Consent and confidentiality in teaching in general practice: survey of patients' views on presence of students

Introduction

Medical schools are expanding their teaching in general practices,1 2 but there are few studies on patients' responses to the presence of medical students at consultations with general practitioners. In 1974 Wright reported that up to 40% of patients in one practice preferred not to discuss personal anxieties, family problems, or sexual problems in the presence of a student.3 Seabrook and Evans discussed general practice teaching with patients and carers.4 Patients expressed concern about whether they would be given a choice about a student being present and reported bad experiences of hospital teaching. Most recently, Cooke et al concluded from a questionnaire survey that only 3% of patients had negative views about the presence of a student.5 We report patients' views about consent and confidentiality using a questionnaire developed from semistructured interviews.

Subjects, methods, and results

The questionnaire had four sections. The first dealt with the patient's past experiences of students in general practice. The second asked about the methods used to inform the patient about the presence of the student. A Likert scale, based on issues that arose in the semistructured interviews, was used to assess the patient's feelings about the presence of a student during consultations. Patients were also presented with scenarios and asked whether they would agree to a student being present in the consulting room.

A total of 480 questionnaires were sent to patients who had attended a teaching surgery in London or Newcastle upon Tyne, and 335 were returned and suitable for analysis; the response rate in London was 60% (149/246), and in Newcastle 79% (186/234). The age and sex distributions at each centre were identical: mean age 50 years; 60% female (90/149 in London and 110/186 in Newcastle). Sixty per cent (87/145) of non-respondents were also female.

In both samples, 95% of patients (141/149, London; 176/186, Newcastle) were happy for students to be present during an examination again, but their consent depended on the clinical scenario. All the patients in London and 97% (180/185) of those in Newcastle were happy to have a student present if they had a sore throat, and 95% of both groups (142/149, London; 176/186, Newcastle) would agree if they were consulting because of a chest infection. Of the patients in London 70% (101/145) would agree if the consultation was for emotional problems, as would 67% (125/185) of the patients in Newcastle, but only 50% of patients in both centres (74/149, London; 92/186, Newcastle) would agree to a student's presence if an internal examination was required. Less than 50% (70/145, London; 71/186, Newcastle) would agree if they were consulting because of a sexual problem. Women were significantly less likely to wish to see a student for emotional problems (χ² =5.22; P<0.05), an internal examination (χ²=6.77; P<0.01), or a sexual problem (χ²=4.88; P<0.05).

Altogether 18% (27/149) of the London patients and 9% (17/186) of those in Newcastle had not been asked if they agreed to a student being present, and a larger proportion—28% (39/140) in London and 11% (21/186) in Newcastle—thought that they did not have a choice. Patients had clear views about how they should be informed (1). Preparatory interviews had suggested that patients considered confidentiality important; this is reflected in responses to the questionnaire. Many patients were concerned about students' access to their case notes and whether discussions about patients occurred after they had left the consulting room.

Comment

Although there is general support among patients for the presence of undergraduate students in general practitioners' surgeries, those responsible for organising undergraduate teaching programmes should pay attention to the need to give patients a real choice about whether they see a student. Patients' concerns about access to their records and discussion of their case is problematic as these are often integral to students' learning during teaching consultations. Whether it is appropriate to explain these aspects of teaching to patients requires further consideration.