Medical Students’ Awareness and Attitudes Regarding Boundary Issues

doi:10.21203/rs.3.rs-2112671/v1

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Medical Students’ Awareness and Attitudes Regarding Boundary Issues

https://doi.org/10.21203/rs.3.rs-2112671/v1

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Professional boundaries promote safe and effective healthcare. Whilst sexual boundary violations have been a research focus, it has been suggested that non-sexual boundary violations may represent a ‘slippery slope’, whereby crossing relatively minor boundaries can progress to serious boundary violations. Medical school presents an opportunity to support medical students with strategies to manage boundary challenges more effectively as doctors. The current study aimed to examine medical students’ awareness and confidence in managing boundary crossings and compare findings across year groups. Students in years 1, 3 and 5 of a five-year undergraduate program at one medical school in Australia, were invited to participate in an anonymous online survey which used multiple choice and free text questions to explore reactions to five scenarios demonstrating some level of boundary crossing. Students were asked about prior training and suggestions for future training. Quantitative data was analysed using omnibus chi-square tests and Kruskal-Wallis one-way ANOVAs for non-parametric data; free text data was analysed using coding and grouping similar themes. Final year students most accurately identified boundary crossings yet were somewhat more willing to cross ‘grey’ or less clear-cut boundaries. Year 3 students consistently reported the lowest levels of confidence in managing scenarios. Students reported little to no formal teaching relevant to the scenarios presented and supported inclusion of education regarding boundary issues in formal curricula. Our findings further suggest a need for education regarding management of the clinician-student power dynamic and there is demand from students for more teaching and support around ‘grey’ boundary crossings.

Boundary crossings

medical students

mixed-methods analysis

online survey

cross-sectional analysis

attitudes and awareness

subtle boundary issues

Literature review

Boundaries, in the context of health practitioners, have been defined as “the edge of appropriate or professional behaviour, transgression of which involves the clinician stepping out of the traditional clinical role”(1). A boundary crossing is such a transgression, while boundary violations are acts which are definitively unethical and may span behaviours that are inappropriate, cause harm or prompt litigation. Establishing and maintaining boundaries is critical in keeping patients safe and protecting the wellbeing of medical practitioners and students (2). While a boundary crossing may or may not lead to a violation, a transgression of boundaries has the potential to detract from the professional doctor-patient or doctor-student relationship.

Boundary crossings and violations in medical practice may have either become more common due to a deliberate move to reduce formality in medicine (3, 4) or appear to have become more common due to an increase in discussion and reporting. While sources describe different and often contrasting ideas around boundaries such as whether they are necessary to the doctor-patient relationship or whether transgression is inherently detrimental to such a relationship, they all agree that boundary crossings tend to be situational, and vary in level of severity and impact. They may present as ‘mild’ or ‘benign’ in nature and may go undetected due to their ambiguous, multifactorial, or ‘grey’ nature. These boundary crossings may skirt the edges of professional behaviour though may not necessarily have a direct negative impact or repercussion on the student-doctor (5), or doctor-patient relationship. Due to this, consequences of this conduct may be underappreciated by doctors themselves, (4, 6) thereby minimising corrective intervention undertaken. This constitutes a potentially dangerous model referred to as the “slippery slope”, where crossing relatively minor boundaries may progress into severe boundary violations in later professional practice (3, 7).

Students enter the clinical landscape and inadvertently enrol in the ‘hidden curriculum’, learning both professional and unprofessional behaviour through observation and modelling after their mentors. The latter is reflected in studies discussing trends of students’ professional qualities declining as they progress through their clinical training, attributing this to systematic desensitisation to ethical and moral dilemmas (8). Studies also show that a record of unprofessionalism in students is associated with boundary crossings or violations as practitioners; a perpetual cycle of bad behaviour (9, 10). As students are confronted with suffering and disease, studies show they may cope by becoming emotionally distant at the expense of the doctor-patient relationship (11, 12). Studies have demonstrated links between burnout and unprofessional conduct (13) where progressive fatigue and desensitisation can leave students vulnerable to becoming both victims and perpetrators of boundary crossings (8, 12, 14, 15). To preserve the culture of altruism and curtail the incidence of boundary transgressions, we must demystify their causes and presentations.

Other studies suggest that crossings can begin with the clinician or student having the best intentions for the patient. Boundary issues may arise from a desire to achieve a kind of ‘mutual’ empathy with the patient through self-disclosure. This may also manifest in the failure to enforce rules out of sympathy for a student or patient, displays of favouritism or unconscious bias (8). Some minor boundary crossings may enhance the doctor-patient relationship such as acceptance of small gifts, while some are inevitable such as dual relationships between a rural general practitioner (GP) and their patients in a small community (16). In these cases, social invitations or encounters and requesting personal contact details may be unavoidable. Other commonly cited issues in the literature include engaging in business or financial deals, asking students or patients to lie and inappropriate contact in physical examination (2, 12). Ultimately, it is imperative to know the difference between a slight transgression of a boundary to complement the doctor-patient relationship and a violation which damages it.

The impact of extensive, existing literature on ‘black and white’ boundaries is seen in the teaching of overt and extreme boundary violations that is widely available at medical schools, including the Joint Medical Program (JMP). The five-year program comprises a two-year theory-based curriculum, followed by three clinical years full-time in the hospital. All formal ethics teaching occurs in the first three years of the program through mandatory seminars, which are interactive and scenario based. Core subjects discussed include patient confidentiality, sexual relationships and understanding medico-legal situations.

Despite current ethics teaching, many studies outline a deficit in medical education with regards to more common and subtle interactions, particularly from the unique position and perspective of a medical student in the hospital (13). Medical students are particularly vulnerable to being subject to boundary crossings themselves from doctors due to the intimacy and power imbalance of student-doctor interactions and inexperience. Consequently, students report feeling ill-prepared when encountering boundary crossings, particularly as their role may be poorly defined as they navigate the hospital setting (14). Indeed, students are often unaware of these minor boundary violations (17) or are hindered in reporting their seniors due to the fear of forming hostile relationships or academic disadvantage (8). Furthermore, despite increasing literature outlining the need for more education and the proven efficacy of teaching around boundary crossings (including proposed models to improve learning outcomes), medical education on boundary issues has not changed in the last 10 years (18). Incorporating teaching and applying the knowledge gleaned from literature is therefore likely to better equip medical graduates to maintain healthy professional relationships and navigate boundary issues throughout their careers.

A few studies have proposed ways to educate medical students in a way that is engaging and effective. Video vignettes have demonstrated success in teaching 3rd year medical students about the ‘greyer’ areas of boundary crossings, with a statistically significant improvement in students’ understanding of grey areas after watching the video vignettes (19) and improved student confidence approaching grey, or subtle, boundary issues (20).

Rationale

The literature is clear that better awareness of boundary crossings amongst future health professionals is important for preserving patient safety, protecting medical practitioner and student well-being, and maintaining professional doctor-patient relationships – however, limited knowledge exists. For example, there does not appear to be significant literature examining the gap in knowledge around levels of awareness and confidence in managing subtle boundary challenges, nor on how this differs across different stages of training. Furthermore, there is a specific lack of such knowledge from an Australian context, and certainly from students of the Joint Medical Program. This gap in the literature is a primary focus of our study.

We chose to base our approach on that of Gaufberg et al. (2006) (2) who asked medical students questions around their awareness and confidence using scenario vignettes, because it is an effective way to examine cohorts across different year groups. However, instead of interviewing participants directly, our study used an online survey with three of the vignettes from the previous study – an approach much easier to accomplish in light of COVID-19. Further, as our study design contained elements of the study by Gaufberg et al.(2006) (2), it was valuable to compare results. Comparisons could also be made between three different years of the program, allowing us to determine whether awareness and attitudes shift as students progress through medical school. Our online survey employed both quantitative and qualitative methods, as sole reliance on quantitative data does not facilitate exploration of nuances of experiences and ideas beyond our line of questioning, and qualitative methods allow participants the freedom to describe their own stories in their own language. Qualitative methods were appropriate for analysing the free-text responses that were anticipated to largely include anecdotal data.

No study has so far sought to investigate this topic via a cross-sectional mixed-methods analysis. By sampling three different cohorts of the same medical program at different levels of their degree, much-needed practical insight can be gained. We hope that this will be a springboard for further research into effective educational tools, which may then be integrated into formal medical curricula.

Aims And Hypotheses

This study aimed to assess medical students’ awareness and attitudes around subtle and ambiguous boundary issues and whether this changes over the course of medical training. We aimed to examine students’ ability to identify boundary crossings, their prior education of boundary issues and their level of confidence encountering these challenges.

The literature suggests that attitudes and awareness regarding subtle boundary issues could either improve (4, 13, 17, 21–23) or degrade (8, 24, 25) across the duration of the medical degree. We hypothesised that we would be able to ascertain an attitude and awareness shift as students progress through the program.

Design

This cross-sectional study employed an online survey which included both selected and constructed response items, followed by quantitative and qualitative analysis of the data.

Approval was obtained from University of Newcastle’s Human Research Ethics Committee.

Sample

Students studying in the Joint Medical Program (JMP) in years 1, 3 and 5 in 2021 were recruited as participants as they reflect different stages of ethics training in the JMP. Students entering medicine in year 1 with no formal background in health ethics likely reflect community attitudes and judgement. Year 3 students have completed all formal ethics training and begin their first placements in the workplace. Year 5 students are in their pre-intern year, having amassed both clinical experience and concluded the core theory course.

Participants were recruited from the existing pool of 1^st, 3^rd and 5^th year medical students who are members of their year group Facebook pages. Total potential sample size was estimated at 510 across all three year groups. We estimated engagement of 10% of this sample. Given the absence of any local information, even a small response rate could provide important information, and studies indicate that a response rate of <10% is typical for online studies (26).

Procedure

A link to an online survey was posted on the Facebook forum pages directed at 1^st, 3^rd and 5^th year medical students. The survey was created using Qualtrics, an online survey platform, and contained a combination of close-ended "Yes" or "No" questions, Likert scale, and open-ended questions to gather both quantitative and qualitative data. Respondents were asked to read through five clinical scenarios each involving a medical student faced with a boundary challenge in which the most ethical response was not clear.

Measures

We adapted three clinical scenarios from Gaufberg et al. (2006) (2) and added two novel scenarios based on important boundary issues identified in the literature review and in the context of an Australian medical student (Table 1) . Since the Gaufberg et al. (2006) (2) study, the integration of digital software in the hospital and widespread use of social media have raised issues around privacy, safety and professional conduct (17). We also identified dual relationships to be a common boundary issue students may encounter due to the footprint of the JMP across rural sites.

Table 1. Description of each scenario vignette

Scenario	Description
Gift giving	An adult son thanks a medical student for taking excellent care of his father while he was hospitalized and hands the student an envelope. After the son has departed, the medical student finds a thank-you card containing $80 cash.
Self-disclosure	While giving her health history, a patient reports she has recently quit smoking. The medical student commends the patient on her good choice and reveals that she too had recently quit smoking. Later in the interview the patient reveals difficulty with alcohol and asks the medical student if she has ever had a hangover.
Errand	A medical student who has been waiting on the ward all day for the opportunity to insert a central line for their patient is asked by a supervisor to pick up food for a team party. The timing of the errand conflicts with the procedure.
Social media contact	After talking with a patient on the wards, the medical student receives a notification showing that this patient is now following them on Instagram.
Dual relationships	A medical student on the wards notices a patient who they know outside of the hospital. The patient becomes visibly excited to see the medical student and mentions how he feels the treating team hasn’t fully explained the plan. He asks the medical student to have a look in the notes and tell them what’s going on with his treatment.

Respondents then answered a set of questions in response to each clinical scenario (Table 2).

Table 2. Outline of questions asked after each scenario vignette

Question number	Question asked	Scale type	Answer options
1	Is this a boundary crossing?	Likert scale of 1-5	Definitely not Probably not Unsure Probably Definitely yes
2	Have you had any formal teaching on this type of scenario?	Binary	Yes or No
3	How confident would you feel in negotiating this?	Likert scale of 1-5	Extremely unconfident Unconfident Neither confident nor unconfident Confident Extremely confident
4	If you were the medical student, what would you do and why?	Open text box	N/A

A final question was asked at completion of the survey:

‘Do you have any suggestions for how the JMP could improve the teaching of boundary crossings/issues or how to navigate them?’ (open text box).

Time required to complete the survey was estimated at approximately half an hour.

As an incentive, the first 21 respondents were eligible for a $5.00 Gloria Jeans coffee voucher (on provision of their contact details); all respondents were entered into a draw for 5 x $50 Woolworths gift cards. The survey was left open for a total of six weeks, after which winners were chosen. The Woolworth gift card draw winners were chosen by a random number generator, and all five vouchers were sent out via email.

Analysis

The following steps were undertaken for qualitative data analysis (Table 3):

Table 3. Steps undertaken for qualitative data analysis

Step number	Action taken
1.	Similar responses to each scenario were grouped into codes or ‘Key Ideas’.
2.	Each of the three researchers independently matched responses to codes, creating individual data sets.
3.	Each researcher calculated the percentage of responses attributed to each code
4.	The mean number of responses grouped by each researcher into those codes was calculated; results are shown in Table 4 (see Appendix).

A small number of responses were not relevant to the subject, for example one answer ‘Recommend they seek GP’s advice or re-present to hospital’ in response to Scenario 5. This was removed as an answer in Figure 17 but remains in the data table (see Appendix).

For quantitative analysis, responses to Question 1 were collapsed into 3 groups: “definitely not” and “probably not” as “no”; “probably yes” and “definitely yes” as “yes” and “maybe” was retained as a separate group. Cases where the year group of the respondent was unknown were excluded from all vignette analyses, but retained for analysis of the final question at the end of the survey.

In preliminary analyses, omnibus chi-square tests were conducted to test for significant differences across the three year groups for each scenario regarding whether students considered it to represent a boundary crossing, how confident they would be about managing the situation and whether they reported having had any formal teaching relevant to the scenario. Where differences were significant or approached significance, further testing to examine pair-wise differences was conducted using Kruskal-Wallis one-way ANOVAs for non-parametric data for boundary crossing and confidence as these could be considered ordinal data.

A total of 54 people completed the survey with 15 first year students, 18 third year students, and 20 fifth year students, a response rate of 10%. One student’s year group was unknown due to a malfunction with the survey, and only their responses to the question asking for teaching suggestions were included.

Demographic data was limited, however all students were undergraduate medical students studying in the Joint Medical Program, where most students are in the age range of 18-25 years old.

See Tables 3-6 in Appendix for complete data sets of qualitative and quantitative data, the analysis of which is shown below and grouped according to scenario.

Scenario 1 – Gift Giving

A consensus across the year groups was that they would return the money (Figure 1). A higher proportion of first years gave this answer.

The most common answer among 3^rd years was to talk to someone more senior for advice, however it was more common for 1^st years to do this compared to both 3^rd and 5^th years. Almost no one in any year group answered that they would accept the money.

One student in year 3 asserted that a boundary was crossed yet chose to accept the monetary gift, a decision which was a striking anomaly.

Most respondents across the year groups believed that accepting a gift of money was a boundary crossing (Figure 2).

Fifth year medical students were the most confident in handling this situation, while the 3^rd years were the least confident (Figure 3).

Responses regarding formal teaching were similar between 3^rd and 5^th years with only a minority of respondents having received formal teaching on this scenario. This is contrasted to 1^st years, in which no respondents reported formal teaching (Figure 4). This was a statistically significant finding (p=0.011).

No other findings were statistically significant.

Scenario 2 – Self-disclosure

The overall most common answer was that students would answer the patient’s question and disclose their experience (Figure 5). This was the most common in 1st and 3rd years, and second most common answer in 5th years. In the words of one 5^th year, “I think self-disclosure would be beneficial in this situation”.

The most common answer for 5^th years was to redirect the conversation to focus elsewhere. Many respondents in other years also suggested to either redirect or avoid answering the question.

There was a trend in which some respondents said they would show understanding without self-disclosing. This answer became more common with increasing year level.

Only 5^th year students suggested making a joke of the question, and only 1^st years suggested enquiring as to why the patient is asking. Several 3^rd years responded that they were unsure of what to do in this situation.

Most 1^st and 5^th years believed that self-disclosure was a boundary crossing while 3^rd years were split in their responses (Figure 6).

5^th year medical students were largely confident in handling this situation, while 3^rd years were mostly unconfident and 1^st years were neither confident nor unconfident (Figure 7).

Most respondents across all year groups denied receiving any formal teaching on this scenario (Figure 8). However, 5^th years more commonly responded ‘had formal teaching’ or ‘don’t know’ than 3^rd years. All 1^st years denied having any formal teaching on this type of scenario.

None of these findings were statistically significant.

Scenario 3 - Errand

The overall most common answer was to refuse the consultant’s request and ask to stay for the procedure instead. The most common answer for 3rd years was to ask if alternate arrangements can be made to collect food. Almost double the proportion of 3rd years proposed this compared to the other year groups (Figure 9).

Fewer 5^th years answered that they would pick up the food. A few 5^th years answered that they would report the incident and escalate the situation. 1^st and 3^rd years, by contrast, were more willing to pick up the food as requested.

3^rd years were the only group with no responses asking for alternate procedural learning opportunities to be arranged.

5^th year and 3^rd year medical students would more often respond that scenario 3 was a boundary crossing than not, whereas most 1^st year medical students believed that this wasn't a boundary crossing (Figure 10). This was a statistically significant finding (p=0.018). The proportion of respondents endorsing the option ‘not a boundary crossing’ was also lowest in 5^th year, followed by 3^rd year and then 1^st year.

More 1^st and 5^th years reported feeling confident in managing this situation compared to 3^rd years, who mostly felt unconfident in handling this situation (Figure 11). This was statistically significant (p=0.016)

Across all year groups, almost all respondents denied receiving any formal teaching regarding this scenario (Figure 12).

Scenario 4 – Social media contact

Strong consensus across the groups was that they would not accept the request. Answers differed in terms of how they would manage the request and in preventative measures (Figure 13).

1^st years more often reported taking a more direct approach and explaining to the patient that a boundary had been crossed or asking the patient to unfollow. 3^rd years often reported that they would decline the request.

5^th years commonly answered that they would block the patient, with this becoming less common for 3^rd years and again with 1^st years.

Most respondents across all year groups believed that scenario 4 was a boundary crossing (Figure 14).

Most respondents across all year groups also felt confident in handling social media contact by a patient (Figure 15). However, 3^rd year medical students were less confident and more unsure in handling the situation compared to 1^st and 5^th year medical students.

Most 1^st years denied receiving any formal teaching, and 3^rd years also more commonly reported having ‘no formal teaching’ than having ‘had formal teaching’ (Figure 16). However, 5^th years had an equal number of respondents reporting ‘had formal teaching’ and having ‘not had formal teaching’.

None of these findings were statistically significant.

Scenario 5 – Dual relationships

5th years appeared more willing to inform the patient about their treatment plan without consulting the responsible medical team, compared to 3^rd or 1^st year students (Figure 17). However, one 3^rd year student stated, "I do not think this is a boundary crossing because the student did not intentionally seek out this patient".

1^st years most often described relaying the patient’s concerns to the responsible medical team, with this becoming a less common answer with 3^rd years and again with 5^th years.

Most respondents across all year groups believed that scenario 5 was a boundary crossing (Figure 18).

1^st years were the most confident in handling scenario 5, followed by 5^th years and then 3^rd years (Figure 19). While ‘confident’ was the most popular response for 1^st and 5^th years, 3rd years were more likely to respond with ‘unsure’.

Most 1^st years denied having received any formal teaching for scenario 5 (Figure 20). An equal number of 3^rd year medical students responded with ‘no formal teaching’ or ‘unsure’ about formal teaching, with only a minority reporting having had formal teaching for dual relationships. 5^th years mostly responded with ‘no formal teaching’, but also had the highest proportion of respondents indicating prior formal teaching when compared to 1^st and 3^rd year medical students.

None of these findings were statistically significant.

Suggestions for how the JMP could improve the teaching of boundary crossings:

Thirty-five students (63.6% of respondents) engaged with this query, with eleven 1^st years, twelve 3^rd years and twelve 5^th years responding.

Table 4. Frequency of responses within coding groups developed from ‘Request for Suggestions for Teaching’

Coding groups for responses of ‘Request for Suggestions for Teaching’	Year 1	Year 3	Year 5	Total
“Lecture”	0	2	2	4
Acting/role play	2	1	2	5
Case/scenario-based teaching	4	5	6	15
Online modules	1	0	0	1
Boundary issues/ethics PBL or discussion forum	4	1	4	9
Teaching based on students’ real-life experiences from placement	1	0	0	1
General request for more/improved teaching	1	2	3	6
Identify supports available for students when faced with boundary issues	0	1	0	1
Additional ethics teaching in 3rd-5th years	0	0	1	1
Does not believe teaching would improve boundary issues attitudes/awareness	0	0	1	1
No input	0	1	1	2
Unsure	1	0	0	1

Case/scenario-based teaching and role-play around ‘grey’ boundary issues was cited the most, with an interactive PBL-tutorial or discussion format being a popular mode of delivery.

Aside from suggestions to improve the JMP, feedback on the scenarios was also collected in some students’ responses. They were described to be

‘great and super relevant’, and

‘all situations that I have experienced similar versions of on the ward, but didn't exactly know how to navigate’.

Students also commented on the existing ethics curriculum, recalling

‘most of our teaching around ethics to be more based around the law and less every day encounters’.

This was echoed by another student, who stated that

‘ethics teaching we had in early years was interesting, and valuable - but not practical in terms of what we actually face as medical students’.

Students feeling ill-prepared or poorly supported was a shared sentiment. Students felt that many of the situations were common yet they

‘only felt confident navigating those which had been specifically addressed’ and requested

‘more explicit and common examples of situations which may arise on placement and how to deal with them’.

This may also be supported by many students’ general request for more teaching.

Our study results represent how subtle, ‘grey’ boundary issues in the clinical landscape may be navigated by students of the Joint Medical Program (JMP) based at the University of Newcastle and University of New England, Australia.

Variability in opinion of whether a boundary was transgressed was most evident in the self-disclosure and errand scenarios. In the case of self-disclosure, the scenario may have held ambiguity as students described both helpful and harmful effects. Year 5 students indicated that self-disclosure may be a tool used to display empathy and enrich rapport with the patient. The errand scenario was the lone case where a patient was not a party in the interaction. No student pointed out the potential boundary crossing on the part of the supervisor in requesting a personal errand, independent of its conflict with students’ learning. This may indicate a lower level of awareness regarding boundary issues between clinician and student, or worry about the consequences of passing the clinical rotation and is a finding consistent with the study by Gaufberg et al. (2006) (2). Specific education and support may empower students to advocate for their learning.

It is important to distinguish awareness from attitudes as some boundary crossings are not conclusively bad and may not necessitate particular action. However, in an examination of awareness without an assessment of attitudes, we may fail to detect any inconsistencies between the two. This was observed in the gift-giving scenario where a student asserted that a boundary was crossed yet chose to accept the monetary gift.

An overarching trend emerged regarding confidence where 3rd year students reported a lower level of confidence compared to their year 1 and 5 peers. This self-reported low confidence may highlight a need for additional support during the period of transition as 3rd year students begin their initiation into the clinical world. Despite the similarity in confidence of years 1 and 5, their approach in managing the scenarios tended to differ. This may prompt enquiry whether preferred responses change over time as students navigate the hospital system. For the 5th year respondents, it is encouraging to record a high degree of confidence, as they are one year removed from their internship and role as practising clinicians. We hope this is supported by solid foundations in clinical knowledge and ethical judgement.

Students also reported little to no formal teaching on all the scenarios. This may indicate students have no standardised model or shared level of awareness and attitude for ‘grey’ boundary issues. Almost two thirds (64%) of our participants engaged with the request for suggestions to improve teaching of boundary issues. Students resonated with the relevance of the 5 boundary scenarios and believed that integration of education regarding boundary issues would be impactful in formal curricula. Considering the top recommendations of scenario-based teaching, role play and PBLs are devices that are already widely used within the JMP, it supports the efficacy of these educational strategies and presents an existing mechanism to implement them.

Scenario 1 (gift giving) was more clearly perceived to be a boundary crossing than the other examples. This was consistent with the students in the study by Gaufberg et al. (2006) (2). Additionally, far fewer 1st year respondents sought the advice of someone more senior, compared to years 3 and 5. A possible explanation for this may be a lack of experience or awareness of the nature of the clinical team, with exposure to this relationship increasing through hospital placements during the clinical years of the degree (3, 4, and 5), resulting in a greater representation of this idea in polled years 3 and 5.

With scenario 2 (self-disclosure), most students polled from 1st and 3rd year groups did not think that the act of self-disclosure constituted a crossing of boundaries. The greater number of 5th year students choosing to redirect the conversation to focus on the patient may indicate development of a more sophisticated understanding of the clinician-patient relationship, and the importance of appropriate history taking during progression through the course. The trend of responding with understanding while avoiding self-disclosing increasing with year group adds further support to the notion that students’ professional capacity and understanding of appropriate patient-clinician interactions develop as they progress through the course. In contrast, students in Gaufberg et. al’s (2006) (2) study mainly chose to not disclose and redirect, citing reasons of professionalism and maintaining objectivity.

Analyses of the responses to scenario 3 (errand request) indicate that progression through the course improves students’ understanding of their role in the team, which is supported by the fact that few 5th years chose to pick up the food. That this group also more commonly chose to report and escalate the incident may indicate a heightened sensitivity to this situation and may reflect a common scenario in the hospital setting, and these students have had the most previous real-life experience. 3rd years were the only group unwilling to ask for alternate procedural learning opportunities to be arranged, potentially reflecting a loss of confidence in making requests of superiors, having only spent a short time within the hospital setting. Several students also indicated a fear of receiving a poor supervisor report driving their decision. No student identified the boundary crossed by the consultant in making the request, prompting the suggestion for further education in this area. Maintaining the relationship with superiors may shape students’ attitudes regarding boundary crossings around requests for errands.

Strong consensus across the three year groups in scenario 4 (social media) to deny the social media request indicates that awareness of the inappropriateness of social media contact with patients is present even without further ethics teaching during the course. This is likely due to a greater familiarity with social media among younger people in general. Of the groups, 1st years more often elected to take a direct approach and explain to the patient that a boundary has been crossed and ask the patient to unfollow. This could be in keeping with the reduced exposure 1st year students have had to the hospital environment, as such an approach would be time-consuming and difficult, reflected in the 3rd and 5th years’ underrepresentation in this category.

In scenario 5 (dual relationships and confidentiality), analysis of the responses indicated that choosing to explain the patient's plan without consulting the responsible medical team increased with increasing year, despite this action being a breach of confidentiality and professional ethics. Matching this trend is a relative decrease in willingness to inform the treating team of the patient's concerns, from the most popular answer for 1st years, decreasing with 3rd years and again with 5th years. These two trends may indicate an increase in personal confidence with progression throughout the course, however may also indicate a decline in adherence to professional boundaries of this nature. This may be consistent with previous studies (8-14) and may warrant further education on this subject during medical school.

Limitations

We did not gather any specific demographics data to preserve anonymity and keep the survey short. This limited our ability to examine associations with gender and age – however, age is mostly homogenous within the cohort examined, and small numbers overall may have resulted in insufficient power for further analysis.

We received a response rate of ~10% of the total pool of potential respondents. While this was our goal, it limits the generalisability of our study to the entire sample pool. Similarly, as we only surveyed students of one medical school, we can only draw direct conclusions about the Newcastle/Armidale Joint Medical Program. However, future studies may expand on our study by applying it to a broader audience.

The vignette format of the five scenarios may not elicit a true reflection of the attitudes of the medical students. Our study could have used video to minimise the number of responses which may have been impacted by not reading the vignette properly, as was suspected for several responses. Furthermore, simulating scenarios where participants could be observed for problem solving approaches may yield more accurate representations of attitudes. However, this option was not feasible for this study given limited funding and the COVID-19 pandemic. However, it remains a viable option for future study.

Strengths

By employing both qualitative and quantitative analysis, our study was able to gather important information on the awareness of medical students regarding grey boundary areas in a novel way. The scenarios chosen were realistic and common, with students indicating a preference for more specific teaching regarding each scenario. We standardised the questions so that each scenario could be compared side-by-side and allowed free-text so that new solutions could be suggested for each of the scenarios by the respondents, rather than a simple multiple-choice questionnaire as would be the case if we used a purely quantitative approach.

Collecting data anonymously may have increased students’ comfort with participating, and this was a prime consideration.

Limiting our total sample pool to medical students in the same university allowed us to streamline our approach and limit external variables which may have impacted the validity of the study.

Using coffee voucher incentives for the first 21 respondents encouraged quick responses, while having all respondents go into the draw to win a greater prize encouraged continued participation even when all the coffee vouchers had been exhausted.

We found that student confidence increased with progression through the course, alongside a decrease in willingness to seek supervisor support. We propose this may be the result of both real-life experience in challenging situations, combined with increased problem-solving capacity. The intriguing finding that 1^st and 5^th year students showed more confidence in their management of the scenarios compared to 3^rd year students despite largely suggesting different solutions warrants further study. It is likely that exposure to the actual complexities of the hospital environment beginning in third year shakes the students’ confidence, but further years of experience resolves this.

Other key findings related to differing approaches across the year groups, and the choice to compare these yielded meaningful information around how these issues change over time. We found that 5^th years were the most comfortable with disclosing information to a patient whose care they were not involved in, and recommended further education regarding this. We found that 5^th years were less willing to complete the errand request than 1^st years and suggested that this difference represents an improved understanding of their role within the medical team, and may also relate to being more assertive about their learning needs. Finally, we found that no student identified that the errand request constituted a boundary crossing on the part of the consultant and suggested that there is a need for further education regarding the management of the clinician-student power dynamic.

We were able to gain insightful recommendations from students to integrate boundary issue education into the formal curriculum through scenario-based teaching in interactive tutorials and discussions. The data illustrate that the demand for teaching and support around 'grey’ boundary crossings exists. We hope this may propel the introduction of more nuanced boundary issue teaching in medical schools that better reflects the realities of clinical practice and prompts further research into this important area.

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No competing interests reported.

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Medical Students’ Awareness and Attitudes Regarding Boundary Issues

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