In this study, we investigated whether patient gender influences student management in terms of communication, clinical assessment, investigations, diagnosis, and proposed care.
Study design and setting
Medical school in Switzerland consists of 6 years divided into 3 years of a bachelor’s program and 3 years of a master’s program. At Lausanne University Medical School, students undergo a summative assessment of clinical competencies through the summative OSCE at the end of their fifth study year, just before entering 10 months of internship. During the OSCE, history taking, physical examination, and diagnostic and therapeutic management are assessed through station-specific checklists. Communication competencies are assessed at every station by using the same global rating scale derived from the Analytic Global OSCE Rating developed by Hodges and McIlroy (13), which consists of four items that explore the ability of students to respond to the patient’s needs, the quality of the structure of the interview, and verbal and nonverbal expression. In the spring of 2017, fifth-year medical students underwent an OSCE that included five stations, each lasting 13 minutes. The OSCE took place over 2 days: half of the students were assessed on day 1, the remainder on day 2. On day 1, students were exposed to two different gender-sensitive OSCE stations. Half of the students encountered a female standardized patient (SP), and the other half a male SP. Apart from gender, all other patient characteristics (habits; medical, social, and family history) were similar.
Students, SPs, and examiners were all blinded to the purpose of the study.
Half of the fifth-year medical students (n = 110) at Lausanne University Medical School, who were taking their OSCE on day 1 of the OSCE session in March 2017, took part in the study. Evaluation was made by eight examiners for the first vignette, two women and six men, and by four examiners for the second vignette, all men. According to the standard setting of our OSCE, all examiners directly observed the student-SP encounter and filled out the evaluation form during the encounter.
Case vignettes and their evaluation
Vignette 1: Generalized anxiety disorder: The case was summarized as follows: “A middle-aged patient presents to her or his family doctor’s practice with generalized anxiety. The manifestations are an anxious feeling, trouble sleeping, agitation, and brooding over a hypothetical drama occurring in her or his family. The patient also mentions thoracic oppression when asked, and spontaneously presents anxiety about his/her financial situation without objective reasons. She or he seems tense, is talkative, and is somewhat focalized on her or his concerns, playing with the pen and often changing position.” Students were asked to take a medical history, propose investigations, arrive at a diagnosis, refer the patient, and/or reschedule the patient for a follow-up appointment (students were not asked to perform a clinical examination). Students were evaluated on the following: medical history (13 items: asking about the nature [characteristics] of symptoms; beginning, trigger, and evolution of symptoms; first episode or not; associated symptoms; symptoms of depression; suicidal thoughts; hallucinations; quality of sleep; substance abuse; helping strategies; previous medical history), arriving at a diagnosis, proposing further investigations and follow-up, and communication. Items of communication were rated on a 5-point scale from “completely” (5 points) to “not at all” (1 point). All other items were considered to be “completed” (2 points), “partially completed” (1 point), or “not completed” (0 points), with certain items of medical history only being “completed” (2 points) or “not completed” (0 points).
Vignette 2: Ascending aorta dissection: The case was described as follows: “An older patient of tall and slim build presents with acute chest pain. The pain is described as violent, extending to the shoulder blades, having started 2 hours earlier. The patient has a cold feeling in his/her left foot. The patient is known for untreated hypertension. On examination, the patient is ill looking, has higher blood pressure on the right arm than on the left, and a diastolic murmur over the aortic area. The pulse is obliterated on the left leg.” Students are expected to recognize the vascular origin of pain and arrive at a diagnosis of type A aortic dissection. A secondary objective was to fulfill an appropriate clinical examination. Students were evaluated on the following: medical history (nine items: trigger, nature of pain, evolution of pain, dyspnea, accompanying symptoms, cardiovascular risk factors, previous medical history, medication, family medical history), clinical examination (five items: measurement of blood pressure, blood pressure on both arms, cardiac auscultation, femoral pulses, radial pulses), arriving at a diagnosis, proposing a computed tomography (CT) scan to confirm the diagnosis, identifying the emergency, proposing analgesia, and communication skills. Points were attributed in the same manner as for Vignette 1.
The vignettes are not available for publication due to confidentiality issues.
Single checklist item scores of the students who evaluated female versus male SPs were compared by using chi-squared tests for each item.
We also created scores to summarize the numerous points of medical history and physical examination (only in Vignette 2). Scores were created as the sum of all points through all items of one category of medical history or physical examination (only in Vignette 2). For Vignette 1, the global score for medical history summed to a maximum of 30 points per student (minimum 0 points). For Vignette 2, the score for medical history resulted in a maximum of 20 points, and the score for physical examination resulted in a maximum of 11 points. The scores between students encountering female SPs and those encountering male SPs were summed and the total results compared by using the Wilcoxon-Mann-Whitney test.
In addition, results were analyzed by using linear regressions, with scores as the dependent variable and student gender, SP gender, and the interaction between these two variables as independent variables in order to assess whether there was an interaction between SP and student gender. The interaction with the examiners’ gender was not analyzed, in consideration that there were few examiners (four per vignette) and only male examiners evaluated the second vignette.
The STATA 14 statistical package was used for statistical analysis. A P value of < 0.05 was considered statistically significant.