A controlled trial of educational strategies to teach medical students brief intervention skills for alcohol problems

Multidimensional Evaluation of Screening Brief Intervention and Referral to Treatment Training for Medical Students

OBJECTIVE

Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an evidence-based approach to identifying and addressing alcohol use in non-specialty settings. Many medical schools teach SBIRT, but most published evaluations of these efforts exclude rigorous skill assessments and teaching methods.

METHODS

During the 2017-2018 academic year, 146 third-year medical students received classroom-based learning on SBIRT and motivational interviewing (MI) and at least two SBIRT practices with feedback as part of a 4-week psychiatry clerkship. The objective of this curriculum was to improve SBIRT knowledge, attitudes, and confidence and enable learners to skillfully deliver SBIRT. Outcomes evaluated included satisfaction, knowledge, attitudes and confidence, and clinical skill in delivering SBIRT to a standardized patient (rated by the actor, as well as an expert).

RESULTS

Results indicated acceptable satisfaction at post-curriculum and significant improvements in attitudes and knowledge from pre- to post-curriculum. On the clinical skills exam, all students were rated as having mastered at least 80% of SBIRT elements by standardized patients and 91.8% were rated at this level by a faculty expert. Student attitudes and knowledge were unrelated to expert ratings, and standardized patient ratings had limited associations with expert ratings.

CONCLUSIONS

These results suggest curriculum objectives were achieved and provide unique contributions to the SBIRT curricular outcome research for healthcare trainees. Other findings included that trainee knowledge and confidence may not relate to skill, and standardized patient feedback provides different information on SBIRT and MI skill than expert ratings.

Interventions for improving medical students' interpersonal communication in medical consultations

BACKGROUND

Communication is a common element in all medical consultations, affecting a range of outcomes for doctors and patients. The increasing demand for medical students to be trained to communicate effectively has seen the emergence of interpersonal communication skills as core graduate competencies in medical training around the world. Medical schools have adopted a range of approaches to develop and evaluate these competencies.

OBJECTIVES

To assess the effects of interventions for medical students that aim to improve interpersonal communication in medical consultations.

SEARCH METHODS

We searched five electronic databases: Cochrane Central Register of Controlled Trials, MEDLINE, Embase, PsycINFO, and ERIC (Educational Resource Information Centre) in September 2020, with no language, date, or publication status restrictions. We also screened reference lists of relevant articles and contacted authors of included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), cluster-RCTs (C-RCTs), and non-randomised controlled trials (quasi-RCTs) evaluating the effectiveness of interventions delivered to students in undergraduate or graduate-entry medical programmes. We included studies of interventions aiming to improve medical students' interpersonal communication during medical consultations. Included interventions targeted communication skills associated with empathy, relationship building, gathering information, and explanation and planning, as well as specific communication tasks such as listening, appropriate structure, and question style.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Two review authors independently reviewed all search results, extracted data, assessed the risk of bias of included studies, and rated the quality of evidence using GRADE.

MAIN RESULTS

We found 91 publications relating to 76 separate studies (involving 10,124 students): 55 RCTs, 9 quasi-RCTs, 7 C-RCTs, and 5 quasi-C-RCTs. We performed meta-analysis according to comparison and outcome. Among both effectiveness and comparative effectiveness analyses, we separated outcomes reporting on overall communication skills, empathy, rapport or relationship building, patient perceptions/satisfaction, information gathering, and explanation and planning. Overall communication skills and empathy were further divided as examiner- or simulated patient-assessed. The overall quality of evidence ranged from moderate to very low, and there was high, unexplained heterogeneity. Overall, interventions had positive effects on most outcomes, but generally small effect sizes and evidence quality limit the conclusions that can be drawn. Communication skills interventions in comparison to usual curricula or control may improve both overall communication skills (standardised mean difference (SMD) 0.92, 95% confidence interval (CI) 0.53 to 1.31; 18 studies, 1356 participants; I² = 90%; low-quality evidence) and empathy (SMD 0.64, 95% CI 0.23 to 1.05; 6 studies, 831 participants; I² = 86%; low-quality evidence) when assessed by experts, but not by simulated patients. Students' skills in information gathering probably also improve with educational intervention (SMD 1.07, 95% CI 0.61 to 1.54; 5 studies, 405 participants; I² = 78%; moderate-quality evidence), but there may be little to no effect on students' rapport (SMD 0.18, 95% CI -0.15 to 0.51; 9 studies, 834 participants; I² = 81%; low-quality evidence), and effects on information giving skills are uncertain (very low-quality evidence). We are uncertain whether experiential interventions improve overall communication skills in comparison to didactic approaches (SMD 0.08, 95% CI -0.02 to 0.19; 4 studies, 1578 participants; I² = 4%; very low-quality evidence). Electronic learning approaches may have little to no effect on students' empathy scores (SMD -0.13, 95% CI -0.68 to 0.43; 3 studies, 421 participants; I² = 82%; low-quality evidence) or on rapport (SMD 0.02, 95% CI -0.33 to 0.38; 3 studies, 176 participants; I² = 19%; moderate-quality evidence) compared to face-to-face approaches. There may be small negative effects of electronic interventions on information giving skills (low-quality evidence), and effects on information gathering skills are uncertain (very low-quality evidence).  Personalised/specific feedback probably improves overall communication skills to a small degree in comparison to generic or no feedback (SMD 0.58, 95% CI 0.29 to 0.87; 6 studies, 502 participants; I² = 56%; moderate-quality evidence). There may be small positive effects of personalised feedback on empathy and information gathering skills (low quality), but effects on rapport are uncertain (very low quality), and we found no evidence on information giving skills. We are uncertain whether role-play with simulated patients outperforms peer role-play in improving students' overall communication skills (SMD 0.17, 95% CI -0.33 to 0.67; 4 studies, 637 participants; I² = 87%; very low-quality evidence). There may be little to no difference between effects of simulated patient and peer role-play on students' empathy (low-quality evidence) with no evidence on other outcomes for this comparison. Descriptive syntheses of results that could not be included in meta-analyses across outcomes and comparisons were mixed, as were effects of different interventions and comparisons on specific communication skills assessed by the included trials. Quality of evidence was downgraded due to methodological limitations across several risk of bias domains, high unexplained heterogeneity, and imprecision of results. In general, results remain consistent in sensitivity analysis based on risk of bias and adjustment for clustering. No adverse effects were reported.  AUTHORS' CONCLUSIONS: This review represents a substantial body of evidence from which to draw, but further research is needed to strengthen the quality of the evidence base, to consider the long-term effects of interventions on students' behaviour as they progress through training and into practice, and to assess effects of interventions on patient outcomes. Efforts to standardise assessment and evaluation of interpersonal skills will strengthen future research efforts.

Substance Use Disorder Education in Medical Schools: A Scoping Review

PURPOSE

As medical schools adapt their curricula to prepare future physicians for the opioid crisis and for treating patients with substance use disorders (SUDs), educators should refer to courses described in the literature. This scoping review aimed to (1) provide a comprehensive evaluation and summation of peer-reviewed literature reporting on SUD education in medical schools globally and (2) appraise the research quality and educational outcomes reported in SUD education studies in medical schools.

METHOD

The authors searched 6 databases (3 Ovid MEDLINE databases, Embase, ERIC, and Web of Science) from inception through May 25, 2018. Original English-language research studies focusing on medical students and describing SUD education in medical schools were included. The Medical Education Research Study Quality Instrument (MERSQI) was used to assess included studies.

RESULTS

Of 3,178 articles identified, 43 met inclusion criteria. Studies were conducted in 9 countries. Most reported on educational interventions for tobacco (n = 20; 47%); others reported on interventions for SUDs broadly (n = 15; 35%), alcohol (n = 8; 19%), and opioids (n = 1; 2%). The mean MERSQI score was 12.27 (standard deviation 2.30). Four studies (9%) reported on educational outcomes at the level of behaviors or patient or health care outcomes. The majority (n = 39; 91%) reported significant benefits.

CONCLUSIONS

Educational interventions relating to SUDs were effective in improving medical students' knowledge, skills, and attitudes. Educators should develop courses that achieve higher-level educational outcomes, increase education on opioid use disorders, and focus on the greatest public health concerns.

Impact of a primary care training program on the prevention and management of unhealthy alcohol use: A quasi-experimental study

OBJECTIVE

To assess the impact of a training program targeted to Primary Care (PC) professionalson the acquisition of communication skills, attitudes, and knowledge about the prevention and management of unhealthy alcohol use.

METHODS

A quasi-experimental, pre- and post-intervention study was performed in PC centers of Cordoba (Spain). Family doctors, residents and nurses participated in the study. The intervention was based on a motivational interviewing training program, which consisted in a workshop on learning skills, attitudes and knowledge about the alcohol management. PC providers were videotaped with a standardized patient in order to check the clinical and communication competencies acquired. A descriptive, bivariate and multivariate analysis was carried out (p < 0.05).

RESULTS

PC providers' communication skills and attitudes showed significant improvements in the variables studied (p < 0.001), as well as in the clinical interview evaluation parameters.

CONCLUSION

The present study reveals the impact of a training program targeted to PC professionals on communication skills, attitudes, and knowledge about the prevention and management of patients with unhealthy alcohol use.

PRACTICE IMPLICATIONS

Training activities targeted to PC providers represent a valuable strategy to improve communication skills, attitudes and knowledge of these professionals in their clinical practice.

Simulation in Undergraduate Psychiatry: Exploring the Depth of Learner Engagement

OBJECTIVES

Simulation-based methodologies are increasingly used in undergraduate medical education to expand students' exposure to complex clinical scenarios. Engagement of students in these simulation-based methodologies is a key determinant of their success in learning. Thus, the authors conducted a systematic review to (1) identify simulation methods in use within the undergraduate psychiatry curriculum and (2) assess learner engagement using these methods.

METHODS

Following a PRISMA methodology, the authors searched MEDLINE, ERIC, and PsychINFO databases from 1977 to 2015. Studies applying simulation in undergraduate psychiatric education were reviewed. The depth of learner engagement was assessed using Kolb's four-stage learning cycle.

RESULTS

Of 371 publications identified, 63 met all the inclusion criteria: 48 used standardized patients and 16 used online or virtual learning case modules. Only one study used high fidelity mannequins. Three studies satisfied multiple stages in Kolb's Learning Cycle, including a single study that addressed all four domains.

CONCLUSIONS

Despite the varied uses of simulation across other health disciplines, there were few novel or innovative uses of simulation in undergraduate psychiatric education since the last review in 2008. Expanding on the use of simulation to improve communication, build empathy, and decrease stigma in psychiatry is essential given the relevance to all facets of medical practice. Given the complexity of psychiatry, simulation interventions should extend beyond communication scenarios. Medical students need more opportunities to reflect and debrief on simulation experiences and integrate learning into new contexts. Faculty development should focus on these novel approaches to simulation to deeply engage learners and enhance outcomes.

A SBIRT curriculum for medical residents: development of a performance feedback tool to build learner confidence

A major barrier to actualizing the public health impact potential of screening, brief intervention, and referral to treatment (SBIRT) is the suboptimal development and implementation of evidence-based training curricula for healthcare providers. As part of a federal grant to develop and implement SBIRT training in medical residency programs, the authors assessed 95 internal medicine residents before they received SBIRT training to identify self-reported characteristics and behaviors that would inform curriculum development. Residents' confidence in their SBIRT skills significantly predicted SBIRT practice. Lack of experience dealing with alcohol or drug problems and discomfort in dealing with these issues were significantly associated with low confidence. To target these barriers, the authors revised their SBIRT curriculum to increase residents' confidence in their skills and developed an innovative SBIRT Proficiency Checklist and Feedback Protocol for skills practice observations. Qualitative feedback suggests that, despite the discomfort residents experience in being observed, a proficiency checklist and feedback protocol appear to boost learner confidence.

How is an electronic screening and brief intervention tool on alcohol use received in a student population? A qualitative and quantitative evaluation

Background

A previous study among Antwerp college and university students showed that more male (10.2%–11.1%) than female (1.8%–6.2%) students are at risk for problematic alcohol use. The current literature shows promising results in terms of feasibility and effectiveness for the use of brief electronic interventions to address this health problem in college and university students. We evaluated this type of intervention and cite existing literature on the topic.

Objective

To develop a website, www.eentjeteveel.be, to motivate college and university students with problematic alcohol use to reduce alcohol consumption and increase their willingness to seek help.

Method

The website contained a questionnaire (Alcohol Use Disorders Identification Test [AUDIT]) for students to test their alcohol use. According to their answers, the students immediately received personalized feedback (personal AUDIT score and additional information on risks associated with alcohol use) and a suggestion for further action. Afterward, students could send an email to a student counselor for questions, guidance, or advice. To obtain in-depth qualitative information on the opinions and experiences of students, we held 5 focus group discussions. The topics were publicity, experiences, impressions, and effects of the website. We analyzed the quantitative results of the online test in SPSS 15.0.

Results

More than 3500 students visited www.eentjeteveel.be; over half were men (55.0%). A total of 34 students participated in the focus group discussions. The mixture of quantitative and qualitative methods to evaluate the intervention allowed a thorough analysis and provided complementary results. The intervention was well received by the student population. However, some minor aspects should be reconsidered, such as website publicity and providing students with options that were added after intermediate evaluation. The intervention increased the motivation of students to think about their alcohol use but could not stimulate them to change their behavior. The website attracted relatively more male than female students and more students in the high-risk group than in the low-risk group. The high-risk group was more inclined to seek advice or guidance (23/400, 6%; χ²_{2 = 32.4,} P < .001) than the low-risk group (34/1714, 2%; χ²_{2 = 32.4,} P < .001).

Conclusions

We gained unique insight into students’ experiences, opinions, and perceptions with regard to the intervention. The results show that the intervention was positively received in the population, and the willingness to seek help was increased. However, real behavior change needs further research. The results of this study can assist health providers and researchers in better understanding college and university students’ perceptions of eHealth initiatives.

Standardized patient walkthroughs in the National Drug Abuse Treatment Clinical Trials Network: common challenges to protocol implementation

BACKGROUND

Training research staff to implement clinical trials occurring in community-based addiction treatment programs presents unique challenges. Standardized patient walkthroughs of study procedures may enhance training and protocol implementation.

OBJECTIVES

Examine and discuss cross-site and cross-study challenges of participant screening and data collection procedures identified during standardized patient walkthroughs of multi-site clinical trials.

METHOD

Actors portrayed clients and "walked through" study procedures with protocol research staff. The study completed 57 walkthroughs during implementation of 4 clinical trials.

RESULTS

Observers and walkthrough participants identified three areas of concern (consent procedures, screening and assessment processes, and protocol implementation) and made suggestions for resolving the concerns.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

Standardized patient walkthroughs capture issues with study procedures previously unidentified with didactic training or unscripted rehearsals. Clinical trials within the National Drug Abuse Treatment Clinical Trials Network are conducted in addiction treatment centers that vary on multiple dimensions. Based on walkthrough observations, the national protocol team and local site leadership modify standardized operating procedures and resolve cross-site problems prior to recruiting study participants. The standardized patient walkthrough improves consistency across study sites and reduces potential site variation in study outcomes.

Undergraduate medical education in substance use in Ireland: a review of the literature and discussion paper

BACKGROUND

Medical complications of substance use are a considerable cause of morbidity and the role of the physician in the care of such problems has consistently been demonstrated. Appropriate knowledge and skills are necessary to carry out this role.

AIMS

To review the literature on training undergraduate medical students in identifying and managing substance misuse and to discuss the implications of this literature for Irish medical education.

METHODS

A search of the literature was performed using keywords; "substance-related disorders", "undergraduate" and "curriculum". All abstracts were reviewed and the full text of relevant abstracts was studied and references reviewed for further articles.

RESULTS

Despite an increase in prevalence of the problem of drug and alcohol use in Ireland and the UK, this has not been reflected in undergraduate medical curricula. In the UK, minimal time is devoted to formal teaching of medical undergraduates in the area of substance misuse and many doctors do not have the appropriate knowledge, skills, attitudes and confidence to treat patients with such problems. In Ireland, no data has reported formal undergraduate teaching hours in the area of drug and alcohol misuse. Internationally, substance abuse curricula have been developed and implemented in medical schools in the United States and Australia.

CONCLUSION

While substance misuse is increasing in prevalence, this is not reflected in the composition of medical curricula, especially in Ireland. International best practice whereby undergraduate curricula that adequately address substance misuse and related issues are systematically developed and implemented, is recommended for adoption by Irish medical schools.

Undergraduate medical education in substance abuse: a review of the quality of the literature

PURPOSE

To prepare to develop a medical school curriculum on substance abuse disorders (SADs), the authors conducted a review of the quality of the sparse published literature.

METHOD

The authors searched MEDLINE (1950 through December 2008) using OVID, PsycINFO, and PubMed to identify all studies of SAD interventions targeted toward undergraduate medical students. Of the 1,084 studies identified initially, 31 reported sufficient data to allow the authors to evaluate quality using Medical Education Research Study Quality Instrument (MERSQI) scores. The authors also determined the impact of the studies by considering three-year citation rate and journal impact factor. A detailed review of the literature provided data on contact hours and intervention content.

RESULTS

The three-rater intraclass correlation coefficient for total MERSQI score was 0.82 (95% confidence interval: 0.70-0.90). The mean MERSQI score was 10.42 of a possible 18 (SD 2.59; range: 6.33-14.83). MERSQI scores were higher for more recently published studies and correlated with three-year citation rate but not impact factor. The mean contact time for 26 studies was 29.25 hours (range: 0.83-200 hours).

CONCLUSIONS

The literature provides a variety of educational methods to train medical students in SAD detection and intervention skills. This literature is of variable quality and provides limited guidance for development of curricula and medical education policy. Better methods of curriculum evaluation and publication guidelines would help ensure that this literature has a positive impact on educational practice and public health.

Effect of feedback from standardized patients on medical students' performance and perceptions of the neurological examination

BACKGROUND

Feedback can have a powerful influence on the performance of learners, and has traditionally been provided by faculty.

AIM

This study set out to explore whether feedback from a standardized patient (SP) can improve students' performance of the neurological examination.

METHODS

A randomized controlled design was used with final year medical students. The control group did not receive any feedback. The intervention groups received either written feedback or a combination of written and verbal feedback. A written test was given prior to the intervention to assess comparability of the three groups. Pretest and post-test scores on the neurological examination were compared. Attitudinal questionnaires were administered at the time of the posttest, and 6 months later.

RESULTS

Students receiving feedback from the SPs had significantly greater scores on the posttest than the control group. In the intervention groups, students receiving both verbal and written feedback scored significantly higher than those who received only written feedback. More positive perceptions of learning outcomes and the value of SP feedback were noted in the intervention groups.

CONCLUSION

SP feedback was associated with a significant increase in student scores on the neurological examination, as well as more favorable perceptions of the experience.

Impact of vital signs screening & clinician prompting on alcohol and tobacco screening and intervention rates: a pre-post intervention comparison

Background

Though screening and intervention for alcohol and tobacco misuse are effective, primary care screening and intervention rates remain low. Previous studies have increased intervention rates using vital signs screening for tobacco misuse and clinician prompts for screen-positive patients for both alcohol and tobacco misuse. This pilot study's aims were: (1) To determine the feasibility of combined vital signs screening for tobacco and alcohol misuse, (2) To assess the impact of vital signs screening on alcohol and tobacco screening and intervention rates, and (3) To assess the additional impact of tobacco assessment prompts on intervention rates.

Methods

In five outpatient practices, nurses measuring vital signs were trained to routinely ask a single tobacco question, a prescreening question that identified current drinkers, and the single alcohol screening question for current drinkers. After 4-8 weeks, clinicians were trained in tobacco intervention and nurses were trained to give tobacco abusers a tobacco questionnaire which also served as a clinician intervention prompt. Screening and intervention rates were measured using patient exit interviews (n = 622) at baseline, during the "screening only" period, and during the tobacco prompting phase. Changes in screening and intervention rates were compared using chi square analyses and test of linear trends. Clinic staff were interviewed regarding patient and staff acceptability. Logistic regression was used to evaluate the impact of nurse screening on clinician intervention, the impact of alcohol intervention on concurrent tobacco intervention, and the impact of tobacco intervention on concurrent alcohol intervention.

Results

Alcohol and tobacco screening rates and alcohol intervention rates increased after implementing vital signs screening (p < .05). During the tobacco prompting phase, clinician intervention rates increased significantly for both alcohol (12.4%, p < .001) and tobacco (47.4%, p = .042). Screening by nurses was associated with clinician advice to reduce alcohol use (OR 13.1; 95% CI 6.2-27.6) and tobacco use (OR 2.6; 95% CI 1.3-5.2). Acceptability was high with nurses and patients.

Conclusions

Vital signs screening can be incorporated in primary care and increases alcohol screening and intervention rates. Tobacco assessment prompts increase both alcohol and tobacco interventions. These simple interventions show promise for dissemination in primary care settings.

Evaluating and training substance abuse counselors: a pilot study assessing standardized patients as authentic clients

Clinician training and supervision are needed to transfer evidence-based practices to community-based treatment organizations. Standardized patients (SPs) are used for clinician training and evaluating. However, to be effective for substance abuse counselors, SPs must realistically portray substance abuse treatment clients. The current study assessed authenticity of SPs as substance abuse treatment clients. Twenty-one substance abuse counselors interviewed SP(s) with differing profiles. Counselors provided quantitative and qualitative ratings of SP authenticity. Counselor responses to the study procedures were analyzed as well. Quantitative results include high-authenticity ratings for the SPs but counselors' subjective responses varied. Counselor's rated the experience of participating in the study positively and provided constructive comments for future applications of this methodology. Results support future work on SPs as teaching and evaluation tools in substance abuse counseling. Findings also illustrate the need to refine definitions of authenticity for SPs as substance abuse clients.

Using a standardized patient walk-through to improve implementation of clinical trials

This report describes a standardized patient (SP) walk-through to facilitate implementation of a clinical trial within the National Drug Abuse Treatment Clinical Trials Network (CTN). SPs are actors trained to portray a set of symptoms consistently across interactions with multiple clinicians. The Oregon/Hawaii Node of the CTN employed one SP to pilot participant screening processes in a study testing a combined pharmacological and behavioral therapy for women and men dependent on prescription opioid analgesics. The SP mimicked an individual seeking treatment and "walked" through study intake processes. Findings such as study staff members' inadequacy in describing issues of patient confidentiality and problems explaining the Health Insurance Portability and Accountability Act led to modifications to the clinical implementation of the study. Research coordinators and the staff found the use of an SP to be highly effective. The node is now making routine use of SPs in the implementation of CTN protocols.

Screening, Brief Intervention, and Referral to Treatment (SBIRT): toward a public health approach to the management of substance abuse

Screening, Brief Intervention, and Referral to Treatment (SBIRT) is a comprehensive and integrated approach to the delivery of early intervention and treatment services through universal screening for persons with substance use disorders and those at risk. This paper describes research on the components of SBIRT conducted during the past 25 years, including the development of screening tests, clinical trials of brief interventions and implementation research. Beginning in the 1980s, concerted efforts were made in the US and at the World Health Organization to provide an evidence base for alcohol screening and brief intervention in primary health care settings. With the development of reliable and accurate screening tests for alcohol, more than a hundred clinical trials were conducted to evaluate the efficacy and cost effectiveness of alcohol screening and brief intervention in primary care, emergency departments and trauma centers. With the accumulation of positive evidence, implementation research on alcohol SBI was begun in the 1990s, followed by trials of similar methods for other substances (e.g., illicit drugs, tobacco, prescription drugs) and by national demonstration programs in the US and other countries. The results of these efforts demonstrate the cumulative benefit of translational research on health care delivery systems and substance abuse policy. That SBIRT yields short-term improvements in individuals' health is irrefutable; long-term effects on population health have not yet been demonstrated, but simulation models suggest that the benefits could be substantial.

The influence of structured education and clinical experience on the attitudes of medical students towards substance misusers

Negative attitudes to patients with substance misuse disorders form a well-recognised barrier to the implementation of best practice. The influence of structured education and clinical experience on the attitudes of medical students towards substance misusers was investigated at an Australian university. First-year students were surveyed before and after 3 weeks of drug and alcohol education and in the same year, fourth-year students were surveyed before and after a 9-week block. Males, older students and those with prior clinical experience tended to have more negative attitudes. Attitudes improved significantly after exposure to interactive learning modules which included contact with patients with substance dependence, including individuals in remission. The level of dislike of problem drinkers significantly decreased after teaching. After fourth-year education, students reported a greater sense of responsibility towards providing intervention and less anticipation of discomfort working with these patients. In particular, confidence and attitudes towards heroin users improved near the end of training after contact with illicit drug users in the small group or individual interview setting. By the end of drug and alcohol education, less than half (42%) of students reported they could not imagine working with substance misusers as a career. Findings support the provision of structured drug and alcohol education and supported clinical experience for every medical student if appropriate evidence-based treatment is to be provided.

Medical students' knowledge about alcohol and drug problems: results of the medical council of Canada examination

PURPOSE

To determine knowledge of a national sample of medical students about substance withdrawal, screening and early intervention, medical and psychiatric complications of addiction, and treatment options.

METHODS

Based on learning objectives developed by medical faculty, twenty-two questions on addictions were included in the 1998 Canadian licensing examination.

RESULTS

The exam was written by 858 medical students. The average score on the addiction questions was 64%. Students showed strong knowledge of the clinical features of medical complications. Specific knowledge gaps were identified for withdrawal treatment protocols, low-risk drinking guidelines, taking an alcohol history, substance-induced psychiatric disorders, and Alcoholics Anonymous.

CONCLUSION

Medical students are knowledge-deficient around key learning objectives in addictions. The deficiencies were in areas of basic knowledge that could be learnt with little difficulty.

Implementation of brief alcohol intervention in primary health care: do nurses' and general practitioners' attitudes, skills and knowledge change?

Brief alcohol intervention reduces heavy drinking, but its implementation has been challenging. The purpose was to evaluate self-reported changes in attitudes, skills and knowledge regarding brief intervention among nurses and general practitioners (GPs) during an implementation project. A questionnaire survey was used before and after the implementation to all nurses and GPs working at the time in the seven primary health-care centres of the city of Tampere, Finland. Several positive changes indicate an increased amount of knowledge regarding brief intervention among the professionals during the implementation. This was found especially among the nurses. The success in increasing the knowledge can also be seen in a decrease of training needs. Instead, attitudes and skills among the professionals did not seem to develop positively. Increasing motivational skills especially seems to be the future challenge.

A longitudinal evaluation of medical student knowledge, skills and attitudes to alcohol and drugs

AIM

To examine the knowledge, skills and attitudes of medical students to alcohol and drugs as training progresses.

DESIGN

A longitudinal, prospective, cohort-based design.

SETTING

The four schools of medicine in New Zealand.

PARTICIPANTS

All second-year medical students (first year of pre-clinical medical health sciences) in New Zealand were administered a questionnaire which was repeated in the fourth (first year of significant clinical exposure) and then sixth years (final year). A response rate of 98% in the second year, 75% in the fourth year and 34% in the sixth year, with a total of 637 respondents (47.8% male) and an overall response rate of 68%. QUESTIONNAIRE: The questionnaire consisted of 43 questions assessing knowledge and skills -- a mixture of true/false and scenario stem-based multiple-choice questions and 25 attitudinal questions scored on a Likert scale. Demographic questions included first language, ethnicity and personal consumption of alcohol and tobacco.

FINDINGS

The competence (knowledge plus skills) correct scores increased from 23.4% at the second year to 53.6% at the fourth year to 71.8% at the sixth year, being better in those students who drank alcohol and whose first language was English (P < 0.002). As training progressed the student's perceptions of their role adequacy regarding the effectiveness of the management of illicit drug users diminished. For example, at second year 21% and at sixth year 51% of students felt least effective in helping patients to reduce illicit drug use. At the sixth year, 15% of sixth year students regarded the self-prescription of psychoactive drugs as responsible practice.

CONCLUSION

Education on alcohol and drugs for students remains a crucial but under provided part of the undergraduate medical curriculum. This research demonstrated that while positive teaching outcomes were apparent, further changes to medical student curricula need to be considered to address specific knowledge deficits and to increase the therapeutic commitment and professional safety of medical students to alcohol and drugs.

A randomized trial of teaching clinical skills using virtual and live standardized patients

BACKGROUND

We developed computer-based virtual patient (VP) cases to complement an interactive continuing medical education (CME) course that emphasizes skills practice using standardized patients (SP). Virtual patient simulations have the significant advantages of requiring fewer personnel and resources, being accessible at any time, and being highly standardized. Little is known about the educational effectiveness of these new resources. We conducted a randomized trial to assess the educational effectiveness of VPs and SPs in teaching clinical skills.

OBJECTIVE

To determine the effectiveness of VP cases when compared with live SP cases in improving clinical skills and knowledge.

DESIGN

Randomized trial.

PARTICIPANTS

Fifty-five health care providers (registered nurses 45%, physicians 15%, other provider types 40%) who attended a CME program.

INTERVENTIONS

Participants were randomized to receive either 4 live cases (n=32) or 2 live and 2 virtual cases (n=23). Other aspects of the course were identical for both groups.

RESULTS

Participants in both groups were equivalent with respect to pre-post workshop improvement in comfort level (P=.66) and preparedness to respond (P=.61), to screen (P=.79), and to care (P=.055) for patients using the skills taught. There was no difference in subjective ratings of effectiveness of the VPs and SPs by participants who experienced both (P=.79). Improvement in diagnostic abilities were equivalent in groups who experienced cases either live or virtually.

CONCLUSIONS

Improvements in performance and diagnostic ability were equivalent between the groups and participants rated VP and SP cases equally. Including well-designed VPs has a potentially powerful and efficient place in clinical skills training for practicing health care workers.

Lecture versus standardized patient interaction in the surgical clerkship: a randomized prospective cross-over study

BACKGROUND

Medical schools increasingly are incorporating the standardized patient (SP) interaction as a teaching and testing modality to prepare students for United States Medical Licensing Examination Step 2 Clinical Skills. Although SP interactions provide a safe environment in which to practice clinical skills, little is known about medical students' perceptions of the instructional SP interaction in comparison with the classic didactic lecture. We hypothesized that students would enjoy and value an instructional SP interaction more than a didactic lecture, and that this perception would be enhanced if the lecture immediately preceded the instructional SP interaction.

METHODS

Students on the junior surgery clerkship from January to December 2004 were randomized into 2 groups. Group A (n = 71) received an hour-long didactic lecture about peripheral vascular disease followed by a 20-minute instructional SP interaction in which the SP portrayed a patient with lower-extremity claudication. Group B (n = 72) received the SP interaction first, followed by the lecture. All students received an identical quiz about peripheral vascular disease after the second educational encounter, whether the SP interaction or the lecture. Student perceptions were surveyed by written questionnaire before and after the session by using a 5-point Likert scale, with 5 being the most favorable rating. Data (perceptions, performances on the quiz and the SP interaction, clerkship grades) were compared using the Student t test or the Mann-Whitney rank sums test.

RESULTS

Although all students on average enjoyed and valued the lecture more than the SP interaction (P <.001), group A students enjoyed the SP interaction more than group B (3.3 +/- .9 vs. 2.8 +/- 1.0, P = .008), and they perceived the SP interaction as having more value to their overall education (3.3 +/- 1.0 vs. 2.8 +/- 1.0, P = .004). Group A students performed statistically better on the physical examination (66% +/- 19% vs. 40% +/- 16%, P <.001) and communication portions (90% +/- 11% vs. 79% +/- 12%, P <.001) of the SP checklist than group B, but not on the history portion. Student confidence in their own history and physical examination skills increased similarly for both groups.

CONCLUSIONS

The classic lecture format not only is enjoyed and valued as a learning tool more by our surgical clerkship students than the instructional SP interaction, but having a lecture just before an SP interaction increased perceived enjoyment and value of the SP interaction and enhanced performance on the SP checklist. These data suggest that educators can improve student perceptions and attitudes surrounding the instructional SP interaction by using strategically timed lectures.

Effects of screening and brief intervention training on resident and faculty alcohol intervention behaviours: a pre- post-intervention assessment

BACKGROUND

Many hazardous and harmful drinkers do not receive clinician advice to reduce their drinking. Previous studies suggest under-detection and clinician reluctance to intervene despite awareness of problem drinking (PD). The Healthy Habits Project previously reported chart review data documenting increased screening and intervention with hazardous and harmful drinkers after training clinicians and implementing routine screening. This report describes the impact of the Healthy Habits training program on clinicians' rates of identification of PD, level of certainty in identifying PD and the proportion of patients given advice to reduce alcohol use, based on self-report data using clinician exit questionnaires.

METHODS

28 residents and 10 faculty in a family medicine residency clinic completed four cycles of clinician exit interview questionnaires before and after screening and intervention training. Rates of identifying PD, level of diagnostic certainty, and frequency of advice to reduce drinking were compared across intervention status (pre vs. post). Findings were compared with rates of PD and advice to reduce drinking documented on chart review.

RESULTS

1,052 clinician exit questionnaires were collected. There were no significant differences in rates of PD identified before and after intervention (9.8% vs. 7.4%, p = .308). Faculty demonstrated greater certainty in PD diagnoses than residents (p = .028) and gave more advice to reduce drinking (p = .042) throughout the program. Faculty and residents reported higher levels of diagnostic certainty after training (p = .039 and .030, respectively). After training, residents showed greater increases than faculty in the percentage of patients given advice to reduce drinking (p = .038), and patients felt to be problem drinkers were significantly more likely to receive advice to reduce drinking by all clinicians (50% vs. 75%, p = .047). The number of patients receiving advice to reduce drinking after program implementation exceeded the number of patients felt to be problem drinkers. Recognition rates of PD were four to eight times higher than rates documented on chart review (p = .028).

CONCLUSION

This program resulted in greater clinician certainty in diagnosing PD and increases in the number of patients with PD who received advice to reduce drinking. Future programs should include booster training sessions and emphasize documentation of PD and brief intervention.

Training medical providers to conduct alcohol screening and brief interventions

Although progress has been made in developing a scientific basis for alcohol screening and brief intervention (SBI), training packages are necessary for its widespread dissemination in primary care settings. This paper evaluates a training package developed for the Cutting Back SBI program. Three groups of medical personnel were compared before and after SBI training: physicians (n = 44), medical students (n = 88), and non-physicians (n = 41). Although the training effects were at times dependent on group membership, all changes were in a direction more conducive to implementing SBI. Physicians and medical students increased confidence in performing screening procedures, and students increased self-confidence in conducting brief interventions. Non-physicians perceived fewer obstacles to screening patients after training. Trained providers reported conducting significantly more SBI than untrained providers, and these differences were consistent with patients' reports of their providers' clinical activity. Thus, when delivered in the context of a comprehensive SBI implementation program, this training is effective in changing providers' knowledge, attitudes, and practice of SBI for at-risk drinking.

Didactic lecture versus instructional standardized patient interaction in the surgical clerkship

BACKGROUND

Medical schools increasingly employ the standardized patient interaction (SPI) as a teaching and testing modality to prepare students for USMLE Step 2 Clinical Skills (Step 2 CS). However, little is known about the perceptions medical students have toward SPIs. We hypothesized that the SPI would increase the self-confidence of surgery students in their history and physical examination (H&P) skills as compared with the classic lecture format and that students would perceive the SPI as a valuable learning tool.

METHODS

Students (n = 126) on the junior surgery clerkship were randomized into two groups. Group A (n = 61) received a didactic lecture on acute appendicitis. Group B (n = 65) participated in an SPI in which the portrayed patient had acute appendicitis. Student perceptions were surveyed by written questionnaire pre- and postencounter using a 5-point Likert scale, with 5 being the most favorable rating. Data (perceptions, performances on the SPI, clerkship grades) were compared using a Student t test followed by the Mann-Whitney rank sums test.

RESULTS

Group A "enjoyed" the lecture format more than group B "enjoyed" the SPI format (3.4 +/- 0.1 versus 2.6 +/- 0.1, P <.001) and perceived the lecture as having more value to their overall education (3.5 +/- 0.1 versus 2.6 +/- 0.1, P <.001) than the SPI group. Surprisingly, student self-confidence in their H&P skills increased after the didactic lecture (from 3.6 +/- 0.1 to 4.1 +/- 0.1, P = .001) but not after the SPI (from 3.6 +/- 0.1 to 3.8 +/- 0.1, P = not significant).

CONCLUSIONS

The didactic lecture format was not only enjoyed and valued more than the SPI, but our surgery students also perceived it as superior to the SPI in building confidence in history and physical examination skills. These findings suggest that surgical educators should develop ways to improve students' perceptions and attitudes surrounding the surgical SPI.

ASSERT: the effectiveness of a continuing medical education video on knowledge and attitudes about interpersonal violence

PURPOSE

Developing ways to educate busy clinicians is especially challenging when the subject includes medical, social, and legal aspects, as is the case with interpersonal violence (IPV). Organizations such as the American Medical Association and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) recommend routine IPV screening for patients. Videotape efficiently provides training in multiple locations using experts from different fields. The authors created and evaluated a multidisciplinary continuing medical education (CME) videotape on IPV.

METHOD

The video, ASSERT: A Guide to Child, Elder, Sexual, and Domestic Abuse for Medical Professionals, was developed by experts from medicine, social work, nursing, and law. The video featured role-plays to demonstrate different approaches to these difficult clinical encounters. Pre- and post-viewing questionnaires assessed the video's effectiveness.

RESULTS

In all, 120 physicians and 172 other personnel (e.g., nurses, social workers) at 24 sites associated with four academic medical centers completed paired questionnaires. Using a conservative level of significance (p <.002), there was significant improvement for physicians in 77% of the knowledge items and 75% of the attitude items from pre- to post-viewing questionnaires. A total of 73% of viewers would recommend the video to colleagues.

CONCLUSIONS

The IPV video, using experts from multiple disciplines, improved knowledge and attitudes about child, elder, sexual, and domestic violence, and was rated highly by clinicians. The video was useful for preparing for a JCAHO accreditation visit.

Randomized controlled trial on the effects of a skills-based workshop on medical students' management of problem drinking and alcohol dependence

The purpose of this study was to determine whether a skills-based workshop will improve medical students' management of problem drinking and alcohol dependence in simulated patients. Seventy-six 3rd and 4th year Ontario medical students were randomized to receive a 3-h workshop on either problem drinking and alcohol dependence or depression (control condition). Students then completed eight simulated office visits (OSCE stations) with simulated patients presenting with depression, problem drinking or alcohol dependence. Examiners completed a checklist of the questions asked and advice given by the student, and simulated patients and examiners completed a global rating scale. Four months later, students were sent a survey on their knowledge, attitudes, and behavior towards patients with alcohol problems. The alcohol group received significantly higher assessment and management checklist scores and global rating scores than did the depression group (p < 0.01) and performed better on almost all aspects of clinical management of both problem drinking and alcohol dependence. On the follow-up survey (n = 55) the alcohol group showed a significant increase in beliefs about self-efficacy in managing alcohol problems (p < 0.05) and had greater knowledge of reduced drinking strategies, but the two groups did not differ on other measures. A skills-based workshop causes marked short-term improvements in medical students' management of problem drinking and alcohol dependence, an increase from baseline to postworkshop in self-efficacy beliefs that was sustained through to follow-up, and greater knowledge of reduced drinking strategies. Repeated reinforcement of clinical skills may be required for a long-term impact on clinical behavior.

Improving emergency medicine residents' approach to patients with alcohol problems: a controlled educational trial

STUDY OBJECTIVE

We determine whether training using a structured skills-based intervention would improve emergency medicine residents' knowledge and practice in screening and intervening with patients presenting to the emergency department with alcohol problems.

METHODS

In a controlled trial conducted at 2 similar emergency medicine residency programs associated with urban, Level I trauma centers, a 4-hour didactic, video, and skills-based workshop was conducted. Main outcome measures included (1) scores on changes in self-reported knowledge, current practice, self-efficacy, role-responsibility, attitudes and beliefs, and provider readiness to change from baseline to 1 year after intervention and (2) change in practice as measured by record review before and after intervention.

RESULTS

The intervention group (n=17) had a significant increase in knowledge scores (P <.001) and practice with regard to percent of medical records with evidence of screening and intervention (17% before versus 58% after; 95% confidence interval [CI] 31 to 50; P <.001); no change was observed in the control group (n=19). These increases were significantly different between groups (95% CI 30 to 54; P <.001). There were no significant differences within or between groups for composite scores derived for current practice, self-efficacy, role responsibility, or readiness to change.

CONCLUSION

A brief, structured, educational intervention for residents contributed to significant improvement in knowledge and practice with regard to patients with alcohol problems.

Interactional skills of students from traditional and non-traditional medical schools before and after alcohol education

OBJECTIVE

To compare alcohol-related intervention and general interactional skills performance of medical students from a traditional (Sydney) and a non-traditional (Newcastle) medical school, before and after participation in an alcohol education programme about brief intervention.

DESIGN

In two controlled trials, students received either a didactic alcohol education programme or didactic input plus skills-based training. Prior to and after training, all students completed videotaped interviews with simulated patients.

SETTING

The Faculties of Medicine at the University of Newcastle and the University of Sydney, Australia.

SUBJECTS

Fifth-year medical students (n=154).

RESULTS

Both alcohol-related intervention and general interactional skills scores of the Newcastle students were significantly higher than those of the Sydney students at pre-test but not after training. Although alcohol-related interactional skills scores improved after training at both universities, they did not reach a satisfactory level. The educational approach used had no effect on post-test scores at either university.

CONCLUSIONS

Significant baseline differences in interactional skills scores favouring non-traditional over traditional students were no longer evident after both groups had been involved in an alcohol education programme. Further research is required to develop more effective alcohol intervention training methods.

Low-cost video-films in the teaching of undergraduate and postgraduate medical students

The high cost of producing good-quality video-films for teaching has hindered the use of this method, which has been shown to improve significantly the efficiency of teaching and the retention of knowledge. During the last five years, a series of short video-films has been produced using inexpensive video-cameras and home video-recording and editing equipment. A variety of techniques were developed to allow recording of lecture presentations, while using the equipment as a teaching aid, without the need for technical staff. The positioning of the camera, the monitor, the slide projector and lighting were critical to the productions. Similar productions at low cost were obtained from recordings of operating theatre sessions, tutorials and clinical ward rounds. A survey of students exposed to teaching with video-film as part of a lecture presentation confirmed that the subject matter being taught was more easily understood and enjoyable and generated more discussions on than other forms of teaching.

Teaching medical students alcohol intervention skills: results of a controlled trial

OBJECTIVE

To assess the relative effectiveness of videotape feedback and lecture methods for teaching alcohol brief intervention skills.

DESIGN

In a controlled trial, two student blocks received a manual, lecture and demonstration about the principles and practice of brief alcohol intervention. In addition, experimental students made a 20-min videotape and participated in a 1.5-h small group feedback session. Prior to and after training, all students completed questionnaires and videotaped interviews with simulated patients.

SETTING

Faculty of Medicine and Health Sciences of the University of Newcastle, Australia.

SUBJECTS

Final-year medical students.

RESULTS

Levels of alcohol-related knowledge, attitudes and interactional skills as well as general interactional skills were significantly improved after teaching. Alcohol-related interactional skills that were unsatisfactory at pretest reached satisfactory standards at post-test. An intergroup comparison of the improvement between pre- and post-teaching scores indicated that there was no significant difference in the effectiveness of the two methods.

CONCLUSIONS

Training can improve medical student performance in alcohol intervention. Further research is required to examine the relative effectiveness of different teaching methods.