Medical student teaching in a private hospital: A positive experience for patients, students, and staff.

Title: Medical student teaching in a private hospital: A positive experience for patients, students, and staff.

Short Title: Medical student teaching in a private hospital.

Authors: Farnaz Sanaei, Margaret Schnitzler, Kirsty Foster & Mark Arnold.

Institution: North Shore Hospital St Leonards, Sydney NSW, AUSTRALIA and the Northern Clinical School, University of Sydney, NSW, AUSTRALIA

Corresponding Author: Associate Professor Mark H Arnold, Northern Clinical School, Level 7 Kolling Building Royal North Shore Hospital St Leonards, Sydney NSW AUSTRALIA. A/Prof Arnold’s contact details: Tel: 61 029 419 5258. FAX: 61 029 413 3458. EMAIL: [email protected]

Author Details: Farnaz Sanaei RM, B Sc M Sc PhD, Project Manager North Shore Private Hospital and Northern Clinical School University of Sydney, Sydney NSW AUSTRALIA. Margaret Schnitzler MB BS (Hons) FRACS PhD, Academic Coordinator (Surgery) North Shore Private Hospital, Associate Professor (Surgery) Northern Clinical School, Staff Specialist, Royal North Shore Hospital, and Visiting Medical Officer, North Shore Private Hospital, St Leonards, Sydney NSW AUSTRALIA.. Kirsty Foster BSc MB ChB MRCGP DRCOG MEd (ALGC) PhD, Senior Lecturer in Medical Education & Sub Dean Education, Sub Dean International, Northern Clinical School, University of Sydney, Sydney NSW AUSTRALIA.. Mark H Arnold MB BS FRACP MBeth, Academic Coordinator (Medicine) North Shore Private Hospital, Associate Professor (Medicine) Northern Clinical School University of Sydney, VMO Rheumatologist, Royal North Shore Hospital and Visiting Medical Officer North Shore Private Hospital, St Leonards, Sydney NSW AUSTRALIA.

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Abstract Title: Medical student teaching in a private hospital: A positive experience for patients, students, and staff. Authors: Farnaz Sanaei, Margaret Schnitzler, Kirsty Foster & Mark H. Arnold

Objectives: To assess the acceptability and feasibility of introducing medical students into clinical placements in a private hospital. Design, setting and participants: North Shore Private Hospital is co-located with Royal North Shore Hospital and Northern Clinical School. Following the introduction of medical student clinical placements, focus groups and detailed interviews were conducted with 32 medical students, 28 patients, 30 Visiting Medical Officers and allied health staff. In addition, a semi-structured questionnaire was administered to 158 patients. Written student evaluation of each placement was also reviewed. Data were analysed using descriptive statistics and thematic analysis. Main outcome measures: We assessed whether student teaching was practically achievable in this setting and acceptable to all participants. The views and attitudes of participants toward medical students in a private hospital were also explored. Results: There was a high degree of acceptability amongst all groups of participants. 94% of patients were willing to be interviewed and examined by medical students. Some major themes identified were the favorable environment, enhanced access to clinical settings and experiences, overall advantages for all participants and potential challenges. Conclusions: Medical student teaching in a large private hospital can offer accessible and suitable clinical training opportunities. The concept of private hospital inpatients participating in student education is acceptable to patients, students, teachers and allied health staff. Perceived barriers to the participation of private patients in student teaching did not materialize from the perspective of any of these groups.

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Introduction Medical students numbers have increased significantly from 2007 to 2012 (Medical Deans of Australia and New Zealand, 2012). The Australian and New Zealand Medical Deans’ 2008 National Clinical Training Review suggested that changes in the established manner of teaching would be required to meet this demand (Medical Deans of Australia and New Zealand, 2008). The majority of elective surgery in Australia is now performed in private hospitals, as is much obstetric care (Dent MM et al., 2010, Brown L and Barnett JR, 2004) and other procedural work (Brown L and Barnett JR, 2004). More often, patients with chronic diseases are managed in non-hospital ambulatory settings, and these two trends potentially limit students’ exposure to the very conditions which they will deal with in their working lives (Dent MM et al., 2010). Prior to the expansion in medical student numbers, local research indicated that as many as 49-60% of patients in public hospitals may be practically unavailable to participate in student teaching (Olson LG et al., 2005, Calenza A et al., 2011), necessitating “ alternatives to teaching hospitals for acquiring clinical skills”, and likewise Crotty opined that we “urgently need to expand clinical teaching into the private sector”(Crotty BJ, 2005). Armstrong’s observation that “patients on the private teaching services are as sick and present the same general range of illness as do the public teaching ward patients” (Armstrong SH, 1952) holds true for case-mix comparisons between Australian private and public hospitals (Nichol B, 2007). In Australia, there are several co-located public teaching and private hospitals (Brown L and Barnett JR, 2004) which offer an opportunity to expand teaching capacity (Brooks PM et al., 2003), though in the Australian setting (Crawford D, 2010), this mode of student teaching has only recently been specifically evaluated (Tiong MK et al., 2013) The establishment of NSPH as a teaching hospital of the University of Sydney (UoS) allowed us the opportunity to study a collaborative approach to the clinical education of medical students in a private hospital collocated with a UoS teaching hospital, and well established clinical school.

Methods: Setting North Shore Private Hospital (NSPH) is a 241 bed hospital co-located with a 628 bed teaching hospital Royal North Shore Hospital (RNSH). Graduate students at the Sydney Medical Program (SMP) from stages 1-3 (years 1-4) received part of their clinical training at NSPH. In 2010 funding was received from the Department of Health and Ageing to increase clinical training capacity and NSPH was utilised to provide additional clinical placements. An ethnographic approach was used to capture the views of inpatients, stage 3 students spending a one month clinical attachment and staff at NSPH. Ethical approval was obtained from the UoS Human Research Ethics Committee and Northern Sydney Central Coast Human Research Ethics Committee. Data collection and analysis

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Data collection involved in-depth one-on-one and (focus group interviews) with all involved (n= 28 inpatients, 30 staff and 32 students). In addition, a patient questionnaire was developed using the literature and piloted with patients, Visiting Medical Officers (VMOs) and University faculty staff before final administration to all patients (n=158). Interviews were transcribed and analysed thematically. Descriptive analysis was performed on data generated from the questionnaires.

Results: More than 90% of inpatients were willing to be involved in medical student history taking, physical examination and the observation of procedures. Only eight of the 158 patients to whom the questionnaire was administered expressed that they did not want to be involved.

Questionnaire results are presented in Table 1: “Patient responses to questions about involvement in medical student teaching”.

Four main themes were identified via descriptive analysis: 1. Enhanced access to clinical settings and experiences The private setting provided students with opportunities that may not always be available in the public attachment. a. Interaction with VMOs VMOs and students expressed the view that teacher-student interactions were more individualised in the private setting, in the office and operating theatre. “But I think here (Private) they certainly benefit from one to one time with a VMO that often you don’t get at all in the public hospital” (VMO33) b. Less competition for patient access The small number of students and the lack of junior medical staff at NSPH contributed to the favourable clinical experience. In the operating theatre, students had more opportunity to assist during surgery. “I think really the lack of other students is the main advantage here because you don’t go into a patient and you never get the excuse that they’ve already seen fifty thousand other students..”(S28 Y3). “So basically there are a lot of students... and it’s not just students but also interns, registrars. Everyone is in different stages of their training, so you are all vying for teaching opportunities and teaching time with clinicians” (S2Y3).

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c. Inter-professional learning Nursing staff generally have greater clinical responsibility where there are few junior doctors, and students valued the close relationships with nursing staff. “Well I think it’ll just get that relationship brewing between the nursing staff and the doctors because obviously we have to work very close together so it’ll just kind of show the doctors what the nurses actually do and I suppose visa-versa with the nurses …” (NUM9) “In terms of nursing and the clinics, they were very valuable experiences, because you get to see how the hospital is run in all aspects of health care rather than just the specialists and the doctors” (S4- 7Y3).

2. Favourable environment The hospital environment was considered to be conducive to a detailed and confidential discussion of patient history, and physical examinations. Clinicians found it easier to find patients who were suitable for, and willing to be involved in teaching. Patient refusals were the exception. Teaching was rated to be more pleasant, and less rushed. a. Layout of rooms and wards Almost all rooms are single occupancy, allowing greater patient privacy and confidentiality. In the adjacent public hospital, most patients are accommodated in four bed wards, making discussion of sensitive clinical or social issues difficult. Yeah it just made it a lot easier being in a private room. You just shut the door and chatted to them and you don’t have to worry about your voice being too loud. It made it much easier. (S24-S26 Y3) “The teaching environment has been really favorable. The physical surroundings, the single rooms, privacy, quiet, that just makes it a lot easier then if you’re in a ward situation with thin curtains and lots of noise” (VMO34) b. Hospital less busy The hospital environment is generally quieter and teaching is less frequently interrupted by day to day ward activities. As distinct from their experiences in a public hospital, students feel that they are less of a disruption to ward activities. “I definitely agree in terms of the hospital environment that it’s a lot less crazy than in the wards. A lot more privacy that really helps when you are doing history and examinations”(S8-S10 Y3). “They perhaps can have a bit more time with the patients because they’re not as rushed and there’s not as many people around and not as many students. So therefore they probably get a little bit more benefit in that regard” (VMO33). c. Co-location with Public Hospital and University

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The co-location of NSPH with RNSH allows students to access the physical facilities and resources of the Northern Clinical School and to attend scheduled teaching sessions. In addition, students are able to interact and socialise with their peers who are attached to RNSH, reducing any perception of isolation. Students are able to see patients in both hospitals, maximising their clinical exposure. “Having a campus like this, where the private and public are side by side, it just doubles the amount of learning that the students can get exposed to” (VMO30). 3. Overall advantages a. Patients’ sense of contributing to medical training The majority of patients were willing to have medical students involved in their care, recognised the need for students to have patient contact, and were positive about their contribution to medical education. “It’s great! I mean people have got to learn and they’re only going to learn with experience. The best way they can is to talk to patients. And if patients give them the right feedback well they’ll even learn more” (P9). “The patients that we’ve asked to have the medical students have been very grateful. They’ve had no problems ever accepting that. I was always a little bit worried that they’d feel unusual about that, but in fact they’ve been very grateful” (VMO35) b. Staff development Some staff commented that the presence of students encouraged them to maintain a high standard of care and to demonstrate evidence-based practice. “Well it’s always good for me because it always challenges me and makes me think okay maybe I need to explain that a bit more and do I know it as well as I should?” (VMO35). “I think having medical students does keep you on your toes and keep you somewhat ensuring that what you’re saying is legitimate and correct and right” (VMO30). c. Reduced pressure on the Public Hospital system The scheduling of bedside tutorials at NSPH reduces congestion on the public hospital wards, particularly in Stages 1 and 2 when all tutorials are scheduled on one or two days each week. “Well it has been an untapped resource because so much of patient care is in the private setting, particularly elective surgery. So I suppose it’s giving access for students to that large group of patients who haven’t been traditionally involved” (VMO34).

d. Better understanding of different health systems Another benefit of exposing medical students to the private sector is to give them general experience of this health care setting. The exclusion of exposure to this substantial component of hospital services from medical education presents an unbalanced view of the health care system.

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“For the students, I think it’s given them insight into another whole part of the health system that they otherwise wouldn’t have had. It’s a significant area of Australian health care” (VMO34). “Seeing the two sides of health care in Australia, rather than just the public system…its pretty useful ” (S4-7Y3). 4. Challenges encountered Participants identified some challenges which may have an impact on the clinical experience of students. a. Lack of medical team structure One major challenge indentified was the lack of a medical team structure at NSPH. While there are accredited registrars as well as fellows in several specialties, there are no interns or residents. Ward care is provided by nursing staff with input from career medical officers (CMOs). This means that students had to be more self-directed, particularly in ward-based activities. “Well the big difference is usually there’s not a junior medical officer team in the private hospital... So in that sense there’s less of a unit structure, which I think can be a disadvantage” (VMO34). “… one difference between being in the public and the private was that because patient care is so focused on the nurses rather than having the interns and the residents running around, they tend to give us things to do, like taking blood…”(S17-S19Y3). b. Lower patient acuity The acuity level of patients is generally lower at NSPH than in the public hospital, particularly as most emergency patients are admitted via the Accident and Emergency Department at RNSH. Patients with multiple co-morbidities and complex social problems are also less likely to be admitted to private hospitals. “I guess in terms of patients at the Private there wasn’t any acute surgery and I think that’s one thing that would have been interesting; maybe some acute general surgery. And then, I guess in terms of complexity, some of the patients weren’t particularly complex”(S31).

c. Potential decrease in efficiency Staff commented on how the presence of students can have an impact on their work practices, particularly with regards to time management. “You’re sort of a little bit slower obviously because you want to sit down and explain it to them…” (VMO33) “ The only challenge would be if the work load is really heavy and they do impact on the nurses because its a bit more work for them” (NUM24)

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DISCUSSION: Colquhoun et al concluded that since no one facility can fully meet all students’ educational needs, “medical schools may have to be quite deliberate in their utilisation of academic hospitals, community hospitals and primary care, matching student allocations carefully to sources of relevant learning opportunities”(Colquhon C et al., 2009). This study suggests that there are potential advantages and disadvantages to the utilisation of a co- located private hospital as a specific venue for medical student education. Integrating NSPH as a Northern Clinical School rotation effectively created extra teaching capacity (previously lying “fallow”) with enhanced access to patients and engagement of clinical teachers. The engagement of patients in a co-located private hospital may deliver a reciprocal benefit to patients in the public hospital, as there is a potential to reduce serial examinations of patient by students and postgraduates (Olson LG et al., 2005, Crotty BJ, 2005, May C et al., 2009). At present there are fewer students at NSPH than at RNSH, so there is less competition for access to patients, particularly at times when several tutorial groups’ sessions overlap. Despite suggestions that patients who do not participate in medical student teaching are moral “free- riders”, benefiting from practitioners’ skills learnt whilst caring for past (often public) patients, no obligation can be imposed for patients to participate (Brown L and Barnett JR, 2004, Lowe M et al., 2008). Furthermore, it is counter to the principle of distributive justice to impose a duty of participating in teaching on non-paying patients, as distinct from those who pay for their care. The notion that private patients would often refuse to see medical students was not observed in our study, and Australian data suggests that 70% of patients “would never refuse…a medical student”(Salisbury K et al., 2004). The vast majority of patients in our study indicated their assent to medical student involvement in their care, were often enthusiastic, and did not consider that paying for health care exempted them from participating in medical student education (Magrane D et al., 1994). Altruism is a pro-social, supererogatory act, generally considered to elicit positive feelings of self-worth (Bishop JP and Rees CE, 2007), and can be a positive example for students (Bishop JP and Rees CE, 2007, Faulkner LR and McCurdy RL, 2000). Other patient benefits include the potential for increased knowledge of their condition, and undeniably, a measure of companionship (Coleman K and Murray E, 2002). Patients may take an active role as student teachers, “experts…exemplars of their condition...facilitators of the development of students’ professional skills and attitudes”(Stacy R and Spencer J, 1999). Occasionally patients will misinterpret the extent to which students will be involved with their care (Magrane D et al., 1994), are unsure of their privacy, and are sometimes embarrassed (Coleman K and Murray E, 2002). However, our experience supports the general observation that most patients approached respectfully and non-coercively, with continually negotiated consent during the teaching encounter will be willing to participate in medical student education, regardless of the setting (Grant V, 1994, Howe A and Anderson J, 2001, Magrane D et al., 1994). Co-location made it easier for senior staff to participate in teaching as the majority have appointments at both the public and private hospitals, and many have their offices within or in close proximity to the private hospital, permitting students to attend private consulting rooms without the need to travel. Co- location allowed several private practitioners who had left the public system to reconnect with academia.

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In a less closely supervised context, a relatively high level of autonomous learning is required, and so the potential educational experience is dependent on student motivation; as Perrot et al emphasise, “independent self-directed learning requires…a willingness to exert high levels of effort towards educational goals” (Perrot LJ et al., 2001) This required supervisors to actively facilitate self-directed learning with some students due to the lack of a more formal team structure (Dornan T et al., 2005), as at RNSH. As multidisciplinary/interdisciplinary team care is a specific aim of the Sydney Medical Program, we were able to promote and achieve this by allocating times to work with nursing and allied health staff. Students varied in the extent to which they felt able to approach patients independently, and sought assistance from nursing staff in identifying and recruiting suitable patients. The establishment of student placements required the recruitment of staff, and establishment of an organisational infrastructure separate from the adjacent Clinical School. The NSPH website and written patient admission information materials state that NSPH is a teaching hospital (Ramsay Health, 2012), and that participation in teaching is entirely voluntary. Fifty-five VMOs have participated in teaching since the program was introduced at NSPH. Our results may not be replicable in other co-located facilities or in “stand-alone” private hospitals through matters of funding, logistics and the availability of specific staff to implement such a program. However, our experience to date has been positive, and the teaching program is currently being expanded to include other disciplines.

CONCLUSION: Augmenting medical student placements through the engagement of a public/private co-location has the potential to expand the base of medical student teaching in a relatively simple manner which is both acceptable and practical to patients, students and staff alike.

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PRACTICE POINTS: 1. The changing nature of hospital case-mix in Australia potentially limits student exposure to patients with acute and subacute conditions. 2. Practically, many patients are “unavailable” to participate in student education in Australian Public Hospitals. The engagement of patients in a co-located Private Hospital increases the educational opportunities of students. 3. There is no evidence to support the notion that private patients should not or would not wish to participate in medical student education. 4. Private patients overwhelmingly expressed a willingness to be involved in medical student education. 5. Integration of medical student teaching into the day to day routine of a Private Hospital was enthusiastically embraced by patients, teachers from all disciplines and medical students.

DECLARATION OF INTERESTS: The authors report no declarations of interest.

Acknowledgements:

Mr Greg Brown, CEO, North Shore Private Hospital

Professor Jonathan Morris, Associate Dean and Head of School, Northern Clinical School, The University of Sydney

Ms Carol Himmelhoch, Academic Coordinator, Perinatal and Womens’ Health, North Shore Private Hospital.

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TABLE 1: Patient responses to questions about involvement in medical student teaching.

Questions General (n=158)

Missing/

% Yes % No Unsure Are you willing to be

seen / examined by a

medical student? 92 6 2

Are you willing for a

medical student to take

a medical history? 94 5.5 0.5

Are you willing for a

medical student to examine you? 94 5 1

Are you willing for a

medical student to

observe a procedure? 90 8 2

Are you willing for a

medical student to

carry out a procedure

under medical 2 missing and

supervision? 60 34 4 unsure

Are you willing for a

medical student to be 23 (all

present in the missing

consulting room? 70 7 answers)

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BIOGRAPHICAL NOTES ON THE AUTHORS:

Farnaz Sanaei (RM, B Sc M Sc PhD) is the Medical Student Project Manager at North Shore Private

Hospital and Northern Clinical School University of Sydney. She is a qualitative researcher who....

Margaret Schnitzler (MB BS (Hons) FRACS PhD) is the Academic Coordinator (Surgery) North Shore

Private Hospital, and Associate Professor (Surgery) at the Northern Clinical School, University of

Sydney. Margaret is a colorectal surgeon/medical educator....

Kirsty Foster (BSc MB ChB MRCGP DRCOG MEd (ALGC) PhD) is the Senior Lecturer in Medical

Education & Sub Dean Education, Sub Dean International, at the Northern Clinical School, University of Sydney. Kirsty is a medical educator whose research interests examine...

Mark Arnold (MB BS FRACP MBeth) is the Academic Coordinator (Medicine) North Shore Private

Hospital, and Associate Professor (Medicine) at the Northern Clinical School, University of Sydney.

Mark is a rheumatologist/medical educator, with a background in bioethics and normative standards in medical practice; his research examines the interface between technos and phrenos in student education.

15 | Page Sanaei F, Schnitzler M, Foster K and Arnold M MedEd Publish www.mededworld.org