation; and they appear to have

some discriminatory power. The scales were designed

to be quantitatively meaningful (i.e. a 50% score cor-

responded to a neutral response) so it was pleasing to

note that PS (77%), SA (65%) and SS (69%) all

comfortably exceeded a neutral response.

Patient satisfaction was not in¯uenced by the pa-

tient's or doctor's sex in contrast to prior studies.4

Those of lower social class and older patients were

more satis®ed. It should be noted that although these

trends were statistically signi®cant they were relatively

small. It is not possible to tell whether they were ac-

counted for by differential response rates. Appointment

Medical students in ENT outpatient clinics · D Hajioff & M Birchall 671


duration did not correlate with PS; however, it did not

vary greatly in this study. Of greatest importance to this

study is the observation that the presence (and number)

of students had no discernable effect on satisfaction.

Thirty-six per cent of patients actually preferred to

have a student present and only 9% did not want one

present. Student acceptability was higher among older

patients (but in this case social class had no effect in

contrast with a study of residents in clinic3). The

number of students (up to four) did not seem to

matter, nor whether time was spent with the student

alone. (It is not known what factors determined which

patients spent time alone with students: it is possible

that they were selected for their apparent willingness to

see students but their satisfaction and student accept-

ability scores were no different from those who did not

spend time alone with students.) Fourteen per cent

expressed a desire to spend some time alone with the

doctor and those that did were more accepting of

students. It is not known what factors determined

which patients actually did spend time alone with a

doctor so such patients may not be comparable with

those that did not see a doctor alone: the apparent

increase in student acceptability in the former group

may therefore be illusory. However, it would appear

that there is no reason from most patients' point of

view why they should not spend time alone with

students but in return they should be offered the

opportunity to spend time alone with their doctor. It

may be that it is possible to select those patients for

whom this is especially important.

Students were signi®cantly more satis®ed at centre B

(74%) than at centre A (64%), where appointments

were prolonged and students saw patients alone. It is

not possible to determine from these data whether

location exerted a causal effect, whether longer

appointments in themselves were preferred, or whether

the opportunity to see patients alone was contributory.

The investigators' impression is that the latter is a

major factor given that 92% of students reported that

they liked to see patients alone, whereas only 65% liked

to watch the doctor. None of these variables affected

patient satisfaction or student acceptability. Davis &

Dent suggested that orthopaedic students learnt more

from a clinic than a ward round.6 However, rapid

outpatient exposure was associated with lower objec-

tive structured clinical examination scores in surgery

than exposure to emergency admissions.9 This is

consistent with our students' apparent preference for

longer appointments during which they could see pa-

tients alone.

There are two important questions that this study

cannot answer: ®rst, does the increased student satis-

faction resulting from the chance to see patients

themselves actually depend on lengthened clinic

appointments? and secondly, do increased clinical

knowledge and skills parallel student satisfaction? The

authors believe that teaching and active learning in

clinics will inevitably lengthen appointments, but that

an expensive reduction in patient numbers may require

further objective evidence of improved learning.

It is not known how far these results can be gener-

alized to clinics in other locations and specialities.

Gynaecology, psychiatry and paediatrics, for example,

are likely to have special considerations. It is however,

possible to make some general recommendations. The

signi®cant minority (9%) of patients who do not desire

the presence of students should be made aware of their

right to see a doctor alone. A larger proportion of pa-

tients also wish to exercise this right without excluding

students entirely. Up to four students are acceptable to

patients, although other studies have suggested a limit

of two to three.5 Students should be active participants

in clinics (that may require restructuring) rather than

passive observers. Further investigation of these issues

is warranted given the increasing role of clinics in

medical education.

References

1 Glasser M, Bazuin CH. Patients' views of the Medical Educa-

tion Setting. J Med Educ 1985;60:745±56.

2 Simons RJ, Imboden E, Martel JK. Patient attitudes toward

medical student participation in a general internal medicine

clinic. J Gen Intern Med 1995;10:251±4.

3 Reichgott MJ, Schultz JS 1983 Acceptance by private patients

of resident involvement in their outpatient care. J Med Educ

58:703±9.

4 Fennema K, Meyer DL, Owen N. Sex of physician: patients'

preferences and stereotypes. J Fam Pract 1990;4:441±6.

5 Bishop F, Matthews FJ, Probert CS, et al. Patients' views on

how to run hospital outpatient clinics. J Roy Soc Med

1990;84:522±3.

6 Davis MH, Dent JA. Comparison of student learning in the out-

patient clinic and ward round. J Med Educ 1994;28:208±12.

7 Cohen G, Forbes J, Garraway M. Can different patient satis-

faction survey methods yield consistent results? Comparison of

three surveys. BMJ 1996;313:841±4.

8 Perneger TV. What's wrong with Bonferroni adjustments. BMJ

1998;316:1236±8.

9 Chatenay M, Maguire T, Skakun E, Chang G, Cook D,

Warnock GL. Does volume of clinical experience affect per-

formance of clinical clerks on surgery exit examinations? Am

J Surg 1996;172:366±72.

Received 22 April 1998; editorial comments to authors 28 August

1998; accepted for publication 16 December 1998

Medical students in ENT outpatient clinics · D Hajioff & M Birchall672


Appendix 1: Patient questionnaire about ENToutpatient clinics

Section A was completed by all patients and asked the

patient's age, sex and the doctor's sex. It also asked the

job of the highest wage-earner in their household (or

previous job if retired or unemployed). Patients were

then asked to circle a number 1±5 in response to the

following statements. 1 corresponded to strongly dis-

agree, 3 to neither agree nor disagree and 5 to strongly

agree. The statements were: Ì did not feel embarrassed

to discuss personal matters.' Ì was encouraged to ask

questions.' Ì was given as much information as I

wanted from the doctor.' Ì felt I was treated as an

individual, not just another case.' `There was enough

time to discuss everything on my mind.' Ì was happy

with my overall experience in clinic.' `My medical

problems were dealt with competently and thoroughly.'

Section B was completed only if the patient had a

student present. It asked the number of students, sex of

the students and whether time was spent alone with the

students or the doctor. The following statements were

scored on the ®ve-point scale used in section A: Ì

preferred having medical student(s) present.' Ì feel my

treatment was better because students were present.' Ì

did not feel embarrassed by the student(s).' Ì wanted

time alone with my doctor.'

Appendix 2: Student questionnaire about ENToutpatient clinics

This recorded the number of students and doctors

present and whether the student spent most of his time

seeing patients alone or watching the doctor's consul-

tation. They then scored the following statements on

the ®ve-point scale as used above: Ì found the clinic

helpful to learn about ENT in general.' Ì found the

clinic useful in developing ENT history taking skills.' Ì

found the clinic useful in developing ENT examination

skills.' Ì found the clinic useful in learning the essential

facts of ENT.' Èach appointment provided enough

time for learning.' `The number of students was not

excessive.' Ì saw a suf®cient variety of conditions in the

clinic.' `The doctors made good use of the clinic as a

teaching opportunity.' Ì like to see patients on my

own.' Ì like to sit in on doctors' consultations.¢ Ì was

happy with my overall experience in clinic.'

Medical students in ENT outpatient clinics · D Hajioff & M Birchall 673


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