The primary health care centre visit was reported as very useful or useful by 90% of all reporting students. No student reported the visit as useless or waste of time.
Attitudes of the practitioners towards their patients
The GPs were described as: good listener, actively present, interested, funny, cheerful, respectful, genial, warm, cosy, caring, friendly, empathic, neutral, objective, correct, effective, competent, and diplomatic. Some students reported that the consultation was pleasant, even though negative expressions were used for the practitioner such as reserved or distant. Only a few students observed attitude problems, such as a dismissive attitude, unwillingness, sneering at the patient or anxiety.
Two thirds (70%) of the students reported positive or very positive attitude of GPs towards the concerns of their patients. Students reported that the GPs treated patients as human beings, not only as patients or clients. Moreover, students observed that GPs allowed patients to express themselves freely: In my opinion doctor Y's attitude towards the patients was objective but human. She did not remain distant. When I observed her work, I felt that she really cares, and concentrates thoroughly on each and every case. She had a good contact with her patients, and the patients described their complaints to her openly. Doctor Y spared enough time for explaining facts to patients, and the patients actively inquired for more information, if anything was left unclear (43/F).
Students perceived that patients could feel safe and comfortable with GPs with differing attitudes: The younger doctor was more spontaneous and quicker in a way. He normally made jokes and chatted, and at times he could act very efficiently and solve a problem quickly. Perhaps he could see who needed support, and who only needed treatment. The older doctor was very correct; his social distance to patients seemed greater, but most probably this did not adversely affect the encounter. Although he was warm to the patient, he made sure not to step on the patient's toes. This appeared as slow movements and considerateness. On the other hand this made me think the doctor was listening and allowing enough time for the patient (60/M).
GPs adjusted their communication at the patient's level. Medical students observed different ways of communication depending on the patient: The doctor knows how to handle patients and is able to adapt her communication. She normally listens to a talkative patient and at times makes focusing questions. She encourages a shy patient to talk about his/her symptoms and asks more questions (55/F).
In some cases, GPs seemed to clarify their messages with drawings: Doctor S gives clear and comprehensible instructions which she also reinforces with various drawings if necessary. At the end of the session she also checks with some questions that the patient has understood the message (114/F). But in some cases they did not give adequate guidance in health matters: It was strange how passively patients made use of immunization services, even though they are free of charge for certain high-risk groups, and how little people know about vaccinations and other procedures. A young man belonging to the high-risk group because of his asthma came for a specific reason. He asked if he should get an influenza vaccination, and the doctor recommended it. The man suspected that such a vaccine could weaken his own resistance to diseases. Is there a principle in Finland that only the doctor knows what to do with the patient? As far as I am concerned, I want to rectify this problem. In my opinion the patient should not even need to ask what happens, information should be given automatically, but of course hectic work makes interaction difficult (122/M).
Several students reported GPs as having strong opinions about unhealthy life-styles, but at the same time behaving diplomatically: The doctor was very empathic, although strict with some patients when necessary. A couple of times I noticed that the doctor looked amused when the patient asked a medically funny question. This episode did not have any importance anyway, and at the end of the day the doctor explained the medical conception patiently, and at times looked for additional information for the patient. The doctor tried to explain things clearly, and patients had the opportunity to inquire about their concerns. The doctor as a family practitioner knows the patients and thus is able to adjust his behaviour and communication style according to the patient (66/F).
Some students reported that the GP whose communication with ordinary patients was emphatic turned to more distant with children, mentally retarded, elderly, and socially marginalised patients. Similar aloofness was observed with accident and emergency cases.
Students reported that the working pace of GPs in accident and emergency departments is hectic: Both doctors behaved differently in the A&E department than in the non-acute clinical sessions. In my opinion, this was merely due to the high number of patients in the A&E department, where the hectic working pace simply could not be handled. The fairly cold attitude put me off in the beginning, but afterwards I realized that it is the only way to cope with the chaotic situation (94/M). In addition, students perceived and reported GPs working style as mechanical and distant: Also on the ward the same attitude of help and support was present, but one could not help getting the impression that chronic patients are like things, plants or animals, features which the doctor investigates with the nurse and introduces to a guest (89/M).
The computer screen and the concentration of GPs on other matters (incoming telephone calls, and other staff members entering the consultation room) were experienced as disturbing factors in doctor-patient communication: I did not feel comfortable with the habit of all the doctors of staring at the computer screen while listening to the patient. Many times the patients, while they were still speaking, started to look at me as if they were explaining their concerns to me (63/F).
Students reported continuity of care as an important element of the doctor-patient-relationship: ... Patients seem to be very open with regard to their illnesses. Doctors behave like patients' family members. Based on our discussions with patients, they feel comfortable in seeking medical help from their own family doctors and are bold enough to ask them for help, unlike in the case of an unknown doctor. Also doctors gave positive feedback about the family doctor system; it often helps when one knows the concerns of the patient in advance. So, no time is wasted on getting to know each other (54/F).
The reports suggest that the primary health care centre visit may have a positive effect on the early professional growth of medical students and seems to turn negative attitudes towards primary health care into more positive attitudes. Several students observed identity forming rituals; they appreciated that they were introduced to the clients as GPs' "colleagues". Similarly, wearing white uniform, stethoscopes, getting small gifts from pharmaceutical representatives etc. and recognition by other staff members were reported to help them adapt to the primary health care centre work as team members:It was nice to dress in the white uniform for the first time and feel what it is like to be a practising doctor (114). The best thing was that I had a chance to examine sinuses or auscultate lungs and heart on my own (57).