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Rapid Responses: Rapid Responses published:
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Didactic training alone unlikely to change behavior
- Mark L Willenbring (8 November 2008)
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Changing medical students' attitudes to alcohol misuse
- Ferhal Utku, Ken Checinski (17 November 2008)
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Responses from the authors
- Erica Frank, Lisa Elon, Timothy Naimi, and Robert Brewer (20 November 2008)
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Alcohol consumption in medical students
- Michael John, Pippa Oakeshott (25 November 2008)
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Mark L Willenbring, Director Treatment & Recovery Research NIAAA/NIH
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Frank et al. are to be commended for their article describing the drinking habits and associated characteristics of medical students. Although the authors exercised appropriate caution interpreting the implications of this study, one particular finding has the potential for misunderstanding. The finding in question is the association between training (some/none vs. extensive) and frequency of counseling. Since required "extensive" training in screening, assessment and management of heavy drinking is rare in medical schools, students receiving extensive training are most likely to have sought it out as an elective. Multiple studies have documented that a subset of physicians are enthusiastic supporters of such screening, but that training rarely induces those not already so inclined to take it up (e.g. Anderson et al., Alcohol and Alcoholism, 39:351-356, 2004.) To conclude that implementing more mandatory training in medical schools will increase screening and counseling rates by physicians after graduation would be incorrect. It is disheartening but not surprising that students' interest declined as a result of medical school training. Clinical behavior is modeled and taught by residents and attending physicians practicing in the way they are most comfortable. It is probable that except for a few hardy souls interest further declines during post-graduate medical training. Until clinical training experiences routinely model and reinforce physician screening and assessment of heavy drinking, didactic education alone is highly unlikely to achieve the desired result. Competing interests: None declared |
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Ferhal Utku, Honorary Clinical Lecturer St George's, University of London, London SW17 0RE, Ken Checinski
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Frank et al. provide a lucid and stimulation discussion of many factors that influence alcohol interventions by US medical students. However, we feel they do not go far enough. At St George's, University of London, each medical (and other health care) student receives four sessions about their own behaviour and health during the first semester. The mixture of didactic and small group teaching includes peer learning with the student union, an introduction to the counselling services and orientation to the principles of disciplinary and fitness to study procedures, all of which are examinable. There is discussion about contentious issues such as "You need alcohol to make a social occasion pleasurable" and all students learn the basics about illicit drugs and their effects. Teachers come from a variety of medical disciplines and other professions as it is very important for the topic to be seen by colleagues and students alike as being of universal interest. Once the courses diverge, only the medical students receive a further six hours mixed teaching on their behaviour and health at the beginning of their final year, covering additional learning objectives such as the role of the General Medical Council in relation to their health and practice. These issues are covered in their final written examination. All this occurs in addition to substance misuse teaching in various modules of the course (eg gastroenterology, psychiatry and general practice). Our experience of this approach for more ten years is that examination and normalisation of students' own attitudes and behaviours towards substance misuse, both individually and in groups, are prerequisite to their optimal subsequent treatment of patients' misuse of alcohol and drugs. Competing interests: None declared |
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Erica Frank, Professor University of British Columbia, Lisa Elon, Timothy Naimi, and Robert Brewer
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We thank BMJ’s readers for their valuable and thought-provoking responses to our article, and respond to them below. We found that more training in alcohol-related counseling was a strong independent predictor of increased counseling practices reported by senior medical students. Dr. Willenbring raises the possibility that this relationship may be accounted for by additional training obtained through electives chosen by students who were already interested in counseling. While this is a reasonable hypothesis, in our understanding few medical schools offer many such electives, while most offer varying degrees of counseling training as part of their core medical education during pre-clinical and clinical years. Further, there are only a few extra-scholastic alcohol-related medical student electives (e.g., the Annenberg Physician Training Program in Addiction Medicine, and the Betty Ford Summer Institute). Our assertion is supported by additional analyses. We found that at ward orientation, school-level percentages of reporting extensive training ranged from 6 to 33%. During senior year the range was 19-46%. Between these two time points, increases at individual schools ranged from a low of 6 percentage points (28% to 34%), up to 25 percentage points (7% to 33%). Additionally, these data clearly slope -- medical schools providing more alcohol training at orientation to wards were also more likely to have provided more training to their graduating physicians. We should also mention that the study cited by Dr. Willenbring pertains to those already in clinical practice; our study was about counseling among medical students -- two different populations, with differing contexts that could mitigate the effects of training, including a relative lack of time and/or lack of remuneration for counseling services by practitioners. Our study supports the importance of training as part of the solution, though other systems changes are also needed to optimize counseling in the world of clinical practice. Finally, Drs. Utku and Checinski are to be commended for encouraging their medical students to be healthier, and we would strongly encourage U.S. and other countries’ medical schools to do likewise. We recommend the following articles from our research as additional aids to justifying and conducting health promotion among medical students: Frank E. 2004. “Physician health and patient care.” Journal of the American Medical Association, Vol. 291 (5), pg. 637. Frank E, Elon E, Carrera JS, Hertzberg VS. 2007. Predictors of US medical students’ prevention counseling practices. Preventive Medicine. Vol. 44:1, pgs. 76-81. Frank E, Elon L, Hertzberg V. 2007. Quantitative assessment of a 4- year intervention that improved patient counseling through improving medical student health. Medscape General Medicine. 2007 Jun 14;9(2):58. http://www.medscape.com/viewarticle/557088 Frank E, Smith D, Fitzmaurice D. 2005. “A description and qualitative assessment of a 4 year intervention to improve medical student health.” Medscape General Medicine, http://www.medscape.com/viewarticle/501770. Competing interests: None declared |
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Michael John, 3rd Year Medical Student St George's University of London, Pippa Oakeshott
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Frank and colleagues found a third (1668/4847) of American medical students surveyed drank excessively, and this proportion changed little over time(1). We conducted a cross sectional confidential questionnaire to assess British medical students’ knowledge of the UK Government recommended weekly drinking allowance (21 units for males and 14 units for females) and to investigate how much these students were drinking each week. We also explored the potential impact this might have on their behaviour. In December 2007 one hundred questionnaires were distributed to consecutive second year medical students attending a lecture at St George’s, University of London. The response rate was 87% (87/100). The mean age of participants was 21 (range of 19-39 years) and 39% (34/87) were male. Of the students who responded, 43% (37/87) did not drink alcohol at all and 90% were aware of the Department of Health recommended alcohol limits. However half (14/28) of the women and 45% (10/22) of the men who had drunk alcohol in the previous week had exceeded these with 21% of females and 23% of males drinking over twice the amount recommended by the government. Similarly around half (42/87) had experienced memory loss associated with the high levels of alcohol they had consumed and this was significantly commoner in those who had engaged in regrettable sexual activity (18/20) than those who hadn’t (24/ 65 p < 0.0001). A quarter of male students had taken part in organised drinking competitions. In line with the study by Frank et al(1), nearly a third (24/87) of these medical students said they drank in excess of the recommended guidelines. As outlined in the 2007 publication ‘Medical Students: Professional behaviour and Fitness to practice’, the General Medical Council now bases students’ fitness to practice on their behaviour and not their health. It is clear that as medical students and future doctors we have an example to set and can expect our social behaviour to be far more scrutinised, something we should consider the next time we head for the bar. (2) As Aaron White said in his study of 2005,(3) “If recreational drugs were tools then alcohol would be a sledgehammer.” 1. Frank E, Elon L, Naimi T, Brewer R. Alcohol consumption and alcohol counselling behaviour among US medical students: cohort study. BMJ. 2008;337(a2155). 2. General Medical Council, Medical Schools Council. Medical Students; professional behaviour and fitness to practice. In: Education, editor. London, Manchester: Plain English Approved by the word centre; 2007. 3. White AM. What happened? Alcohol, Memory Blackouts and the Brain. Alcohol Research and Health. 2003;27(2):186-96. Michael John 3rd Year Medical Student, Pippa Oakeshott Reader in General Practice St George’s, University of London Correspondence to: Michael John <m0500393@sgul.ac.uk> Competing interests: None declared |
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