Though tobacco use remains the leading cause of preventable death in the United States., medical schools are not doing enough to train medical students to help their patients quit smoking, a Wake Forest University School of Medicine research team reports in the Sept. 4 issue of the Journal of the American Medical Association.
John G. Spangler, M.D., M.P.H, associate professor of family and community medicine found that part of the problem is that no national curriculum models exist for teaching medical students this vital clinical skill.
After reviewing medical education research studies, Spangler and colleagues found that a number of "enhanced" teaching approaches to training medical students in smoking cessation counseling work better than traditional lectures and handouts. These methods include patient-centered counseling techniques, use of standardized (or "mock") patients, and role playing.
Nonetheless, gaps still exist.
"Tobacco use and dependence are not integrated throughout the four years of medical school curricula," Spangler said, "and no national curriculum exists on what should be taught to medical students regarding the harms of tobacco use or how to help patients quit."
Smokeless tobacco use and cessation are virtually ignored, he said. "No one has studied successful ways to train medical students to help people quit this habit which is also harmful and addictive."
Spangler said most current smokers would quit if their doctor told them directly to do so. "Several studies have documented physicians'' failure to counsel their patients to stop smoking."
He added, "Physicians often perceive they are ill prepared in treating patients addicted to nicotine." A majority of medical school graduates "still are not adequately trained to treat nicotine dependence." The research team reviewed a number of studies in analyzing various educational methods of teaching medical students how to help patients quit. One study they reviewed said that only three medical schools, one of them Wake Forest, "had a required course devoted specifically to tobacco treatment."
One third of the medical schools spent three hours or less teaching smoking cessation counseling during the entire four years of medical school, and more than two thirds of the medical schools "did not require clinical training in smoking intervention techniques." The key elements of an ideal approach are: repeated and consistent advice from doctors to stop smoking, setting a specific quit date and scheduling follow-up visits. With the addition of prescription drugs and individualized contact, cessation rates can be doubled.
But he said that even brief discussions with the patient increased the odds that the patient will quit, a difference that can be measured statistically.
Spangler said that at Wake Forest, first and second years students encounter tobacco- related cases in their small group problem-based learning sessions. "Role playing is used extensively in these sessions."
The entire class rotates through Family and Community Medicine during the third year. There, after a two-hour lecture on techniques for intervening with patients, the students interact with mock patients -- standardized patient instructors who follow a script and give the students feedback.
The students are evaluated using a risk factor interview scale. Later, Spangler said, students identify at least one smoking patient in the clinic and counsel that patient on how to quit smoking.
"Qualitative evaluation among two consecutive classes of third-year medical students found that students were enthusiastic about the program and reported greater self-confidence in their ability to counsel and treat patients who use tobacco," Spangler said.
Comments by Dr. John Spangler
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