Undergraduate education

Directing student response to early patient contact

by questionnaire
Joaquim Edson Vieira, Maria do Patrocnio Tenorio Nunes & Milton de Arruda Martins

Context First year medical students experienced early

patient contact by observing outpatient consultations.
Objectives To evaluate a questionnaire designed to
examine emerging attitudes during the development
of a doctor)patient relationship.
Methods First year medical students participated in
medical outpatient consultations as observers. These
consultations represented a total of 295 registered
clinical appointments. After each observation, the
students completed a questionnaire surveying themes
related to the doctor)patient encounter. An instructor
met the students at the end of the appointments to
discuss the questions raised. The Dundee Ready
Education Environment Measure was used to assess
the course environment.
Results Students found the activity useful and enjoyable. They reported increased self-esteem and
enhanced enthusiasm for the study of medicine. They
completed write-ups describing and evaluating the
questionnaire data. The questionnaire notes showed

Introduction
The ability of medical students to meaningfully consider
the social history of patients appears to decline during
their medical training. Because of this, the teaching of
clinical communication skills has become an increasingly necessary component of medical school curricula,
representing a subject which ought to be taught during
the early stages of medical education.1 During the
doctor)patient encounter, the doctor should seek to
establish a partnership which encourages the individuality of the patient and facilitates the emergence of ideas
about what might be wrong with the patients health.

Internal Medicine Department and Center for Development of

Medical Education (CEDEM), University of Sao Paulo School of
Medicine, Brazil
Correspondence: Joaquim Edson Vieira MD, PhD, Av. Dr Arnaldo, 455
salsa 1216, Sao Paulo, SP 01246-903, Brazil. Tel: 00 55 11 3066
7317; Fax: 00 55 11 3085 0992; E-mail: joaquimev@hotmail.com

homogeneity among the students. The Dundee Measure indicated the students regarded the learning environment positively (622%); social and ambient
conditions were rated highly (646% and 647%,
respectively).
Conclusion The teaching of humanitarian attitudes by
observation of the doctor)patient relationship in practice was welcomed by students. The environment in
which this educational programme was carried out was
considered adequate. The outpatient service schedule
and the limited time available for student instruction on
the part of staff doctors made this activity productive.
The programme motivated students towards higher
achievement and the pursuit of medical responsibility
as well as more developed humanitarian behaviour
patterns.
Keywords
education
medical,
undergraduate
*methods; physician patient relations; outpatient
clinics; communication; attitude; questionnaires.
Medical Education 2003;37:119125

The interaction between a doctor and a patient

occurs by means of various techniques and through
their personal relationship. While the techniques
depend on the application of medical knowledge, the
personal relationship is more complex. Patients have
their own social conventions, attitudes, expectations
and needs, which are not necessarily similar to those of
their doctors, and nor are they always evident.2
The emphasis on learning from patients is not new.
At Guys and St Thomass Hospitals this practice has
been developed in such a way to allow clinical students
to play more active roles and take greater responsibility.
Here, students have welcomed opportunities to see
patients, to deal with undifferentiated problems and to
test themselves as clinicians.3 Interestingly, the programme is also reported to allow students to gain in
confidence and to begin to develop the human qualities
the public expects to see in doctors.3
In a previous study, undergraduate medical students
stationed at an ambulatory clinic used a questionnaire

 Blackwell Publishing Ltd M ED I C A L E D UC A T I O N 2003;37:119125

119

120

Directing student response to patient contact

J E Vieira et al.

Key learning points

Observation of appointments in an outpatient
clinic by first year medical students represents a
unique opportunity to bring to life subjects the
students sometimes consider dry or remote.
A questionnaire directed the students participation and acquainted them with the main aspects of
the doctor)patient encounter and the psychosocial
care involved.
Cultural and social values, rights, obligations and
responsibility were brought to the undergraduates
attention to demonstrate that medicine should
always consider the patients interests first.
Medical students as observers in outpatient clinics
may use questionnaires, the support of a practitioner and the usual facilities from medical services
as part of their early exposure to patient contact.

as an instrument to orient their notes and to identify the

attitudes of in-training doctors. The students, after
observing a clinical appointment and making a short
round with a staff doctor, reported an increasing
interest in better study of hard biomedical subjects,
such as biochemistry.4 It is reasonable to suppose that
not all students are aware of exactly what they need
to master in order to practise medicine. Opportunities
to observe outpatient appointments have been shown to
be successful in motivating preclinical students to study
basic science subjects more thoroughly.5
This report aims to describe a questionnaire and its
use as a facilitator during a teaching programme
concerned with attitudes in the doctor)patient relationship. The investigation also reports on the methodology employed, indicating that general medical
practice has a key role to play in providing early
experience of patient contact.

Methods
The programme took place at the outpatient clinic of
the General Medicine Service, Hospital das Clnicas of
the University of Sao Paulo Medical School (HCFMUSP). A total of 41 first year medical students were
enrolled on the programme. They were split into
groups of 1012 students, which were later allotted to
either morning or afternoon sessions. The programme
was scheduled to take place in eight 4-hour sessions,

the last two of which were reserved for the presentation

of a final report. Students were allowed direct interaction with patients by means of a short interview and
they observed medical appointments on an individual
basis. The HCFMUSP has a capacity of 2000 ward
beds and undertakes 75 000 ambulatory appointments
per month in all medical specialties. The General
Medicine Service deals with approximately 4000 of
these appointments.
Patient interviews were carried out in the waiting
room. The patients main self-described demographic
characteristics were recorded, along with their own
impressions about their conditions of health. Immediately after this, the students attended the outpatient
consulting rooms, where patients were informed of
their presence. A student could be asked to withdraw
from a consultation if a patient, medical resident or staff
doctor considered this appropriate. A total of 13
in-training doctors responsible for outpatient clinical
training were involved in this study, but students did
not always sit in on consultations with the same doctor.
The students used a questionnaire to guide their
observations (Table 1) and were required to complete
one questionnaire for each doctor)patient encounter
they observed.
The questionnaire used a Likert scale (where
1 very poor, 2 poor, 3 acceptable, 4 good,
5 excellent) designed to capture a range of levels of
patient satisfaction.6 In the consulting room, the
student assumed the role of observer. The last hour of
each 4-hour session was reserved for discussion
between the group of students and their instructor
about the consultations and the clinical findings.
Emphasis was placed on particular aspects of the
encounter, such as the patients rights, the doctors
obligations towards the patient, cultural values in
medical practice and social responsibility. Pathophysiology was also considered in response to student
requests, but to a limited degree.
The Dundee Ready Education Environment Measure (DREEM) was used to assess the programmes
educational environment and climate.7 This consists of
a 50-item questionnaire, with a potential total score of
200 points, and considers five domains of perception:
teaching, teachers, academic achievement, learning
atmosphere and students social relationships. The
higher the score attained, the better these conditions
are held to be.

Results
A total of 295 doctor)patient encounters were registered with completed questionnaires by the 41

 Blackwell Publishing Ltd ME D I C AL ED U C AT I ON 2003;37:119125

Directing student response to patient contact

J E Vieira et al.

121

Table 1 The questionnaire

Identification:
Gender:
Age:
Education level: illiterate elementary high school graduate
Appointment:
Beginning (hh:mm):
End (hh:mm):
Physicians behaviour

13
14
15

Yes No
Yes No
12345
12345
12345
12345
12345
12345
No PE
12345
12345
12345
No tests
12345
No prescription
12345
12345
12345

16

Yes No
Only prescription

1
2
3
4
5
6
7
8
9
10
11
12

Does
Does
Does
Does
Does
Does
Does
Does

the
the
the
the
the
the
the
the

doctor
doctor
doctor
doctor
doctor
doctor
doctor
doctor

greet the patient?

introduce him herself to the patient?
show interest in the patients daily activities?
use open questions?
ask questions with yes or no replies?
allow the patient to interpret his her own problem?
give attention to the main concerns of the patient?
invite the patient to undergo a physical examination (PE)?

Does the doctor keep up a dialogue with the patient during the PE?
Does the doctor provide information about the findings of the PE?
Does the doctor explain the necessity and nature of laboratory tests?
Does the doctor explain about the medicines prescribed?
Does the doctor
Does the doctor
Does the doctor
needed?
Does the doctor

use vocabulary compatible with the patients understanding?

ensure that the patient understands his her own problem?
ensure that the patient understands the prescription or test
give a written orientation?

Patients behaviour
17
18
19
20
21
22

123
Yes
Yes
123
123
123

45
No
No
45
45
45

Is the patient apparently interested in describing his her symptoms to the doctor?
Is the patient concerned about receiving a prescription?
Is the patient concerned about getting lab tests?
Is the patient interested in receiving explanations regarding his her condition?
Is the patient apparently enthusiastic or happy?
How does the patient appear? (shy)talkative)

Students name
Group
Date
Scale: 1 very poor; 5 excellent.

students. The students collated the data and prepared

oral and written presentations. The activity was welcomed by the students, who reported increased selfesteem and enhanced enthusiasm for the study of
medicine. The questionnaire notes showed homogeneity. The Dundee Questionnaire was completed by all
41 students and results indicated that the students
considered both their learning environment and their
social climate to be positive.
The programme finished with the groups reports.
These were qualitatively evaluated by the instructor to

generate a course grade. An open form (without

identification) allowed the students to criticise the
programme. Students said that they had learned a
variety of things from the activity; mainly these involved
developing an awareness of the importance of a
patients individuality and the necessity of showing
interest in the patients life, outwith their health or
illness. The doctors role as an educator, the use of
adequate vocabulary and the quality of information
given were considered by students to be critical to the
doctor)patient relationship.

 Blackwell Publishing Ltd M ED I C A L E D UC A T I O N 2003;37:119125

122

Directing student response to patient contact

J E Vieira et al.

Table 2 Questionnaire with mean grades achieved during appointments (n 295)

Order

Question

Mean

SD

3
4
5
6
7
8
9
10
11
12
13
14
15
17
20
21
22

Does the doctor show interest in the patients daily activities?

Does the doctor use open questions?
Does the doctor ask questions with yes or no replies?
Does the doctor allow the patient to interpret his her own problem?
Does the doctor give attention to the main concerns of the patient?
Does the doctor invite the patient to undergo a physical examination?
Does the doctor keep up a dialogue with the patient during the physical examination?
Does the doctor provide information about the findings of the physical examination?
Does the doctor explain the necessity and nature of laboratory tests?
Does the doctor explain about the medicines prescribed?
Does the doctor use vocabulary compatible with the patients understanding?
Does the doctor ensure that the patient understands his her own problem?
Does the doctor ensure that the patient understands the prescription or test needed?
Is the patient apparently interested in describing his her symptoms to the doctor?
Is the patient interested in receiving explanations regarding his her condition?
Is the patient apparently enthusiastic or happy?
How does the patient appear? (shy)talkative)

39
39
38
32
44
36
36
36
40
41
44
38
40
40
38
30
35

04
02
03
03
03
03
04
06
02
02
03
02
02
04
04
03
04

The DREEM resulted in an overall evaluation of

1244 out of 200 possible points (622%), indicating a
positive student response to the learning environment.
In order to classify rates as high or low, any mean result
to a DREEM question of lower than 20 was considered
inadequate and indicative of an area to be improved.
The students weak perception of the teaching domain
(289603%) has been attributed to the questions
related to the short time spent on teaching (12),
unfocused teaching (1.6) and the emphasis on memorising facts (18). The section concerned with teachers
attitudes (274624%) registered generated no
responses lower than 20. In the section concerned
with academic achievements (189590%), the question related to learning strategies that had worked
before, altered to refer to a condition of discussion
rather than of listening (14), and the question related
to the capacity to memorise (18) were indicated as
hindering learning conditions. While the learning environment won a high level of approval (310646%),
student perceptions highlighted important issues, including a lack of precision regarding time-keeping (07),
a readiness to cheat in tests (15) and a lack of
confidence in asking questions (18). Finally, students
graded social relationships on the programme highly
(181647%) but perceived a low level of interest on
the part of teachers in dealing with students difficulties
during stressful conditions (18).
The 295 encounters were recorded by individual
questionnaires. A few questionnaires with insufficient
data were omitted from the students final report and

have likewise been omitted from the results of this

study. Each student participated in between six and
eight appointments. Use of the questionnaire was fairly
uniform, despite differing conditions of observation
(Table 2). The standard deviation for all questions with
gradations of 1)5 was less than 06. Students felt
comfortable filling in the questionnaire.

Discussion
The results suggest that the programme was conducted
in an environment suitable for learning and that the
questionnaire can be considered an adequate instrument for the independent following of outpatient
consultations by students early in their education.
The waiting room interviews helped the students to
understand the patients views of their own health
conditions and to gain initial impressions of their
social status. This context represents an interesting
opportunity for dealing with communication skills,
taking into account the patients own views of health
and illness. It is worth suggesting that social history
taking should be made a short but integrated part of
the overall first assessment of a patient in order to
improve students and doctors skills in this important
area.
Placing first year medical students in a general
medical outpatient clinic provides a unique opportunity
to enliven themes previously considered dry or remote
by the students. Not only are students able to observe
special moments in the doctor)patient relationship,

 Blackwell Publishing Ltd ME D I C AL ED U C AT I ON 2003;37:119125

Directing student response to patient contact

J E Vieira et al.

but the significance of biochemistry in terms of its

relationship with pathophysiology and physical diagnosis begins to make sense as a component of medicine as
a whole.
At this stage, medical students might be considered
to be closer in understanding to the patients they
observe than to doctors, given their identification as
laypeople. For this reason, there is no conflict between
the interests of in-training residents and those of
undergraduate students during consultations. The
interest of the resident in-training is directed towards
therapy and the outcome of the clinical situations
encountered. The student, however, through the use of
the questionnaire, can focus on the doctor)patient
relationship while retaining a natural degree of curiosity
about the diagnosis. The questionnaire seems to be able
to direct the students attention and preserve their
interest in the patient as a person with a particular
culture, while enthusing them for the knowledge they
will acquire from the consulting session. This complex
situation certainly supports the hypothesis that the
doctor)patient relationship represents a partnership
rather than an isolated professional encounter.
This course considered the use of a questionnaire to
direct student participation during a patient contact
experience, supported by qualified practitioners, at an
early stage of training. It has proved able to acquaint
students with the main aspects of the doctor)patient
encounter and the psychosocial care involving a
subject and his or her family. However, this type of
participation in observing outpatient appointments
may deserve further investigation in areas such as
paediatrics or gynaecology, where some difficulties
may arise.
The mean results from the groups indicate that the
students perceived the doctors under observation as
being highly interested in their patients: the overall
grades given by students were close to 4. The use of
adequate vocabulary attained a higher grade (44). The
attending physicians in this study were doctorsin-training as residents, which may explain the prompt
attention they offered. This may fuel the consideration
of relationships and communication skills during training, thereby steering undergraduates away from undesirable situations where doctors regard their patients as
disease puzzles rather than as people to whom they
should listen and pay attention.8
Students perceived the patients levels of satisfaction as fair (30). Kiyohara et al. showed patients in
similar settings to have higher degrees of satisfaction
with their consultations, although not necessarily at
the time of the consultation.4 Our questionnaire did
not record the patients impressions outside the clinic,

123

where they may have felt more comfortable. It is also

interesting to note that this discomfort might be
occasioned by patients illiteracy, which can cause
embarrassment and compromise the doctor)patient
relationship.9 The suggestion that clinicians should
not assume their patients know how to read should
not be interpreted as an invitation to avoid listening
to them. Promptness to listen results in better
understanding of patients difficulties and offers
opportunities to deal with psychological issues. Cantwell and Ramirez cited inadequacy of skills and a
willingness to avoid awkward questions, as well as
lack of time, as reasons for avoiding psychological
issues.10 These may suggest a lack of confidence that
might be addressed through the provision of more
opportunities for training and counselling from the
early stages of medical school.
The time reserved for group discussion after the
clinical encounters represented an opportunity to deal
with the students wish to understand the interrelated
aspects of medical practice. It is important to emphasise
that the students demand for some pathophysiology
was briefly considered in order to illuminate some
situations and to appraise the disease in question by
taking biological and molecular science issues into
account. At the group discussions, the students were
first asked to identify their patients given names. While
this practice might be seen as routine, it represents a
simple way of directing the students attention to the
patient as a person rather than as a subject of medical
attention only. From here, even the most interesting
clinical diagnosis was discussed in terms of how the
care of doctors and health professionals might lead to
better understanding and control of the disease according to the patients own interpretation. Cultural and
social values, rights, obligations, social responsibility
and other issues were brought to the undergraduates
attention in an effort to underline their value at an early
stage in the students medical education. This practice
adheres to a tenet that ought to be underlined by all
medical educators: that medical practice should always
consider the interest of the patient first. Practitioners
who comply with this rule allow their humanitarian
impulses to serve not only as a means of perfecting their
own practice of medicine but also as an end purpose of
medical practice. In other words, one ought not to learn
medicine from patients, but with persons who can
become partners in the search for some kind of mutual
well-being.
The programmes strategy is based on the SPICES
model (student-centred, problem-based, integrated,
community-based, elective and systematic). It is
student-centred in that questions are discussed with

 Blackwell Publishing Ltd M ED I C A L E D UC A T I O N 2003;37:119125

124

Directing student response to patient contact

J E Vieira et al.

an instructor, and problem-based in that clinical

appointments foster the themes for discussion,
although, as indicated by DREEM, there is an emphasis on memorising facts. The course lacks integration
with any other medical discipline and is not community-based. It is an elective discipline but it is hard to
distinguish as systematic or apprenticeship-based.
However, although there is a systematic approach to
the themes proposed, the opportunities are random,
which, in some senses, makes the course apprenticeship-based.11
It is interesting to note that DREEM detected the
main weaknesses in the course: namely, unfocused
teaching (perhaps related to the practices of the
General Medicine Service) and the short time spent
on teaching (very likely related to schedule pressure).
The students hesitation in discussion was reinforced by
their lack of memorising skills, conflicting with their
interest in some clinical conditions and undermining
their incipient capacity for clinical reasoning. In addition, these two results, relating to discussion and
memory, may indicate conflict in a previous situation
where students were challenged to memorise facts
instead of reasoning. The lack of precision in timekeeping is definitely a negative factor and must be
challenged seriously. It risks undermining the importance of time-keeping and its significance to the
doctor)patient relationship.
The 41 students completed the 295 questionnaires,
collated them and presented the results as a final
report, from which this paper originated. However, the
groups may have shown differences in the number of
encounters they observed, as the morning programme
had a higher number of appointments scheduled.
Moreover, there was no instructor control over the
ways in which students chose to complete their
questionnaires. Although this technical difficulty
seemed not to interfere with the main results presented, a stricter system of control might be proposed to
the students.
The students responses noted as low standard
deviations for the mean grades suggested the questionnaire generated fairly homogenous observations.
Considering that the students had filled in their notes
individually and collated them for the final report only
at the end of the programme, the low deviation may
suggest the instrument is sensitive to the attitudes
investigated. A similar instrument cited in an earlier
report showed almost the same profile for correlated
questions, although not in terms of means.4
In conclusion, early exposure to patients of medical
students as observers in outpatient departments should
be encouraged. Students should receive guidelines to be

followed and findings should be discussed at the end of

the period. The writing up of a report stimulates the use
of the written word for the organisation and presentation of data and ideas. The model can be adapted for
use in different kinds of medical schools, and requires
the same or usual number of hospital or primary care
attending physicians, and the usual facilities from
medical services. Further investigation should address
achievements throughout the medical course within the
context of the themes discussed here.

Contributors
JEV and MdPTN directed the students practice,
designed the questionnaire and prepared the manuscript. MdAM reviewed the text, discussed the results
and supervised the statistics.

Acknowledgements
We would like to thank the students and instructors
who participated in this study and Professor Moacyr
Roberto Cuce Nobre for his support and advice.

Funding
JEV, MdPTN and MdAM are staff members of the
Laboratory of Experimental Therapeutics I, Faculty of
Medicine, University of Sao Paulo, Brazil. This work
was supported by the Fundacao Faculdade de Medicina, a non profit-making organisation that provides
wage supplementing to laboratory staff.

References
1 Humphris GM, Kancy S. Assessing the development of
communication skills in undergraduate medical students. Med
Educ 2001;35:22531.
2 Donabedian A. The quality of medical care. Methods for
assessing and monitoring the quality of care for research
and for quality assurance programmes. Science
1978;200:85664.
3 Higgins PM. Teaching medicine in general practice: the Guys
experience. Med Educ 1989;23:50411.
4 Kiyohara LY, Kayano LK, Kobayashi MLT et al. The
patientphysician interactions as seen by undergraduate
medicine students. Sao Paulo Med J 2000;119:1014.
5 Hampshire AJ. Providing early clinical experience in primary
care. Med Educ 1998;32:495501.
6 White B. Measuring patient satisfaction: how to do it and why
to bother. Family Prac Manage 1999;6:404.
7 Roff S, McAleer S, Harden RM et al. Development and
validation of the Dundee Ready Education Environment
Measure (DREEM). Med Teacher 1997;19:2959.

 Blackwell Publishing Ltd ME D I C AL ED U C AT I ON 2003;37:119125

Directing student response to patient contact

J E Vieira et al.

8 Lieberman JA III. Medical education and patients psychosocial needs. J Family Prac 1999;48:6756.
9 Kefalides PT. Illiteracy: the silent barrier to health care. Ann
Intern Med 1999;130:3336.
10 Cantwell BM, Ramirez AJ. Doctor)patient communication:
a study of junior house officers. Med Educ 1997;31:1721.

125

11 Harden RM, Sowden S, Dunn WR. Some educational strategies in curriculum development: the SPICES model. Med
Educ 1984;18:28497.
Received 16 January 2002; editorial comments to authors 17 April
2002, 14 June 2002; accepted for publication 30 August 2002

 Blackwell Publishing Ltd M ED I C A L E D UC A T I O N 2003;37:119125