Innovative AETCOM session on health care as a right: Experience at the medical college in Puducherry

Abstract

BACKGROUND:

Attitude, Ethics, and Communication (AETCOM) module 2.3 is effective in improving the communication skills of medical students, which in turn will prevent malpractices and litigations against doctors. Module 2.3, ‘Health Care as a Right,’ was aimed at introducing healthcare systems, access, equity in access, the impact of socio-economic situation in determining healthcare access, the role of doctors as key players, and the missing links in the health care systems to students.

MATERIALS AND METHODS:

A teaching and learning activity was developed for MBBS professional year 2 on AETCOM 2.3. The activities planned were an introduction to the topic, a short documentary film using AV aids, role play by the team, group discussion followed by role play by the students, reflective writing, and finally summarizing the session with a take-home message.

RESULTS:

The number of responses received in reflective writing was 114. The thematic analysis of qualitative responses was grouped into categories The facilitating factors were the availability of trained doctors and round-the-clock services, and the hindering factors were disrespect to patients, professional misconduct, long waiting time, etc. The suggestions to improve communication between the doctor and the patient were to listen politely and develop good rapport. The qualities of a good doctor were good communication skills, empathy, professional conduct, etc.

CONCLUSION:

This AETCOM session helped the students understand the healthcare delivery system in the country. It changed their attitude toward patients and improved their communication skills as they were soon-to-become doctors.

Introduction

The provision of healthcare as a fundamental right has been the subject of ongoing debate and discussion worldwide. In recent years, medical colleges have incorporated innovative approaches to teaching this concept to medical students.[1,2] Effective communication between doctor and patient leads to better compliance with treatment, patient satisfactions, and improved health outcomes.[3] One such example is the experience of a medical college in Puducherry, where an Attitude, Ethics, and Communication (AETCOM) session was conducted on the topic of “Health Care as a Right.” The entire concept of the AETCOM module lies on the fundamental principle that changing a person's attitude can change his or her behavior, thereby improving the communication skills of the medical students, which in turn will prevent malpractices and litigations against doctors.[4,5,6] The assessment of AETCOM is preferably done in a real-world simulated scenario and not by written theoretical examinations.[7] The Department of Community Medicine developed a teaching model for AETCOM module 2.3, ‘Health Care As A Right,’ which is integrated with Community Medicine topics ‘Concept Of Health And Disease’ and ‘Healthcare Of The Community’.[5] This session is aimed at introducing healthcare systems, access, equity in access, the impact of socio-economic situation in determining healthcare access, the role of doctors as key players, and the missing links in the health care system to students.[8] And also to sensitize students to the importance of healthcare as a basic human right and the ethical implications of denying it to certain sections of society. The session utilized interactive methods such as role-plays and case studies to engage students and encourage critical thinking. This paper aims to explore the effectiveness of this innovative AETCOM session in enhancing medical students' understanding of healthcare as a right.

Materials and Methods

Study design and setting

A team of faculty and postgraduates from the department of Community Medicine were involved in the teaching and learning activity of AETCOM module 2.3 at the Pondicherry Institute of Medical Sciences in Puducherry.

Study participants and sampling

The session was planned and conducted for 2 hours for MBBS professional year 2. The universal sampling technique was followed, and all the students present for the class were included in the study. The objective was to introduce the healthcare system in India, healthcare rights, the socio-economic implications of healthcare as a right, the missing links, and the implications for and by doctors. The team decided to conduct this session differently from the regular didactic classes.

Ethical consideration

The Institute Ethics Committee's approval was obtained (RC/2022/132). The consent of the student is implied by participation, the results of the study have been used for research purposes, and the identity of the student has not been revealed.

The activities conducted were

1. Introduction to the healthcare system in India and explaining how it is unique and/or different from the healthcare systems of home developed nations using the brief lecture method.

2. A short documentary film on the inequitable distribution of healthcare, specifying the missing links using audio-visual aids.

3. Role play by postgraduates on disparities at different levels of healthcare, professional misconduct, and inequities in patient care.

4. Group discussion with regard to the pros and cons of the topics presented in role play, followed by reflective writing

5. Summarizing the session with a focus stress on the take-home message.

Data collection tool and technique:

The team made sure that every student stayed attentive, interacted, or shared his or her views at the end of the session. The reflective writing involved students' perceptions and/or views on:

1. The facilitating and hindering factors for patients receiving health care from the health centers,

2. Care at a primary health center level with a focus on the patient's perspective at the health worker level (receptionist, nursing staff, and doctor) and

3. The qualities of a good doctor and the dos and don'ts in doctor–patient relations (including communication)

The students were given adequate time to complete reflective writing. The responses were collected at the end of the session, and thematic qualitative analysis was done. The open-ended questions were given to students in order to express their views and opinions in the reflective writing questionnaire. The number of students present for the session was 114 out of 151. We received 114 responses.

The following points regarding the missing links were discussed: inappropriate seeking of health care services from tertiary care hospitals. The majority of illnesses can be treated at the primary healthcare level, but patients unnecessarily or unknowingly seek tertiary care hospitals for their treatment and holistic approach to health by providing safe water and sanitation.

The reflective writing questionnaire had four questions [Figure 1]

Figure 1.

Questions given to students in the reflective writing session

1. What are the facilitating/hindering factors for patients receiving healthcare from the health center?

2. What are the suggestions to improve communication between the doctor and the patient?

3. What could be done to improve patient care at the primary health care center level?

   1. At the health assistant (attender) level,

   2. At the nurse level and

   3. At doctor level and

4. What do you think are the qualities of a good doctor?

The thematic analysis of qualitative responses was grouped into categories. Repeated responses were grouped into the same category.

Results

For ‘facilitating factors in patients receiving healthcare from the health center,’ the students' responses were availability of trained doctors, availability of round-the-clock services, ambulance facilities, use of advanced technology, good patient care, availability of health insurance schemes, affordability, accessibility, and availing of government health schemes and programs. For ‘hindering factors for patients receiving healthcare from the health centers,’ the responses were corruption, disrespect to patients, poor care to poor patients (disparity in providing healthcare), professional misconduct, medical negligence, social stigma to particular diseases, long waiting time and limited appointments, lack of awareness of services available, high health expenditure, transportation barriers, inaccessibility, shortage of drugs and facilities, non-availability of doctors, taking a long time to receive reimbursement and other monetary benefits, poor infrastructure, and unethical practices [Figure 2].

Figure 2.

Students' responses for facilitating and hindering factors for patients receiving healthcare from health centre center

The students' responses to good doctor-patient communication were to greet the patient on arrival, listen to their complaints patiently and in a polite manner, develop a good rapport, have empathy towards patients, respect the patients, make the patient feel comfortable, speak the language that the patient understands, maintain eye contact, ask open-ended questions, explain the management to the patients, get the patients' consent before examination, maintain confidentiality. The doctor should be trained in communication skills, and the doctor should be easily approachable. The patient should be honest and explain his complaints, and he should address the doctor appropriately.

The don'ts in doctor-to-patient communication were the use of unethical words, poor listening, interrupting patients' conversation/complains, losing temper when the patient repeats his/her complaints, showing disparity among patients of different age groups, socio-economic status, etc., not having adequate time for patient consultations, and not being money-minded.

The students suggestions to improve patient care at the primary health care level were grouped into three levels and were as follows:

1. At receptionist level, he or she should be punctual, polite, loyal, sincere, show empathy, be approachable, have good communication skills, respect all patients equally, not accept bribes to consult the doctor, show no discrimination, and not misuse the power.

2. At nurse level, he or she should be punctual, loyal, faithful, dedicated, work during working hours, follow doctor's orders, have good control of the inventory, be professional, not do unofficial work and/or use mobile phones, engage in malpractice, exploit healthcare resources, or discriminate towards patients.

3. At doctor level, the doctor should be punctual to work, polite, ethical, dedicated, non-judgmental, easily approachable, have leadership qualities, good skill and knowledge, show respect for patients and colleagues, equality, empathy towards patients, professionalism, should not take bribes, express impatience (due to stress, personal problems) towards patients, and do unofficial work during working hours.

The qualities of a good doctor from students' perception were to have good communication skills, leadership qualities, be a good listener, have empathy, compassion, patience, have motive to serve society, have good knowledge and skill, be unbiased in professional conduct, be respectful, kind, ethical, faithful, humble, modest, gentle, non-judgmental, responsible, accountable, be good teacher, be neatly dressed, be updated on recent advances, be noble, and be simple [Figure 3].

Figure 3.

Students' perception of qualities of a good doctor

Discussion

The healthcare delivery system has undergone great change over the past few decades. New and improved drugs, devices, procedures, tests, and imaging machinery have changed patterns of care and the sites where care is provided.[9] In our study, the availability of trained doctors, availability of round-the-clock service, affordability, accessibility of health centers, and use of advanced technology in patient management were a few facilitating factors for patients seeking health care.

It is ideal for the physicians to build a good communication rapport with the patients. Thus, there is a need to help the medical students develop good communication skills with their patients in a healthy way in future. In this study, we have emphasized communication between doctor and patient. Jain et al.[6] conducted a study on evaluating the effectiveness of ‘AETCOM Module’ on the medical interns posted in peripheral health centers of a tertiary care medical college in Kanchipuram, Tamil Nadu, and their reflective feedback has shown that most of the students expressed that they could identify the mistakes they commit while communicating with patients. The interns also expressed that the AETCOM classes would help them become better medical professionals and better doctors with a better understanding of patients' problems. An important attribute of a good doctor that was found among the responses from our study was ‘empathy,’ which was also seen to be an important and most frequently quoted response in a similar study conducted by Hurwitz et al.[10] among 158 first-year medical undergraduate students in Newcastle.

In this study, we have sensitized the students about medical ethical practices to be followed through role play. Shrivastava R et al. in their study stated that training medical students in bioethics must be acknowledged as an important need, as it will eventually determine the safety and well-being of current and future generations of people. It is high time that specific steps are taken to define specific bioethics competencies and integrate them with the existing medical curriculum to benefit both medical students and the general population.[11]

Our study has shown that the undergraduate students' perception of the qualities of a good doctor is kindness. A study conducted by Ahn et al.[12] among university students in Korea also reported kindness as an important attribute of a good doctor. Another study by Maudsley et al.[13] conducted among Junior medical students of the University of Liverpool found that values that were reported to be those of a good doctor include “kindness, listening, and professionalism”.

According to our study, one of the don'ts in communication for a doctor was poor listening. A study done by Miettola et al.[14] among first year medical undergraduate students in Finland also showed a response stating poor listening by staring into the computer screen or getting distracted by staff coming into consultation room during the communication process as a hindrance to effective communication.

In our study, the undergraduate students considered good knowledge and skill as important attributes of being a good doctor. A similar finding was seen in the study conducted by Ahn et al., in which the majority of the students thought the intellect or competency of the doctor was a vital attribute for a good doctor.[11] This helps the medical profession not only to provide the best treatment but also to effectively explain the treatment and prognosis to the patient and patient's attenders, which in turn helps in the development of good rapport, trust, and respect for the doctor and medical profession.

To assess the barriers and linkages to health care showed that the most frequently reported barriers were lack of patient participation, private transportation not available, patients' perception of quality of care, distance to provider, cost of transportation, lack of funding, limited/inconvenient hours, and health services not available in the community, lack of education limits healthcare access in all settings and correlates with lack of knowledge and perceived need, shame and stigma depending on socio-cultural norms, lack of family/social support, lack of information about conditions and treatments reduced care seeking in all settings, perception of services affected by past experiences, where negative past experiences are barriers to care seeking.[15,16] Our study also reported that poor communication, the high cost of health care, the non-availability of services in a particular community, a lack of knowledge or awareness about the disease or available treatment modalities, and a shortage of medicines were some of the hindering factors.

The strengths of this study are that the students' opinions about the medical profession and good and bad behaviors were reflected in the feedback writing. Using multiple teaching and learning methods in the same class helped the students stay attentive and alert until the last session.

Limitation and recommendation

The limitation of this study is that the reflective writing questions could have been better framed than generalized open-ended questions. The answers obtained were mostly single-word adjectives rather than sentences.

A suggestion to improve is that different teaching and learning methods could have been used. Qualitative study methods like focused group discussion and techniques like pile sorting, free listing, pair-wise ranking, force field analysis, etc., could have been used.

Conclusion

The AETCOM session has helped us understand the various views undergraduate students have on health care delivery, its facilitating and hindering factors, the qualities of a good doctor, and their role in connecting the missing links in the health care system. These sessions help the students to understand the whole cascade of nuances involved in providing the best possible patient care and help them to self-evaluate regarding where they stand in the whole process of becoming a competent, knowledgeable, empathetic doctor. They also help them to communicate with coworkers in a respectful manner and in other ways that demonstrate effective communication. Moreover, it gives us even more evidence and a stronger cause for bringing about a change in attitude, following ethics, and acquiring better communication skills by soon-to-be doctors, rather than focusing only on gaining subjects' knowledge and focusing more on developing these skills in the training of undergraduate medical students.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.