Medical Interns Lose Patient-Centred Attitudes as Workload Pressure Mounts, Brazilian Study Finds

Medical students do not arrive at their internships as blank slates. They carry years of classroom instruction, role models, and personal histories that shape how they see the person sitting across from them in a consultation room. But what happens to those attitudes during the two most demanding years of undergraduate medical training? A new longitudinal study from Brazil suggests that the answer depends less on how well students sleep or how satisfied they are with life, and more on the pressure they feel from patient demand and the structure of the clinical learning environment itself.

The research, published in BMC Medical Education by Jomara Oliveira dos Santos Yogui of the Federal University of Juiz de Fora, Danielle Bivanco-Lima of the Faculty of Medical Sciences of Santa Casa de São Paulo, and statistician Tiago M. Magalhães, tracked 83 fifth-year medical students through their clinical rotation at a Brazilian public university. Data collection ran from 30 April 2021 to 16 August 2022, and the researchers administered the Patient–Practitioner Orientation Scale, or PPOS, on three occasions: at the beginning of the internship, at the end of the fifth year, and at the end of the sixth year. The design allowed the team to measure not just snapshots of patient-centred orientation but actual trajectories of change over the two-year period.

The PPOS is a validated psychometric instrument that quantifies how a practitioner views two dimensions of the clinical relationship: sharing control and information with patients, and seeing the disease in the context of the whole person rather than as an isolated biological problem. Scores range along a continuum from a disease-centred pole, in which the doctor retains authority and focuses on pathology, to a patient-centred pole, in which power and information are shared and the psychosocial dimensions of illness are acknowledged. In contemporary medical education, patient-centred care is treated as a fundamental competency and a key determinant of healthcare quality and safety, which is precisely why longitudinal evidence about how it evolves during training matters.

The results revealed a nuanced picture. In the first and third assessment rounds, male students showed higher mean PPOS scores than female students, a difference that reached statistical significance in both rounds. This finding runs counter to some expectations in the literature, where female practitioners are often assumed to hold more patient-centred attitudes. The authors suggest the pattern may reflect group heterogeneity by sex within the cohort, and they caution against overinterpreting a single-institution result.

Perhaps the most striking null result concerned quality of life. The researchers collected a battery of indicators—satisfaction with leisure activities, social support, physical activity, sleep quality, difficulty sleeping, and financial satisfaction—and tested whether any of them tracked with PPOS scores. None did, in any of the three data collections. Burnout and wellbeing narratives dominate much of the conversation about medical trainee attitudes, so the absence of an independent association between wellbeing indicators and patient-centred orientation is technically significant. It suggests that personal wellbeing, at least as measured by these indicators, does not by itself determine whether a future doctor humanises care.

What did matter was perceived workload pressure. In the third assessment, students who reported never feeling pressured by patient demand had significantly higher PPOS scores. In the multivariate analysis, however, no quality-of-life variable or educational climate indicator showed an independent association with maintaining or increasing PPOS scores over time—except for sex, where female students had a lower likelihood of maintaining or increasing their scores, with an odds ratio of 0.75. The authors interpret the workload-pressure finding as evidence that structural aspects of clinical training, rather than individual wellbeing, may shape the development of patient-centred attitudes during internship.

The longitudinal comparison between the first and third assessments added another layer of complexity. Students whose PPOS scores decreased over time had higher baseline scores, while those who maintained or increased their scores presented higher final PPOS values. This pattern suggests a convergence effect: students who entered internship with strongly patient-centred orientations were more likely to see those attitudes erode, possibly under the weight of clinical demands, while those who ended with high scores were more likely to have sustained or built them throughout training. The finding reinforces the central role of the educational environment in shaping patient-centred orientation during medical internship.

Specialty choice produced an unexpected pattern. Interns opting for surgical fields showed a mean PPOS score of 2.44 with a standard deviation of 0.46, and those considering more than one specialty showed an almost identical mean of 2.44 with a standard deviation of 0.45—the highest scores in the cohort, although the difference did not reach statistical significance. The authors suggest this may reflect the growing role of shared decision-making in surgical settings and the increased need for communication skills in operative care, where informed consent and patient expectations carry particular weight. The lack of statistical significance, with a p-value of 0.552, means the observation should be treated as hypothesis-generating rather than conclusive.

Methodologically, the study used non-parametric tests—the Wilcoxon signed-rank test for paired comparisons and the Kruskal–Wallis test for between-group comparisons—with a significance threshold of p less than 0.05. The cohort size of 83 students at a single Brazilian public university limits generalisability, and the authors acknowledge that the PPOS captures orientation rather than observed behaviour in real consultations. Still, the longitudinal design over two years of internship, with three measurement points, is a strength that few studies in this field can claim.

The broader implication is uncomfortable but important. If patient-centred attitudes are not reliably protected by personal wellbeing, and if they can erode during the very years when students are supposed to be learning to humanise care, then medical schools must look at the structure of clinical training itself. Workload pressure, a component of the educational climate, emerged as the factor associated with patient-centred orientation in the final assessment. The authors conclude that structural aspects of clinical training may influence the development of patient-centred attitudes, and that the educational environment plays a central role in shaping them. For educators designing internship rotations, the message is clear: the hidden curriculum of the ward—the pace, the demands, the climate—may teach students as much about how to see patients as any formal lecture on communication ever will.

Subject of Research: Patient-centred care during medical internship: a longitudinal study of humanisation of care in undergraduate medical education

Article Title: Patient-centred care during medical internship: a longitudinal study of humanisation of care in undergraduate medical education

Article References: dos Santos Yogui, J. O., Bivanco-Lima, D., & Magalhães, T. M. (2026). Patient-centred care during medical internship: a longitudinal study of humanisation of care in undergraduate medical education. BMC Medical Education. https://doi.org/10.1186/s12909-026-10453-x

Image Credits: AI Generated

DOI: 10.1186/s12909-026-10453-x

Keywords: patient-centred care, medical education, medical internship, PPOS, educational environment, empathy, specialty choice, Brazil, Patient-centred, care, during, medical