Medical Education 1988, 22, 501-505

The effect of medical education on the attitudes of medical students towards disabled people

S. C. D U C K W O R T H

Rehabilitatiotr Unit , Southamptori General liospital, Southamptori

Summary. The negative attitudes of society towards disability and the resulting prejudicial behaviour affects the lives of disabled people. One of the declared aims of the Faculty of Medicine of the University of Southampton is to improve attitudes. Hence, an attempt has been made to assess differences in the attitudes held by first- and fourth-year medical students, senior house officers and members of the general public towards disabled people. The measurement instrument used was the ‘Attitudes Towards Disabled Persons (ATDP) Scale’. The total num- ber of subjects in the survey was 428, of whom 263 (61 “/o) responded. No significant differences were found between the attitudes of the four groups studied. However, a subpopulation of subjects who agreed with the statement that ‘Dis- abled people cause more problems to doctors than non-disabled people’ had attitudes which were significantly more negative.

Key words: students, medical/*psychol; *atti- tude of health personnel; *handicapped; cduca- tion, medical, undergraduate; internship; England

Introduction

The aim of this study was to investigate the change in attitudes of medical students and junior doctors towards disabled people as they progress through their training. The Faculty of Medicine at the University of Southampton states, in the

Correspondencc: I)r S. C. Duckworth. liehabilita- tion Unit, Level C, West Wing, Southampton General Hospital, Southampton SO9 4XY, UK.

1985 Curriculum Booklet, that one ofthe aims of- the curriculum is ‘the development of appropri- ate attitudes’. An attempt has therefore been made to evaluate this aspect of the curriculum in relation to disabled people.

There is evidence to suggest that negative societal attitudes towards people with disabilities increase the disabling effects of their impairment (Becker 1963; Blaxter 1976; Shearer 1981; Wright 1983). Prejudicial attitudes and stereotypic beliefs reflect negatively on the social, intellectual and physical abilities of disabled people. Health professionals are particularly important in help- ing people with physical disabilities, but the views of doctors may be based on stereotypic beliefs rather than on rational, scientific reason- ing (Volinn 1983) . If their attitudes are such that they behave inappropriately the resulting effects on disabled people may be very considerable (Kerr 1970). This should be recognized and dealt with in an undergraduate curriculum.

An investigation of the extent to which medi- cal students and doctors hold these negative and potcntially stigmatizing beliefs is important for four reasons. Firstly, doctors have a significant impact on the formation of opinion concerning health-related issues, including those of the public, hospital nianagcrs and other health-care staff. Secondly, stereotypic beliefs may directly affect the delivery, and thus the outcome, of medical services to individual patients. Thirdly, the distribution of resources, when funds are short, may be biased towards ‘new technology’ and ‘high profile’ specialties. Finally, doctors may, by their attitudes towards and behaviour with disabled people, influence the beliefs of

502 S. C. Duckworth

medical students and perpetuate into the next generation a negative image of disabled people (Potts 1986).

Investigations into the effects of medical education upon attitudes have produced some important results. Kezler (1974) showed that it tends to increase ‘cynicism’. Difeker (1981) in relation to ‘empathy’ and Pcrriconc (1974) after studying ‘humanitarianism’ both showed that these qualities decrcascd in mcdical students as they progressed through their training. In addi- tion, students’ abilities in exercising intcrpcrso- nal skills havc bcen shown to decline (Helfer 1970). This suggests that as students increase their clinical experience their bchaviour pattern towards patients changes. I t has bcen demons- trated that first-year medical students may be more skilled at dealing with people than those in their final ycar. The first-year students are thought to avoid emotionally difficult subjects less oftcn and to enquire more freely about the patients’ own vicws oftheir problems (Pcndleton 1986). This last point is crucial since disabled people have a far greater knowledge ofthe physi- cal and social implications of their own disabilities.

Negative attitudes displayed by rehabilitation personnel wcre reported by Pcndcrson & Carle- son (198 I ) and Chubon (1982). There are several other studies that have indicated the presence of negative feelings towards patients by doctors and medical studcnts (Cartwright 1967; Ford 1967; Dungal 1978; Hornung 1979).

Much of the evidence cited above supports the view that medical education has a negative effect on attitudes. There has been some work, howcvcr, to support the alternative vicw. Dornbush (1985) found that attitudes towards ccrtain psychological issues were the same in first- and third-year students. Mitchcll (1983) found that attitudes of medical students towards disabled people became morc positive during thcir training. Contact with disabled people on the basis of ‘equal status’ plus educational infor- mation has been shown to be cffcctivc in chang- ing these negative attitudes (Block 1974).

The studies mentioned abovc serve to indicate that the attitudes of medical students and doctors towards disabled people may improve, dcterior- ate o r remain the same during the course of their training. This study aimed to evaluate the effects

of medical education at the University of Southampton.

Methods

Qlrestionrraire

A questionnaire developed by Yuker & Block (1986) was used. From the responses ‘Attitudes Towards Disabled Persons’ (ATDP) were scaled. The ATDP scale is derived from responses to a 30-item qucstionnairc. Its dcsign assumes that some people perccivc disabled individuals as being different from and thus inferior t o non-disabled persons. Subjects were asked to respond to ccrtain statcmcnts about dis- abled peoplc and to indicate how much thcy agreed or disagreed with each statement on a &point Likert Scale. Non-respondents were sent a second questionnaire if they had not replied within 4 weeks.

In addition to the 3 0 qucstions included on the ATDP scale all subjects wcrc askcd to identify other factors (e.g. sex, age and contact with dis- abled people) that may contribute to differences in the attitudes measured. In addition, members ofthe general public, who providcd comparative data, wcrc askcd thcir occupation. The medical students and scnior housc officcrs wcrc asked their intended future career and the duration, in weeks, of any work with disabled patients. Every respondent was invited to agree or dis- agree with the statement ‘Disabled peoplc cause more problems to doctors than non-disabled people’.

Subject selection

The ATDP scale was sent as a postal question- naire to 428 subjects. The subjects were selected from four distinct groups.

Group I : The general public-Ioo subjects were selected a t random from the electoral register of thc Southampton Test Valley Constituency.

Group z: Senior house officers-all 68 SHOs who were employcd by Southampton and South Wcst Hampshire Health Authority at the time of the study.

Group 3: First-year medical students-all I 3 3 students who started their medical course in October 1986.

Students' attitudes towards disabled people so3

Group 4 : Fourth-year medical students-all 127 fourth-year students who started their medi- cal course in October 1983.

Scoring the ATDP scale

follows: Responses to the 3 0 statements were scored as

Strongly agree + 3 Agree + 2 Agree slightly + I

Disagree slightly - 1

Disagree -2

Strongly disagree - 3 The signs of the 12 negatively phrased ques-

tions were changed and the scores summed. The sign of the sum was changed and added to a constant ofgo. This resulted in a theoretical range of scores from o to I 8 0 with lower scores imply- ing more negative attitudes.

Analysis ofdata

One-way analysis of variance was used to investigate the relationship between the mean scores of the four groups. It was also used to compare the relationship of ATIIP scores with other factors within one particular group, for example, age. When data were such that there were only two means to compare, as occurs with sex, a t-test was carried out (SPSSX 1986).

Results

Response rate and A T D P score

The number of responses to the initial and reminder questionnaire was 263, a response rate of 61.4%. The ATJIP scores of the four groups are summarized in Table I . The range of the mean scores was from 120.7 to 125.6 (sd, 13-8-197). The highest individual ATDP score was 168 and the lowest 74.

The ATDP scores in Table I approximate to a normal distribution. In a one-way analysis of variance no significant differences in ATDP scores between the four groups were found (P=033). Thus no change in attitude towards physically disabled people was detected with the ATDP scale during the progress of the selected medical students through their course at Southampton University. Similarly, there were no significant differences between the attitudes of the medical students, senior house officers and members of the general public.

One-way analyses of variance and t-tests were carried out to investigate the relationship between ATDP scores and the other variables. Significant differences ( E - 0 0 s ) in ATDP scores with respect to age, sex, occupation, intended medical career, length of contact with disabled patients and the subject's knowledge of someone with a disability, were not detected.

The data did indicate, however, that the 23.8%

Table I. ATDP scores for each group

ATDP scores . ~. . ~. ..

Group Mean sd Max Min .~ . ~.

I : General public I 207 16.72 I 56 74 2: Senior house officers 123.6 13.76 1 6 0 96

4: Fourth-year students 121.4 17.03 161 82 3: First-year students I 25.6 I 9.70 168 86

Table 2. 1-test comparing those who agreed or disagreed with the statement that disabled people cause more problems to doctors

ATDP scores Yo who .~

Group agreed Agreed Disagreed I value P value

2: Senior,house officers 245 I 14.7 I 26.7 -2'92 0.008

. . . .

I : General public 18.2 1os.o 1243 - 3 . 3 1 0'002

3: First-year students 18.1 110'0 I279 - 3 . 9 0 0'00 I 4: Fourth-year students 25'4 I 16.4 123.7 - 2 . 1 3 0'02 I

SO4 S . C . Duckworth

of subjects who agreed with the statement that ‘Disabled people cause more problems to doctors than non-disabled people’ scored significantly lower on the ATIIP scale. Data indicating their more negative attitudes are summarized in Table 2. A higher percentage of senior house oficers and fourth-year students agreed with the state- ment as compared to the other two groups, but this difference was not at a significant level.

Discussion

In the introduction it was argued that the atti- tudes of society are related to prejudicial behaviour towards disabled people. Within the limits of the method used this study has shown that the attitudes ofselected medical students and junior doctors are no different to those of a sam- ple of the general public. The existence of a sub- population in all groups, with significantly more negative attitudes, could be interpreted in several ways but i t does seem to show discrimination on an attitudinal level.

Mooney (1987) believes that unrecognized prejudices frequently play a major role in the intuitive opinions and judgcmcnts of all those concerned with the evaluation of disability. Wainapel (1987) argues that doctors share these attitudes and have additional negative attitudes towards chronic disabling diseases because they are often not curable. Klein (1982) has shown that doctors admit they have negative feelings about certain types of patients. Despite this most doc- tors believe that they treat all patients equally well and impartially (Drucker 1974). However, different patient groups d o receive differing stan- dards of carc. Egbcrt (1977). in relation to black patients, and Armitage (1979). in relation to women, have shown that both groups receive care which is inferior to that provided for their respective counterparts. In addition, physically attractive patients have been shown to receive better carc (Nordholm 1980).

Further evidence, which supports some of these conclusions, was produced by Ford (1967), who showed that doctors had favourable feelings when approaching situations involving diagnosis and treatment. They had avoidance tendencies when faced by demanding, hostile or severely disabled people. This has important implica- tions, since it can be inferred that doctors will

tend to avoid the needs of disabled people in preference for what are seen to be more challcng- ing diagnostic techniques and therapeutic procedures.

It would appear therefore that in the education of professionals there should be greater emphasis on ability rather than disability. Students should learn to recognize and avoid prejudicial behaviour and the use of misplaced pity, for these influence the self-concept of disabled individuals and adversely affect their chances of becoming rehabilitated (Wright I 972).

Attitudes may also affect the provision of ser- vices when rcsources are short. Attitudes of senior doctors and hospital managers may lead to the diversion of funds from rehabilitation towards more ‘high-tech’ areas of medicine. This will not only affect the delivery of medical ser- vices to disabled people, it will also reduce those community-based services which obtain funding from the National Health Service. Some ofthese problems were highlighted in a report by the Royal College of Physicians of London Physical Disabili ty in 1986 and Beyond.

A recent working party report entitled htegrar- i r g a Positive Concept of‘Disability into Professional Cirrricula (Kings Fund 1987) presented some important ideas of great relevance to medical education. I t was argued that innovative approaches involving disabled people in the training of professionals could be helpful and that these should be fostered from the bcginning of training before defensive barriers arc raiscd. The results of the study reported here indicate that this consideration should be prominent in cur- riculum planning.

It should be noted that there are difficulties in interpreting behaviour towards disabled people from an attitude scale. Nevertheless, it does appear that one of the declared aims of the Faculty of Medicine of the University of Southampton is not being met. The attempt should not be abandoned, however, for long- and short-term attitude changes in a positive direction have been shown to develop in medical students a t other universities.

There are inevitable practical problems that must not be overlooked in bringing about such changes. Medical school curricula are already overloaded with each specialty vying for addi- tional unavailable timc. ‘The medical profession

Students’ attitirdes townrds disabled people so5

is inherently resistant t o change. S o m e professio- nals m a y feel threatened by proposals t o engage disabled people in t h e educat ion of t h e medical profession about t h e non-medical or psycho- social aspects of disability, b u t these problems do need t o be overcome.

Conclusions

( I ) Methods of p r o m o t i n g positive a n d reducing negat ive at t i tude changes, which result in a l tered behaviour patterns in medical s tudents , need t o be identified.

(2) These factors should be incorporated in o r removed f r o m medical school curricula respectively.

(3 ) T h e effects of these factors o n medical stu- dent behaviour should be fully evaluated.

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Received 8January I 988; editorial roniments to author 26 February 1988; acceptedfor puhlicatioti I 5 A p r i l 1988