This study contributed to the understanding of Syrian patients' attitudes towards the involvement of medical students in clinical teaching, as reported by those seen at three main teaching hospitals at Damascus University. Overall, the degree of acceptance of medical students was high, similarly to what was reported in many other studies from developed countries [8
] and the Arab World [24
]. It is worth mentioning that this trend was dominant in the three teaching hospitals studied despite the different socio-economic characteristics of their patients. It is worthy to note that Al Assad Hospital received patients referred from governmental and some private establishments while the service provided at Al Mouassat University Hospital and the Maternity Hospital is less organized, and in the latter two hospitals the services are completely free of charge.
This study also revealed reasons for which patients felt comfortable with the presence of medical students. Those reasons were indeed similar to those reported in the literature including the desire to contribute to medical education, the extra time spent with the patient, and the opportunity to learn more about their medical problem [9
]. Although the need to get patients' consent is a must [3
], our study unfortunately revealed that patient consent is simply absent as more than two-thirds of patients were indeed unaware of their rights to refuse or accept the active involvement of the medical students. O'Flynn and colleagues reported that 28% of patient thought that they did not have a choice about student presence and participation [13
], while Abdulghani and colleagues reported that 45.1% of patients believed that they had not the right to refuse medical students [24
]. The study of Chipp and colleagues showed that 89% of patients admitted that they would expect to have their permission sought before seeing a student [30
]. This issue is very critical, as the need to humanize the medical education is very evident, especially in settings such as ours where patients are the main educational "tools," since clinical skills lab was not introduced until quite recently. Inpatients at hospitals are mainly used for clinical teaching while outpatients are very rarely involved.
It was of interest to find that feeling of safety and comfort is indeed correlated to the presence of a supervisor. This is largely due to the lack of awareness of the extent of students' involvement. This finding is consistent with other studies [22
]. On the other hand, privacy was the main reason behind patients discomfort with Students' involvement.
We analyzed our results as to show the differences between the three hospitals when again findings on women seen at the Maternity University hospital was in agreement with other studies [20
], where all women expressed a preference for students of their same sex and refused male students. This is a pattern that one would expect more in largely Muslim country such as Syria [26
]. Of great interest in this work is that differences in attitudes were not only related to the sex of the patients but was also related to their educational level and socio-economic characteristics, which were evident even after stratifying for patient sex. This is contrary to the study of Shah-Khan and colleagues in Chicago that found no relationship between the economic level or degree of educational attainment and the degree of satisfaction of patients [31
Our study also reported patients' preferences with regard to the scale of medical students' involvement such as the number of students around the bed during the clinical consultation; as well as with regard to the desirable number of students actually examining the patient. Sweeney and colleagues suggested that it is the duty of supervising professor to be aware of the patients' preference taking into accounts the fears and concerns [29
]. Our study highlighted the importance of respecting the patients' preferences especially in a context where those are far from the ideal environment of clinical teaching. In our faculty, we face the dilemma of large number of students with small groups as large as 40 students at each point of time.
The cultural and religious background of our patients did not bring any implications on their attitudes towards medical students. This study highlighted similarities with other parts of the world where the humane needs (respect, dignity) of the patients are similar, however one might argue that the implications of over-dependence on real patients in our clinical teaching setting necessitates more notion of the humane need of the patients.
The main strength of our study is that it analyzed findings by type of hospital and allowed for socio-economic factors. Apparently this needs to be considered when taking any future steps into consideration. The main limitation is that potentially patients might have reported their answers without differentiating between undergraduate and postgraduate students. We do not think that seeking care at a free teaching hospital has negatively affected our findings as selection of the hospital was largely driven by external factors.