Impact of a preventive medicine and nutrition curriculum for medical students

BACKGROUND: United States public health goals call for increased physician counseling about diet and exercise, but many medical schools lack adequate curriculum on these topics. At Harvard Medical School, second-year students take a preventive medicine and nutrition (PMN) course. This study evaluated the impact of this innovative curriculum on students' confidence about addressing patients' diet and exercise patterns and on their own health habits. METHODS: Students enrolled in the 2003 PMN course (N =137) completed a confidential 43-item written survey before and after the course. Surveys were completed by 134 students (98%) and 118 students (86%), respectively. The survey assessed students' diet and exercise habits and students' confidence in their ability to address diet and exercise with patients and family members. RESULTS: Students' confidence in their ability to assess and counsel about diet and exercise significantly improved after the course (all p <0.001). The course was also associated with a decrease in students' self-reported consumption of saturated fat (p =0.002) and trans fatty acids (p <0.001). Following the course, 72% of students perceived an improvement in their diet but only 18% perceived an improvement in exercise habits. CONCLUSIONS: An innovative PMN course improved medical students' confidence in diet and exercise counseling and perceived dietary habits. Improving these mediators of physician counseling in medical students may translate into changes in their practice patterns.     

Prophylaxis and treatment of pregnant women for emerging infections and bioterrorism emergencies

Emerging infectious disease outbreaks and bioterrorism attacks warrant urgent public health and medical responses. Response plans for these events may include use of medications and vaccines for which the effects on pregnant women and fetuses are unknown. Healthcare providers must be able to discuss the benefits and risks of these interventions with their pregnant patients. Recent experiences with outbreaks of severe acute respiratory syndrome, monkeypox, and anthrax, as well as response planning for bioterrorism and pandemic influenza, illustrate the challenges of making recommendations about treatment and prophylaxis for pregnant women. Understanding the physiology of pregnancy, the factors that influence the teratogenic potential of medications and vaccines, and the infection control measures that may stop an outbreak will aid planners in making recommendations for care of pregnant women during large-scale infectious disease emergencies.     

Creating an ideal social and behavioural sciences curriculum for medical students

Medical Education 2010: 44 : 1194–1202 Objectives Undergraduate medical education programmes universally struggle with overfull curricula that make curricular changes quite challenging. Final content decisions are often influenced by available faculty staff, vocal champions or institutional culture. We present a multi‐modal process for identifying ‘need‐to‐know’ content while leveraging curricular change, using the social and behavioural sciences (SBS) as an exemplar. Methods Several multi‐modal approaches were used to identify and triangulate core SBS curricula, including: a national survey of 204 faculty members who ranked the content importance of each of the SBS content areas; a comprehensive review of leading medical SBS textbooks; development of an algorithm to assess the strength of evidence for and potential clinical impact of each SBS construct; solicitation of student input, and review of guidelines from national advocacy organisations. To leverage curricular change, curriculum mapping was used to compare the school’s ‘actual’ SBS curriculum with an ‘ideal’ SBS curriculum to highlight educational needs and areas for revision. Clinical clerkship directors assisted in translating core SBS content into relevant clinical competencies. Results Essential SBS content areas were identified along with more effective and efficient ways of teaching SBS within a medical setting. The triangulation of several methods to identify content raised confidence in the resulting content list. Mapping actual versus ideal SBS curricula highlighted both current strengths and weaknesses and identified opportunities for change. Conclusions This multi‐modal, several‐stage process of generating need‐to‐know curricular content and comparing it with current practices helped promote curricular changes in SBS, a content area that has been traditionally difficult to teach and is often under‐represented. It is likely that this process can be generalised to other emerging or under‐represented topic areas.     

Benefits of a learner-centred abortion curriculum for family medicine residents.

BACKGROUND AND METHODOLOGY: Despite the high prevalence of unplanned pregnancy and abortion in the USA, abortion education in medical schools and residencies is extremely limited. Regardless of their personal views, family physicians will care for many women who have abortions. This article describes the implementation and evaluation of a learner-centred abortion curriculum in a family medicine residency. Residents were surveyed at baseline to assess openness to abortion education. An abortion curriculum was developed and implemented as a routine component of training. Three to four half-day training sessions were tailored to individual residents, with varying levels of participation in providing abortion depending on learners' personal beliefs. Residents completed written surveys before and after participation in the curriculum. RESULTS: The pre-implementation survey had a 90% response rate and showed that routine participation in an abortion curriculum was acceptable to 69% of respondents. The curriculum was implemented and evaluated from 2003 to 2006. All 39 residents participated and 28 (72%) completed both pre- and post-rotation surveys. Comparisons between pre- and post-rotation surveys demonstrated statistically significant improvements in abortion-related knowledge and self-reported comfort with abortion-related skills and significantly more favourable attitudes about abortion training. DISCUSSION AND CONCLUSIONS: Residents were better prepared to care for women with unwanted pregnancies after routine participation in an abortion curriculum. For controversial topics such as abortion, a learner-centred curriculum ensures adequate education for all residents. Future research should assess how routine abortion education affects patient care and whether it results in an increased number of family physicians who provide abortion.     

Injury-prevention counseling among residents of internal medicine

BACKGROUND: The U.S. Preventive Service Task Force's Guide to Clinical Preventive Services and Healthy People 2000 recommend that physicians participate in various counseling activities, including injury prevention. Despite recommendations, rates of physician counseling, particularly injury prevention, are low. This study assessed clinical preventive services and attitudes among physicians. Furthermore, the study illustrates how physicians prioritize injury-prevention counseling relative to other prevention recommendations. METHODS: Personal characteristics (i.e., demographics, specialty orientation, attitudes toward prevention, and personal health behaviors) of the residents were collected by a self-administered survey. We performed a 12-month retrospective chart review of 184 new doctor-patient encounters to determine rates of clinical preventive services that included four injury-prevention services: the use of seatbelts, helmets, and smoke detectors; and the safe storage of firearms. RESULTS: Overall, attitudes toward injury prevention in the context of other clinical preventive services were low. Seatbelt counseling was the only injury-prevention service documented in the charts, and was performed at only one of four clinic sites. CONCLUSIONS: Clinic site as a key predictor of preventive practice may be suggestive of the importance of organizational priorities and professional norms. Future injury-prevention education efforts must aim at improving attitudes of current and future physicians to facilitate positive professional norms.     

Recognition of depression by internal medicine residents

We studied the ability of internal medicine residents to recognize depressive symptoms in a population of lower socio-economic primary care patients. Four hundred twenty patients completed the short form of the Beck Depression Inventory (BDI). Simultaneously, the resident caring for the patient estimated the degree of depression for each patient. One-fourth of the patients scored at or above the moderately depressed level on the BDI and the residents rated 23 percent of their patients as at least moderately depressed. However, the accuracy of the residents' assessment of his or her individual patient was poor (correlation=0.42, sensitivity=0.46, specificity=0.84). Patients with a scored higher on the BDI and were given higher ratings of depression. No other pre-existing medical condition was significantly associated with a higher or lower BDI score. The amount of alcohol consumed and the amount smoked, were both associated with higher BDI scores. Residents varied in their sensitivity to their patients' BDI scores. Some showed high agreement with BDI scores, others low. There were no specific resident characteristics (e.g. year of training, resident gender) that could explain this variability. Patients with a history of depression were given lower resident ratings compared to other patients and patients with a history of depression were given lower resident ratings than predicted by their BDI scores. Residents' ability to accurately diagnose and treat depression in the underprivileged primary care patient can be facilitated by the institution of depression screening in the ambulatory clinic.Robert J. Sliman is assistant professor of medicine, David Jarjoura is associate professor of biostatistics in the division of community health sciences and Andre J. Ognibene is professor and chairman of the department of medicine, all at the Northeastern Ohio Universities College of Medicine, Rootstown, Ohio 44272. Thomas A. Donohue is a student at Case Western Reserve University School of Medicine, Cleveland, Ohio.     

Training internal medicine residents to screen for domestic violence

Internal medicine residency programs will need to train residents about domestic violence to comply with the Residency Review Commission standards. To assess the effectiveness of an educational intervention intended to increase screening of patients for domestic violence by internal medicine resident physicians and identify characteristics associated with increased screening, we used a quasi-experimental, pretest/posttest trial. This was conducted in an internal medicine residency program and its affiliated primary care clinic with categorical internal medicine and combined medicine/pediatrics resident physicians. Exit interview surveys of patients were conducted at baseline and following the educational program. Patients were questioned about demographics and if they were asked about domestic violence during the current visit. Physicians were questioned about demographics and attitudes and beliefs related to domestic violence. Prior to the intervention, only 0.8% (1 of 122) of patients reported being asked about domestic violence. After the intervention, the percentage asked rose to 17% (20 of 116). The odds ratio (OR) for being asked about domestic violence after training was 25.2 (6.1-104). Patients who were younger than 50 years were more likely to be asked (OR 2.5, 1.5-4.6). Caucasian physicians were more likely to ask (OR 2.8, 1.1-7.6). Patients reporting they were taught breast self-examination at that day's visit were also more likely to be screened (OR 2.9, 1.1-7.9). We found evidence that moderately intense training and focusing on results can increase resident physician screening rates for domestic violence. To do so effectively, we recommend a training session similar to this one and continued monitoring of outcome in the clinical setting.