Medical school curriculum characteristics associated with intentions and frequency of tobacco dependence treatment among 3rd year U.S. medical students
Introduction
Physician-delivered tobacco dependence treatment (Ask, Advise, Assess, Assist, and Arrange or the 5As) is associated with patient smoking cessation (Stead et al., 2013, Services TTFoCP, 2001, Fiore et al., 2008) and is recommended by the U.S. Public Health Service Clinical Guideline: Treating Tobacco Use and Dependence (Fiore et al., 2008). Yet, despite its effectiveness, physicians, particularly in the U.S., rarely provide consistent or adequate tobacco dependence treatment (Colleges AoAM, 2007, Ferketich et al., 2006, Thorndike et al., 2007, Thorndike et al., 1998, Centers for Disease C, Prevention, 2013, Goldstein et al., 1997, Tong et al., 2010). Reasons for this vary and include limited time and resources, (Schnoll et al., 2006, Vogt et al., 2005, Ward et al., 2002) but many primarily report limited training as a significant barrier to effectively providing this intervention (Cantor et al., 1993, Lancaster et al., 2000, Pbert, 2003, Cornuz et al., 2002).
Because physicians who receive tobacco dependence treatment training are more likely to use and adhere to treatment guidelines and recommendations compared to untrained physicians (Carson et al., 2012), medical schools can be an optimal time to provide this training. The medical school setting includes opportunity for multiple classroom or online didactics, interaction with standardized patients, small-group discussions with faculty, and opportunities to observe and be instructed by clerkship preceptors. However, reviews of tobacco dependence treatment education in U.S. medical schools found limited educational efforts and missed opportunities to provide tobacco dependence treatment training to medical students (Ferry et al., 1999, Griffith et al., 2013, Fiore et al., 1994, Geller et al., 2008, Powers et al., 2004, Richmond et al., 2009, Richmond et al., 1998, Spangler et al., 2002, Springer et al., 2008). For example, Spangler et al. (2002) found instructional gaps (e.g. few practice opportunities) resulting in only short-term retention of tobacco treatment intervention skills by students (Spangler et al., 2002).
In response to this gap, the Interagency Committee on Smoking and Health published a National Action Plan in 2002–2003 that included the recommendation that the knowledge and skill for providing tobacco dependence treatment be a core graduation requirement for all new physicians and other health care professionals (Fiore et al., 2004). Yet, this and other medical school educational initiatives to enhance medical student knowledge (e.g. preventive medicine), resulted in a typically packed curriculum, that does not necessarily enhance tobacco treatment educational efforts (Council, 2004, Pipas et al., 2004, Pomrehn et al., 2000). Medical schools are now streamlining teaching efforts because adding hours to the curriculum is unrealistic (Benbassat and Baumal, 2012, Langdale et al., 2003). It would be beneficial if medical schools had more effective models to teach tobacco dependence treatment, but such models are presently unknown. Examining which types of learning experiences are best associated with tobacco dependence treatment intentions and increased behaviors by medical students during medical school may help guide curricula reform in tobacco dependence treatment education.
Prior research thus far only has identified student characteristics associated with intentions and tobacco treatment behaviors. These include positive beliefs in preventive medicine, intentions to practice in primary care, greater tobacco knowledge, older age, being a non-smoker, and being female (Frank et al., 2007, Frank et al., 2009). In the current study, our goal was to evaluate if any curriculum characteristics were significantly associated with 5A intentions and behaviors beyond important student-level characteristics. Students reported on a list of curriculum characteristics they experienced during medical school and that included: amount of tobacco classroom instruction, frequency of the use of various instructional methods (i.e. case-based discussions, use of simulated patient encounters, participation in a clinical skills course, and participation in a web-based educational exercise or course), frequency of 5A instruction and observation, frequency of seeing clinic reminders, and perception of their clerkship preceptor/mentor as role models for providing tobacco dependence treatment.
Section snippets
Study design
Study data was collected as part of a 10 medical school group randomized controlled trial (“Medical Students helping patients Quit Tobacco”; R01CA136888, Ockene, PI) designed to evaluate whether a multi-modal tobacco dependence treatment curriculum would enhance student tobacco treatment performance on an Objective Structured Clinical Examination (OSCE) compared to traditional tobacco dependence treatment education. Each component of the curriculum focused on enhancing tobacco knowledge and 5A
Student participation & characteristics
A total of 1484 3rd year medical students across the 10 medical schools were eligible to complete the survey and 1221 completed the survey, for an overall response rate of 82.3%. Response rates differed by school (rates ranged from 49% to 100%) due to school differences in recruitment and accessibility to the 3rd year students (i.e. some students were off-campus completing clinical rotation requirements). As mentioned, surveys with no missing data (N = 1065) were included for this study.
Discussion
Each curriculum-related characteristic and teaching method was positively associated with both student 5A intentions and greater 5A use for tobacco treatment during medical school. Thus, greater exposure to any of the noted teaching/learning methods would be beneficial to enhance medical student education in tobacco dependence treatment. Little is known, however, about which educational methods are most effective for promoting student tobacco treatment skills. Our study is the first to address
Funding
This research was supported by NCI grant 5R01 CA136888 and NCI 5R01CA136888-S to Dr. Ockene and Dr. Hayes respectively.
Conflict of interests
The authors declare that there are no conflicts of interest.
Acknowledgments
We acknowledge Candice Dufour, BS, Diana Bernstein, BA, and Hyung-Joo Kang, MS, for their help in data collection and entry, as well as manuscript preparation. We also acknowledge all research assistants, project coordinators, faculty, preceptors, and other investigators who devoted their time in the larger research project. They are as follows: Andrew Nevins, MD, Anne Woll, MS, Becky Armstrong, MEd, MA, Carrie Bohnert, MPA, Catherine Okuliar, MD, Christi Rinaudo, MA, Christine Danner, MD, Dana
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