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Aged-Care Residents: A Resource for Student Clinical Experience
Nicole Koehler & Christine McMenamin
Monash University, Clayton, Victoria, Australia
Clayton, VIC 3800, Austraila
With an increase in the number of medical students and a decline in opportunities to access hospital patients means that alternative methods of providing formative year medical students with a real clinical experience have to be found. The aim of the present study was to examine students’ and elderly aged-care residents’ perceptions regarding aged-care residents being interviewed by medical students and whether residents are willing to be physically examined by supervised medical students. Second-year medical students (N = 187) and aged-care residents (N = 24) completed an anonymous survey regarding their perceptions of the interview. Medical students and aged-care residents generally had favorable perceptions of the interview. The majority of aged-care residents indicated that they would be willing to be physically examined by supervised medical students. These findings suggest that engaging aged-care residents may be a suitable avenue to provide opportunities for students to have clinical experiences during their studies.
Traditionally medical students attended hospitals to examine patients to practice their professional, communication, history taking and clinical examination skills in a Flexnerian type model.1 However, in more recent times patients have shorter hospital stays, are often too sick to be examined by students, and are more aware of their rights regarding medical student examinations.2-4 An increase in the number of medical students and medical schools within Australia together with a lack of availability of hospital patients has forced medical schools to seek alternative learning opportunities and clinical experiences.5,6
Residents within aged-care facilities often have multiple complex medical problems, and display excellent signs and symptoms (often better than those obtained from hospital patients) that would be useful for educational purposes. Additionally, anecdotal evidence suggests that these residents are usually available and willing to assist medical students. Unlike the short supply of hospital patients suitable for student examinations, there is no shortage of individuals in aged-care facilities because the elderly population within Australia is increasing (e.g., 11.1% and 13.5% of people living in Australia were aged over 65 years in 1990 and 2010 respectively).7
As part of undergraduate medical training at The University of Western Australia (UWA) students visited low-care residential aged-care facilities to interview residents. All residents were preselected as being suitable to participate in the program by personnel from the aged-care facility. Selected residents at these facilities were cognitively intact and able to consent to the interview. Whilst we acknowledge that it may not be easy for inexperienced medical students to establish residents’ predominant complaints given some of the complex medical histories, it must be kept in mind that the purpose of the exercise was not for students to attempt to obtain a detailed history to the same standard as that of an experienced clinician. The aim of the interview was for students to enhance their communication skills, learn how to establish rapport with patients and to practice taking a medical history. The learning experience was specifically not intended for students to make diagnoses or prepare management plans. Interviews were conducted in pairs. During these interviews students obtained background information on the resident such as basic demographics, their duration in residential care, their current amount of social contact, and a complete medical history. Additionally, the one on one nature of the interview provided an opportunity for the resident to impart some of their own life experiences to young medical trainees with limited life experiences. Aged-care residents have informally commented on how much they enjoyed being interviewed by medical students.
Previous studies examined patients’ perspectives of being interviewed by a pair of students in their home, patients’ perspectives of being interviewed by students at a hospital, students’ and patients’ perspectives on bedside teaching, and students’ and patients’ perspectives on clinical teaching in out-patient clinics.8-11 Patients generally enjoyed being involved in the medical education practice and were generally not anxious of the event.8-11 Furthermore, the majority of patients indicated that they would recommend other patients to participate in this activity and would participate again in the future.8,10,11 Thistlethwaite and Cockayne found that 98% of patients indicated that they felt that the students benefited from the interview.8 Students within Nair et al.’s and Robertson et al.’s studies reported that the experience was valuable in terms of developing their professional, communication, and medical history taking skills.10,11 Only a minority of patients reported that they felt that the teaching practice with students breaches confidentiality.10,11
Although, patients in previous studies generally responded positively in relation to interacting with medical students, there were some issues of concern. Patients within Thistlethwaite and Cockayne’s study indicated in their free written comments that some students were unable to sustain an interesting and long interaction with them and recommended that students should be adequately briefed prior to the interview.8 When patients within Nair et al.’s and Robertson et al.’s studies were asked whether they were adequately informed of the session with a medical student prior to the event taking place 37% and 73% of patients respectively reported this.10,11 To the best of our knowledge, no study has directly evaluated students’ and patients’ perspectives, within one study.
This study explores the novel idea of engaging aged-care residents in the education of medical students to provide clinical experiences which were normally obtained in a hospital setting. Furthermore, this study explores whether aged-care residents would be prepared to participate in non-invasive physical examinations by supervised medical students. Therefore the aims of the present study were twofold. First, we intended to examine medical students’ and aged-care residents’ perceptions regarding the medical student interview of aged-care residents (e.g., whether these perceptions are mutual and whether both parties benefited from the experience). Second, we intended to determine whether aged-care residents would be willing to take part in non-invasive physical examinations by supervised medical students. If aged-care residents have positive perceptions of the medical student interviews and are willing to be physically examined then accessing aged-care residents in the future could provide a potential solution to the problem of accessing patients in health care facilities.
All 2008 and 2009 second-year medical students enrolled in the Foundations in Clinical Practice unit at UWA were asked to complete an anonymous survey pertaining to their perceptions of interviewing aged-care residents. The 2008 cohort of second-year medical students took part in interviewing aged-care residents twice; once while they were first-year students and once while they were second-year students. On the other hand the 2009 cohort of second-year students only took part in the aged-care interview once as second-year students.
Aged-Care Resident Participants
Residents were surveyed in 2009. These residents were surveyed towards the end of September 2009 immediately after they participated in the August/September 2009 interview with students. A proportion of these residents had been involved in the student interviews since 2005. Most residents had some form of health related problems – mainly age related (e.g., mobility difficulties). All residents were able to provide informed consent.
Nine aged-care facilities within the Perth (Western Australia) metropolitan area were visited by UWA medical students. For three aged-care facilities students were assigned to a specified resident prior to the visit. Thus the names of these residents were known and therefore a personalized survey package was sent to these residents (N = 18). Students were asked to seek out residents from a preselected pool on their arrival at the remaining six aged-care facilities and thus residents’ names were unknown and remain anonymous. Based on the number of students that attended each facility an equivalent number of survey packages (N = 84) were sent to these aged-care facilities. In this instance care managers were asked to distribute survey packages to the residents concerned.
Ethics approval for the present study was obtained from the UWA Human Research Ethics Committee. The 2008 and 2009 cohorts of students completed the survey within their final lecture (end of October 2008) and in one of their tutorial classes (end of September 2009) respectively. Students were informed that completion and return of the survey implied consent. All residents received a survey package which contained a covering letter inviting them to participate in the study, an information sheet regarding the survey, a consent form which they were asked to sign and return with the survey and a survey written in a large bold font. All participants were informed that all information obtained would be kept confidential. No names or other identifying information was recorded on the surveys.
Students were asked to indicate their gender and age. They were then asked to rate 14 statements on a 7-point Likert scale (1 = strongly disagree, 7 = strongly agree) regarding interviewing aged-care residents while they were in their second year of medicine (see figure 1). Students were also asked whether they would recommend future medical students to participate in the aged-care resident interview (yes vs. no) and to provide a reason for their response.
Aged-Care Resident Survey
Aged-care residents received a survey that was analogous to the student survey with questions being phrased from the resident’s perspective. Aged-care residents were asked to indicate their gender, age and duration in residential care. They were then asked to rate 17 statements on a 7-point Likert scale (1 = strongly disagree, 7 = strongly agree) regarding the interview with medical students (see figure 2). To avoid potential confusion in relation to using the scale a few prompting words relevant to the question were written underneath the scale labels. For example, for the statement “Students were dressed professionally” the words “unprofessional” and “professional” were written underneath “strongly disagree” and “strongly agree” respectively. Aged-care residents were asked whether they would be willing to have a non-invasive physical examination by a supervised medical student (yes vs. no) and provide a reason for their response.
Ninety-one students (n = 47 females) and 96 students (n = 52 females) in the 2008 and 2009 cohorts respectively completed the survey. Students in the 2008 and 2009 cohorts had mean ages of 20.1 years (SD = 2.9; range = 17 – 41, n = 91) and 19.7 years (SD = 1.2; range = 18 – 24, n = 95) respectively.
Rating Scales On average students were on the agree side of the scale for positive statements (statements 1-4, 7, 10-14) and on the disagree side of the scale for negative statements (statements 5, 6, 8, 9) (see figure 1). A one-sample Wilcoxon Signed Rank Test was performed to determine whether the median rating of each statement significantly differed from the midpoint value of the scale (4; i.e., neutral). With the exception of the following three statements pertaining to: 1) the resident explaining responses further if the student did not understand what the resident meant (2008 and 2009 cohorts); 2) the resident being easy to understand (2008 cohort); and 3) the resident not listening to questions asked by the student (2008 cohort), all median ratings were significantly different from the scale’s midpoint value (all ps <.05).
Recommendation of Aged-Care Resident Visit One hundred and fifty-six students (2008 cohort: n = 75; 2009 cohort: n = 81) responded that they would recommend future medical students to participate in the aged-care resident interview, whereas 23 students (2008 cohort: n = 12; 2009 cohort: n = 13) stated that they would not recommend it.
All written comments made by students and residents were independently categorized by the authors. All discrepancies between categorizations were discussed until a decision was reached. Improving communication skills and obtaining experience were the most common reasons stated for why students recommended future students to participate in the aged-care resident interview by the 2008 and 2009 student cohorts respectively (see table 1 in Appendix). Residents having cognitive impairments (e.g., dementia, Alzheimer’s) were the most common reasons cited amongst the 2008 cohort of students for not recommending future students to participate in the aged-care resident interview. On the other hand, amongst the 2009 cohort of students the most common reason cited for not recommending future students to participate in the aged-care resident interview was that students felt that they did not learn anything (see table 1 in Appendix).
Completed surveys were received from 24 aged-care residents (n = 13 females). These residents had a mean age of 85.25 years (SD = 8.42, range = 62 – 98, n = 24), and had spent an average of 2.54 years (SD = 2.43, range = 0.21 – 10, n = 24) in residential care.
Rating Scales Mean ratings for positive statements (1, 3, 5, 6, 9, 14-17) were on the agree side of the scale whereas mean ratings for negative statements (2, 4, 7, 8, 10-13) were on the disagree side of the scale (see figure 2). Like the students’ ratings, a one-sample Wilcoxon Signed Rank Test was performed to determine whether residents’ median ratings significantly differed to the scale’s midpoint value (4; i.e., neutral). The median scores for all statements significantly differed from the midpoint of the scale (all ps < .001).
Physical Examination Nineteen residents indicated that they would be happy to be physically examined by a supervised medical student. The most frequent reasons cited for participating were that they wanted to help medical students (n = 5), that students must obtain experience examining patients (n = 5) and that students need to learn (n = 5). Two residents indicated that they would not be happy to be physically examined by a supervised medical student. One of these residents reasoned that they “do not think there is any need for it" whereas the other did not provide a reason. Another resident indicated that they would not permit to be physically examined by a supervised medical student but commented that "They can do it". Two residents did not answer this question.
In general medical students had positive perceptions of the aged-care resident interview. Similarly to Nair et al.’s and Robertson et al.’s studies on hospital based teaching, medical students generally perceived the aged-care resident interview valuable in terms of developing their professional, communication, and medical history taking skills.10,11 Ratings pertaining to developing communication skills reflected in students’ comments on why they would recommend future medical students to participate in aged-care resident sessions. Although most students recommended the session a few students did not. Some of these reasons centered on having patients with cognitive impairments thus making communication with these patients difficult. However, it must be noted that these were not actual diagnoses but students’ perceptions given that all residents at these facilities were cognitively intact. Students should see the limitations they noted, irrespective of whether they were correct perceptions or not, positively in that they were given the opportunity to practice their communication skills in a challenging situation. On the other hand, some students explicitly stated that they valued such challenges. For example, one student positively commented that the task of interviewing the resident was difficult and thus challenged him to find a way to obtain the information he required.
Overall, aged-care residents had positive perceptions of the aged-care resident interview. Similar to previous studies involving medical students interacting with real patients in a hospital setting aged-care residents in the present study on a whole were not anxious at being interviewed by medical students.10,11 As with patients in Thistlethwaite and Cockayne’s study, aged-care residents also felt that the students benefited from the interview.8 Mean ratings on whether the interview with medical students breached confidentiality suggests that this was not the case in the present study which is consistent with Nair et al.’s and Robertson et al.’s studies involving students interacting with hospital patients.10,11 On average, aged-care residents rated that they were adequately informed of the interview with medical students prior to the event taking place. These results are an improvement to those reported by Nair et al. in which only 37% of patients reported that they were adequately informed of the session with a medical student prior to the event taking place.10 Aged-care residents also responded positively to the notion of permitting medical students to practice their physical examination skills on them.
Thus taken together, aged-care residents’ perceptions regarding the interactions they had with medical students are equivalent, if not superior, to the interactions between medical students and patients in health care facilities reported by previous studies.8,10,11 Therefore, the participation of aged-care residents as a means of providing formative year medical students with a clinical experience involving real patients may be an alternative avenue to traditional hospital based clinical experiences.
In conclusion, medical students and aged-care residents generally had positive attitudes towards the interview. Furthermore, aged-care residents indicated that they would be willing to be physically examined by supervised medical students. Thus engaging aged-care residents as a means of exposing formative year medical students to real patients may be a viable solution to overcoming the shortage of accessing real patients in health care facilities.
Medical history taking, physical examination, real patients
Notes on Contributors
NICOLE KOEHLER, BSc (Hons), MSc, PhD, Grad Dip Ed is a research fellow at the Faculty of Medicine, Nursing & Health Sciences, Monash University, Clayton, Victoria, Australia.
CHRISTINE MCMENAMIN, BSc (Hons), PhD, MBBS, DCH, FRACGP is the director of curriculum (MBBS) at the Faculty of Medicine, Nursing & Health Sciences, Monash University, Clayton, Victoria, Australia.
- Flexner A. 1910. Medical education in the United States and Canada: A report to the Carnegie Foundation for the Advancement of Teaching. Boston: Updyke.
- Braunack-Mayer AJ. Should medical students act as surrogate patients for each other? Medical Education 2001; 35: 681-686.
- Wearn A, & Vnuk A. Medical students and peer physical examination: Two case studies of strategies to improve safety and increase acceptance. Focus on Health Professional Education: A Multidisciplinary Journal 2005; 7: 88-98.
- Annas GJ. A national bill of patients' rights. New England Journal of Medicine 1998; 33: 695-699.
- Eley DS, Young L, Wilkinson D, Chater AB & Baker PG. Coping with increasing numbers of medical students in rural clinical schools: options and opportunities. Medical Journal of Australia 2008; 188: 669-671.
- Joyce CM, Stoelwinder JU, McNeil JJ & Piterman L. Riding the wave: current and emerging trends in graduates from Australian university medical schools. Medical Journal of Australia 2007; 186: 309-312.
- Australian Bureau of Statistics, 2010, Population by Age and Sex, Australian States and Territories, cat. no. 3201.0, viewed 5th April 2012, http://www.abs.gov.au/ ausstats/abs@.nsf/mf/3201.0
- Thistlethwaite JE & Cockayne EA. Early student-patient interactions: the views of patients regarding their experiences. Medical Teacher 2004; 26: 420-422.
- Thomas EJ, Halfler JP & Woo B. The patient’s experience of being interviewed by first-year medical students. Medical Teacher 1999; 21: 311-314.
- Nair BR, Coughlan JL & Hensley MJ. Student and patient perspectives on bedside teaching. Medical Education 1997; 31: 341-346.
- Robertson A, Gibbons P & Carter A. Student and patient perspectives on the interaction between supervisors students and patients during the clinical teaching experience at a university out-patient clinic: a descriptive pilot study. Journal of Osteopathic Medicine 2002; 5: 8-15.
Table 1. Reasons students stated for why they would or would not recommend future medical students to participate in interviewing aged-care residents. Please note that more than one reason was given by some students whereas others gave no reason. The term “hostel resident” is equivalent to the term “aged-care resident”.
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Keywords: Medical history taking, physical examination, real patients
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