Levy, Barcey T. PhD, MD; Merchant, Mary L. PhD
Medical educators should monitor the clinical learning experiences of medical students. Differences in experiences associated with the gender of the student, that of the preceptor, or those of pairs of student and preceptor must be identified and addressed. Although some studies have examined students' training in gender-specific skills, few have investigated whether the gender of the student or preceptor affects the clinical experiences students receive.
For example, Kann1 reported that, although the vast majority of fourth-year medical students reported needing additional training in clinical breast exams, women students performed significantly more clinical breast exams than did men. Louis2 examined gender differences in selected clinical experiences of students during a third-year family medicine clerkship. No significant differences were found for the majority of tasks. Gender-specific differences were found, however, for some gender-specific skills, such as breast examination and testicular examination, which were performed significantly more often by students of the same gender as the patient. These researchers did not report on differences by student—preceptor gender dyads.
Carney et al.3 examined differences in students' experiences with some physical examination components among student and preceptor pairs for students completing a family medicine clerkship. Student and preceptor pairs of women performed more gynecologic examinations than did other gender pairs; few students of either gender (less than 5%) performed genitourinary examinations on any patient. The authors did not report on many clinical skills encountered in the family practice setting.
Our study adds to the literature by examining the levels of experiences with many clinical skills reported by a large number of students during a required community-based family medicine preceptorship over three academic years. We sought to determine whether the gender of students or preceptors was associated with the levels of experience students reported for female-specific, male-specific, or gender-neutral skills.
A total of 491 third-year medical students completed the required three-week family medicine preceptorship during three academic years (1997–2000) at the University of Iowa College of Medicine. Of these, 451 students (92%) rotated one-on-one with a community-based, board-certified, family physician preceptor and participated in all aspects of the clinical and medical practice activities of the preceptor. In all, 123 preceptors were selected by students during the three-year period; 19 were women and 104 were men. Forty students were excluded because they completed their preceptorships at residency sites where they worked with more than one preceptor. Prior to reporting to their preceptors, students received a half day of didactic instruction in the department of family medicine on topics including suturing, dictation, and clinical topics important to family practice.
Immediately upon completion of the preceptorship, students recalled and rated their experiences with 57 skills on a five-point scale: 1 = problem or activity not encountered, 2 = observed/assisted physician with problem or activity, 3 = was supervised by a physician in evaluation/management of problem or activity one to two times, 4 = was supervised by a physician in evaluation/management of problem or activity three to four times, 5 = was supervised by a physician in evaluation/management of problem or activity five or more times.4 We downloaded the data into a standard electronic database. The students' clinical experiences were categorized as female-specific (12), male-specific (3), or gender-neutral skills (42) (see Table 1). Prior to 1999, this information was collected using a scannable form. After that, we began using a Web-based form.
Mean students' ratings of their highest levels of experience were compared separately according to the gender of student and the gender of preceptor using independent t-tests. Because there were well over 30 values for each comparison, the distribution of means could be assumed normal by the central-limit theorem.5 For those skills that differed according to either the student's or the preceptor's gender, we compared mean levels of experience among the four possible gender pairings of student and preceptor using general-linear-model analysis of variance (GLM ANOVA), which adjusts for groups with differing cell sizes. We conducted post-hoc least-significant-difference tests to determine the sources of significant differences. For each skill, we also tested for student—preceptor gender interactions. We considered p values of less than .05 statistically significant. Because we were searching for patterns, despite doing multiple comparisons, we felt justified in keeping the p value at .05 in the analysis of variance.6 We used a standard statistical software package for all analyses.
Differences in Experiences by Gender of the Student
The levels of experiences reported by the students did not differ significantly by gender for 44 of 57 clinical skills (77%). Table 2 shows the significant differences in mean levels of experience for 13 (23%) clinical skills. Men students received significantly more experience than did women students in two of three male-specific skills: instructing patients in testicular examination and prostate examination (both p values <.001). Women students received more experience than did men students for eight of 12 female-specific skills: breast examination, contraception counseling, menopausal symptoms, pelvic examination and Pap smear, prenatal examination, instructing patients in breast examination, vaginal delivery, and managing vaginitis (all p values <.01). Three of 42 gender-neutral skills differed according to the students' gender. Women students received more experience than did men students with preventive health care of 40-to-64-year-olds, and men students received significantly more experience with asthma management and EKG interpretation.
Differences in Experiences by Gender of the Preceptor
The students' reported levels of experience did not significantly differ by preceptor gender for 42 of 57 skills (74%). Table 3 shows the clinical skills where students reported significantly different levels of experience according to the preceptors' gender. No significant difference was found for the three male-specific skills, but for seven of 12 female-specific skills (breast examination, contraception counseling, menopausal symptoms, pelvic examination and Pap smear, instructing patients in breast examination, vaginal smear, and managing vaginitis), students working with women preceptors received significantly more experience than did students working with men preceptors. Reported levels of experience differed for eight of the 42 gender-neutral skills. Women preceptors provided significantly more experience with managing depression and anxiety and men preceptors provided more experience with treating congestive heart failure, flexible sigmoidoscopy, fluorescein examination, joint aspiration or injection, laceration repair, and toenail removal.
Differences by Student—Preceptor Gender Pairs
Using independent t-tests, the students' reported levels of experience differed significantly for 22 clinical skills according to the gender of either the student or the preceptor (see Table 4). We then examined differences with reported levels of experience by preceptor—student gender pairs and found significant differences for 17 of these 22 skills using GLM ANOVA, but no significant student—preceptor gender interaction for any of the skills. For the male-specific skills prostate examination and instructing patients in testicular examination, women students working with any preceptor received significantly less experience than did men students working with a preceptor who was a man. In addition, for prostate examination, men students working with a preceptor who was a woman received significantly more experience than did women students working with a woman preceptor.
Of the nine female-specific skills, eight significantly differed by student—preceptor gender pairs: breast examination, contraception counseling, menopausal symptoms, pelvic examination, prenatal examination, instructing patients in breast examination, vaginal smear, and managing vaginitis. Men students working with preceptors of the same gender received significantly lower levels of experience with these eight skills than did at least some of the other gender pairs. For all of these female-specific skills except prenatal examination, women students working with a woman preceptor reported receiving the highest levels of experience. Women students working with any preceptor received significantly more experience with breast examination, menopausal symptoms, pelvic examination, and instructing patients in breast examination than did men students working with preceptors who were men.
There were significant differences by GLM ANOVA for seven of 11 gender-neutral skills. Men and women students working with preceptors who were men reported receiving significantly more experience than did women students working with women preceptors for five procedural skills: flexible sigmoidoscopy, fluorescein examination, joint aspiration or injection, laceration repair, and toenail removal. For preventive health care of patients aged 40 to 64 years and depression management, women students working with a woman preceptor received significantly more experience than did men students working with a preceptor who was a man.
Unlike the students' experiences with most clinical skills, which students reported to be similar regardless of student gender, their levels of experiences differed for the majority of the gender-specific skills and several procedures. Women students received significantly more experience with many female-specific skills and men students received more experience with several male-specific skills. Preceptors who were women provided more experience with many female-specific skills and with management of depression and anxiety; preceptors who were men provided more experience with several procedures. When we looked at the students' experiences by student—preceptor gender dyads, we found that, for the vast majority of gender-specific skills, the students reported the highest levels of experience in same-gender student—preceptor pairs with patients of the same gender; the lowest levels of experience occurred in same-gender student—preceptor pairs with patients of the opposite gender. However, for several gender-specific skills, students of the same gender as the patient working with preceptors of the opposite gender reported levels of experience comparable to those of same-gender student—preceptor pairs. For several procedures, the highest levels of experience were reported by students of either gender working with preceptors who were men and the lowest levels of experience were reported by women students working with preceptors who were women. We found no evidence for any significant student—preceptor gender interactions by GLM ANOVA, indicating that neither men nor women students reported preferentially more experience with specific clinical skills when working with a preceptor of a specific gender.
The differences we observed in the students' levels of experience with specific clinical skills may reflect a preceptor's practice or actual or perceived patient preferences. For example, the students' reports of higher levels of experience with several procedures when working with preceptors who were men may be because men do more of these in their practices7 or because preceptors who are men are more amenable to allowing students to participate in procedures. For many female-specific examination skills and procedures, patients may be more willing or the preceptors may perceive them to be more willing to have a woman student involved in their care. In one study, women patients were found to be more likely than were men patients to have chosen a physician who was a woman.8 Another study found that women physicians were more likely to engage their patients in discussions of their social and psychological contexts and to deal more often with feelings and emotions.9
Some of the differences these students reported in their levels of experience with gender-specific skills may have arisen from the students themselves. Students may be reluctant to let preceptors know they need more experience in these skills and, thus, may miss learning opportunities. Nonetheless, men students working with women preceptors reported levels of experience with breast examination, menopausal symptoms, and pelvic examination that were comparable to those of women students working with preceptors of either gender. Some of these differences in students' experiences may carry over to family practice residency training, where residents reported more experience with and were more comfortable managing health issues in patients of their gender.10 In addition, Weissman found that family practice residents who were men had significantly lower participation rates than did women residents in deliveries during an obstetrics rotation.11
The limitations of this study include examining experiences of third-year students taking one required rotation at one medical school only. Women preceptors accounted for only 15.4% of our preceptor pool, and relatively few men students rotated with preceptors who were women during this three-year period. However, this percentage is nearly identical to the 15.5% of women physicians nationally working in office-based practice in 1999.12 A strength of our data is that we were able to study the potential impacts of student gender and preceptor gender on clinical skills experiences, because the majority of students were paired with one preceptor for the duration of the rotation. Recall may not have been totally accurate, because the students completed the skills checklist upon finishing the three-week preceptorships as a summary of their experiences rather than recording each patient encounter. Methods that allow students to record their clinical experiences more immediately, while highly desirable, are often not practical in a busy office setting, and they require major resource commitments for data management. Additional research would be necessary to determine factors that might affect student recall.
The different levels of experience we identified for the study were fairly broad categories designed to differentiate lower levels of experience with a given skill (not seen or observed only) from higher levels (did one or two times, did three or four times, or did five or more times). Classification of skills was, in some cases, arbitrary, because we did not collect information regarding the gender of the patient for each patient encounter. For example, the higher levels of experience with preventive health care for patients aged 40-64 years by women students working with any preceptor may reflect the fact that many of these patients could have been women seeking treatment for menopausal symptoms, who may be more receptive to a woman student.13 One could also argue that, unless the differences found here persist across the continuum of medical education, medical students' education is not adversely affected, because students should receive opportunities to practice many of these skills in their other rotations.
However, we have documented that a student's gender affects the levels of experience that the student receives with some skills during the family medicine preceptorship. These differences were particularly prominent for many gender-specific skills. Family medicine preceptors and students should be aware of these potential differences in learning experiences, and efforts should be made to provide students with comparable learning opportunities regardless of gender. Some disparities in experience may be rectified by simply encouraging preceptors to provide students of both genders with experiences in selected skills. The paucity of literature on the topic of differences in students' experiences by gender argues for more research in this area. Future research should confirm these differences and explore the roles of patient preferences and preceptors' influence on the skills students experience. Ways should be found to minimize the differences.
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