Patient Satisfaction with Medical Student Participation in the Private OB/Gyn Ambulatory Setting Katie G. Mellington, MD Faculty Mentor: Benjie B. Mills, MD
Disclosure The authors have no meaningful conflicts of interest
Background Access to healthcare is a profound problem worldwide AAMC projects a shortage of 61,700 to 94,700 physicians by 2025 in the US Training capacity must increase to fill this demand 1
Background In 2014, there were 223 active physicians per 100,000 people in SC Deficit of 28 physicians per 100,000 people compared to the rest of the US 2 USCSOM-G was created to help satisfy this demand 45% of those graduating in SC will stay in SC
Background Meaningful educational opportunities needed Academic medical institutions are at maximum capacity More community preceptors are desired to fill this need Barriers to increasing community physician engagement Perceived decrease in patient satisfaction Fear of decreased productivity Concern for increased time required per patient
Background Patient satisfaction and acceptance of medical students is high 75.8% of patients across multiple disciplines are willing to accept students 8-10 Patients have a desire to contribute to the education of students and prefer to be informed before the medical student arrives 5 Student gender is a factor in patient acceptance of students Male students receive less extensive experience in OB/Gyn due in part to patient refusals 4 Patient comfort is higher with female vs. male students in OB/Gyn 12
Objectives Primary To compare patient satisfaction with their OB/Gyn visit when seen by an attending & medical student pair with patient satisfaction when seen only by an attending Secondary To determine if differences in patient satisfaction, comfort, and other measures exist based on Demographic data Visit characteristics Student gender Tertiary Provide pilot data for validation of the survey instrument
Methods Survey study design Pilot study for questionnaire validation Setting: Greenville Health System Department of OB/Gyn private practice offices Inclusion criteria Patients seen by a provider who serves as a community preceptor Outpatient visit Exclusions < 18 years of age Not willing to read consent and instructions Not voluntarily filling out survey
Methods Patients were asked to voluntarily fill out a survey about today s visit and medical student participation at time of checkout Survey instrument Demographic and visit data Satisfaction and comfort with the visit Likelihood of returning to the provider Likelihood of referring provider to family and friends Assessment of patients desired level of medical student involvement
Visual Analog Scale Traditionally used for pain measurement Increasing usage for subjective factors More accurate than Likert scales Distance in mm = score 0 Very Dissatisfied 100 Very Satisfied
Validation Validation Collingridge method Step 1 Evaluate face validity Step 2 Run a pilot test Step 3 Clean collected data Step 4 Use Principal Components Analysis (PCA) Step 5 Check internal consistency Step 6 Revise your survey
Methods Validation of the instrument Collingridge method Step 1 Evaluate face validity Step 2 Run a pilot test Step 3 Clean collected data Step 4 Use Principal Components Analysis (PCA) Step 5 Check internal consistency Step 6 Revise your survey
Statistical Analysis A 15% difference in patient satisfaction, comfort, happiness, or likelihood was considered significant A power calculation revealed an appropriate sample size to be 23 participants in each group α = 0.05, β = 0.1
Statistical Analysis JMP Pro 12 used for statistical analysis Least squares used to calculate means and standard errors t-tests used to compare means Linear regression and Pearson s chi-square test were used in evaluation of the extent of medical student participation allowed by the patient Pearson s chi-square test was used to evaluate length of visit
Results 66 Surveys Collected 1 survey excluded No answer on student involvement 32 No Student 33 With Student 6 Declined Student 26 No Student Available
Results No differences in demographic characteristics between the two groups Patient satisfaction scores were high, with and without students No statistical differences in satisfaction scores based on presence of a med student alone No differences in length of visit with and without students
Effect of Age 100 95 90 85 < 40 with Student (n=21) >/= 40 with Student (n=12) < 40 without Student (n=20) >/= 40 without Student (n=11) 100 NS NS NS NS p=0.017 NS p=0.025 p=0.008 95 90 85 80 Satisfaction Comfort Likelihood of Return Likelihood of Referral 80 Satisfaction Comfort Likelihood of Return Likelihood of Referral
Effect of Race/Ethnicity 100 White with Student (n=30) White without Student (n=28) p=0.018 p=0.030 100 Other race/ethnicity with Student (n=3) Other race/ethnicity without Student (n=3) NS NS NS NS 95 NS p=0.020 95 90 90 85 85 80 Satisfaction Comfort Likelihood of Return Likelihood of Referral 80 Satisfaction Comfort Likelihood of Return Likelihood of Referral
Effect of Provider Gender Female with Student (n=23) Male with Student (n=10) Female without Student (n=25) Male without Student (n=7) 100 NS NS NS NS 100 NS NS NS NS 95 95 90 90 85 85 80 Satisfaction Comfort Likelihood of Return Likelihood of Referral 80 Satisfaction Comfort Likelihood of Return Likelihood of Referral
Effect of Visit Type OB with Student (n=13) Gyn with Student (n=20) OB without Student (n=5) Gyn without Student (n=26) 100 NS NS NS NS 100 p=0.021 p<0.001 p=0.013 p=0.012 95 95 90 90 85 85 80 Satisfaction Comfort Likelihood of Return Likelihood of Referral 80 Satisfaction Comfort Likelihood of Return Likelihood of Referral
Student Gender Has No Effect Male Female Student (SE) Student (SE) p-value Visit Satisfaction 81.5 (6.1) 95.8 (8.6) 0.094 Visit Comfort 80.6 (6.2) 95.3 (8.8) 0.091 Likelihood of Return 84.3 (6.2) 94.3 (8.7) 0.178 Likelihood of Recommendation 83.6 (6.4) 92.3 (9.0) 0.219 n (%) n (%) p-value Allow Med Student Yes, always 20 (87) 6 (67) 0.186 No or Yes, with restrictions 3 (13) 3 (33) Allow Med Student to Observe Exam Allow Med Student to Perform Exam Yes, always 18 (78) 4 (44) 0.069 No or Yes, with restrictions 5 (22) 5 (56) Yes, always 12 (52) 2 (22) 0.125 No or Yes, with restrictions 11 (48) 7 (78)
Strengths Variety of preceptors queried Only one survey eliminated Use of Visual Analog Scale instead of a Likert scale Large number of male students 9.2% of patients declined a student vs. 24% in the published literature Many survey instrument questions were adapted from Press-Ganey
Limitations Not every patient answered every question (missing data) Very few comments Alteration of perception on responses due to internal and external factors Respondents had to be aggregated into larger groups due to small numbers in more narrow categories (e.g., age, race/ethnicity) Limited generalizability because the patient population was very specific
Conclusions Patient satisfaction, comfort, likelihood of returning to provider, and likelihood of recommending provider to others are all very high with or without medical student participation Some statistically significant differences were noted in patients who were 40 and older, white, and being seen for a Gyn visit Scores remained 82% or higher Patient satisfaction was not affected by student gender Length of visit was not affected by student participation
Discussion Small but significant differences in patient satisfaction were seen in patients who were > 40, white, or being seen for a Gyn visit This difference in satisfaction must be weighed against the anticipated physician shortage and the need to train more physicians
Future Work Conduct a Principle Components Analysis on the survey instrument and complete validation process Survey more practices with a broader patient population Study strategies to improve patient acceptance and satisfaction with student participation
References 1. The Complexities of Physician Supply and Demand: Projections from 2014 to 2025. aamc.org. Association of American Medical Colleges, 5 April 2016. Web. 26 April 2016. 2. 2015 State Physician Workforce Data Book: Center for Workforce Studies. aamc.org. Association of American Medical Colleges, Nov 201. Web. 26 April 2016. 3. Speicher MR, Sterrenberg TR. Students do not reduce patient satisfaction in a family medicine clinic as measured by a nationally used patient satisfaction instrument. Fam Med. 2015 Mar;47(3):227-30. 4. Buck K, Littleton H. Impact of educational messages on patient acceptance of male medical students in OB-GYN encounters. J Psychosom Obstet Gynaecol. 2016 Sep;37(3):84-90. 5. Vaughn JL, Rickborn LR, Davis JA. Patients' Attitudes Toward Medical Student Participation Across Specialties: A Systematic Review. Teach Learn Med. 2015;27(3):245-53. 6. Azher H, Lay J, Stupart DA, Guest GD, Watters DA. Medical student participation in a surgical outpatient clinic: a randomized controlled trial. ANZ J Surg. 2013 Jun;83(6):466-71. 7. Shah-Khan M, Chowdhry S, Brand MI, Saclarides TJ. Patient attitudes toward medical students in an outpatient colorectal surgery clinic. Dis Colon Rectum. 2007 Aug;50(8):1255-8. 8. Choudhury TR, Moosa AA, Cushing A, Bestwick J. Patients attitudes towards the presence of medical students during consultations. Medical Teacher. 2006;28:7, e198-e203 9. Mavis B, Vasilenko P, Schnuth R, Marshall J, Jeffs MC. Medical students' involvement in outpatient clinical encounters: a survey of patients and their obstetricians-gynecologists. Acad Med. 2006 Mar;81(3):290-6 10. Thurman AR, Litts PL, O'Rourke K, Swift S. Patient acceptance of medical student participation in an outpatient obstetric/gynecologic clinic. J Reprod Med. 2006 Feb;51(2):109-14. 11. Law M, Hamilton M, Bridge E, Brown A, Greenway M, Stobbe K. The effect of clinical teaching on patient satisfaction in rural and community settings. Can J Rural Med. 2014 Spring;19(2):57-62. 12. Carmody D, Tregonning A, Nathan E, Newnham J. Patient perceptions of medical students involvement in their obstetrics and gynaecology health care. ANZOG 2011; 51: 553 55.