Students' Report of Preceptor Weight Management Counseling at Eight U.S. Medical Schools.

INTRODUCTION: Primary care providers, using brief counseling, can help patients increase motivation to initiate or maintain weight loss, improve diet, and increase physical activity. However, no prior studies have examined the degree to which primary care preceptors, who are responsible for mentoring medical students during their core clerkships, provide clinical teaching regarding weight management counseling. METHODS: Medical students enrolled in eight U.S. medical schools who had finished their preclinical coursework completed surveys in the spring of 2016 to assess preceptor communication, modeling, feedback, and instruction in weight management counseling, as well as educational cues for patients and chart reminders for physicians. Analysis was completed in 2017 and 2018. RESULTS: Of 738 students completing the survey, the most recent completed clerkships were obstetrics and gynecology (38.1%), family medicine (32.1%), and internal medicine (29.8%). Students in family medicine clerkships reported higher levels of weight management counseling clinical teaching than students completing an internal medicine or obstetrics and gynecology clerkship. Among the main variables of interest across all three clerkships, only 13%-24% of students agreed that preceptors provided clear objectives for learning weight management counseling, and 13%-25% of students agreed that preceptors provided feedback. CONCLUSIONS: Even with a U.S. Preventive Services Task Force recommendation for primary care physicians to provide weight management counseling and endorsement from the major academic primary care societies, students in primary care clerkships report receiving little weight management counseling clinical teaching from their preceptors. The results reinforce the need for medical educators to teach and model weight management counseling for physicians-in-training if they are to achieve Task Force goals. Further research is required to better corroborate self-reported indicators of preceptor to student communication that are described herein.

Design and rationale of the medical students learning weight management counseling skills (MSWeight) group randomized controlled trial.

Physicians have an important role addressing the obesity epidemic. Lack of adequate teaching to provide weight management counseling (WMC) is cited as a reason for limited treatment. National guidelines have not been translated into an evidence-supported, competency-based curriculum in medical schools. Weight Management Counseling in Medical Schools: A Randomized Controlled Trial (MSWeight) is designed to determine if a multi-modal theoretically-guided WMC educational intervention improves observed counseling skills and secondarily improve perceived skills and self-efficacy among medical students compared to traditional education (TE). Eight U.S. medical schools were pair-matched and randomized in a group randomized controlled trial to evaluate whether a multi-modal education (MME) intervention compared to traditional education (TE) improves observed WMC skills. The MME intervention includes innovative components in years 1-3: a structured web-course; a role play exercise, WebPatientEncounter, and an enhanced outpatient internal medicine or family medicine clerkship. This evidence-supported curriculum uses the 5As framework to guide treatment and incorporates patient-centered counseling to engage the patient. The primary outcome is a comparison of scores on an Objective Structured Clinical Examination (OSCE) WMC case among third year medical students. The secondary outcome compares changes in scores of medical students from their first to third year on an assessment of perceived WMC skills and self-efficacy. MSWeight is the first RCT in medical schools to evaluate whether interventions integrated into the curriculum improve medical students' WMC skills. If this educational approach for teaching WMC is effective, feasible and acceptable it can affect how medical schools integrate WMC teaching into their curriculum.

Teaching Medical Students to Help Patients Quit Smoking: Outcomes of a 10-School Randomized Controlled Trial.

BACKGROUND: Early in medical education, physicians must develop competencies needed for tobacco dependence treatment. OBJECTIVE: To assess the effect of a multi-modal tobacco dependence treatment curriculum on medical students' counseling skills. DESIGN: A group-randomized controlled trial (2010-2014) included ten U.S. medical schools that were randomized to receive either multi-modal tobacco treatment education (MME) or traditional tobacco treatment education (TE). SETTING/PARTICIPANTS: Students from the classes of 2012 and 2014 at ten medical schools participated. Students from the class of 2012 (N = 1345) completed objective structured clinical examinations (OSCEs), and 50 % (N = 660) were randomly selected for pre-intervention evaluation. A total of 72.9 % of eligible students (N = 1096) from the class of 2014 completed an OSCE and 69.7 % (N = 1047) completed pre and post surveys. INTERVENTIONS: The MME included a Web-based course, a role-play classroom demonstration, and a clerkship booster session. Clerkship preceptors in MME schools participated in an academic detailing module and were encouraged to be role models for third-year students. MEASUREMENTS: The primary outcome was student tobacco treatment skills using the 5As measured by an objective structured clinical examination (OSCE) scored on a 33-item behavior checklist. Secondary outcomes were student self-reported skills for performing 5As and pharmacotherapy counseling. RESULTS: Although the difference was not statistically significant, MME students completed more tobacco counseling behaviors on the OSCE checklist (mean 8.7 [SE 0.6] vs. mean 8.0 [SE 0.6], p = 0.52) than TE students. Several of the individual Assist and Arrange items were significantly more likely to have been completed by MME students, including suggesting behavioral strategies (11.8 % vs. 4.5 %, p < 0.001) and providing information regarding quitline (21.0 % vs. 3.8 %, p < 0.001). MME students reported higher self-efficacy for Assist, Arrange, and Pharmacotherapy counseling items (ps ≤0.05). LIMITATIONS: Inclusion of only ten schools limits generalizability. CONCLUSIONS: Subsequent interventions should incorporate lessons learned from this first randomized controlled trial of a multi-modal longitudinal tobacco treatment curriculum in multiple U.S. medical schools. NIH Trial Registry Number: NCT01905618.

Tobacco counseling experience prior to starting medical school, tobacco treatment self-efficacy and knowledge among first-year medical students in the United States.

OBJECTIVE: To explore students' tobacco dependence counseling experiences prior to medical school and their associations with tobacco counseling self-efficacy, and familiarity with and perceived effectiveness of tobacco dependence treatment among first-year medical students in the United States. METHOD: In 2010, 1266 first-year medical students from 10 US medical schools completed a survey reporting their clinical experiences with specific tobacco counseling skills (e.g., 5As) prior to medical school. The survey also included questions on tobacco counseling self-efficacy, perceived physician impact on smokers, and familiarity and effectiveness of tobacco-related treatments. RESULTS: Half (50.4%) reported some tobacco counseling experiences prior to medical school (i.e. at least one 5A). Students with prior counseling experiences were more likely to have higher tobacco counseling self-efficacy, and greater familiarity with medication treatment, nicotine replacement treatment, and behavioral counseling for smoking cessation, compared to those with no prior experiences. Perceived physician impact on patient smoking outcomes did not differ by prior tobacco counseling experiences. CONCLUSIONS: Many first-year medical students may already be primed to learn tobacco dependence counseling skills. Enhancing early exposure to learning these skills in medical school is likely to be beneficial to the skillset of our future physicians.

Medical school curriculum characteristics associated with intentions and frequency of tobacco dependence treatment among 3rd year U.S. medical students.

OBJECTIVE: Physicians play a critical role in addressing tobacco dependence, yet report limited training. Tobacco dependence treatment curricula for medical students could improve performance in this area. This study identified student and medical school tobacco treatment curricula characteristics associated with intentions and use of the 5As for tobacco treatment among 3rd year U.S. medical students. METHODS: Third year medical students (N=1065, 49.3% male) from 10 U.S. medical schools completed a survey in 2009-2010 assessing student characteristics, including demographics, tobacco treatment knowledge, and self-efficacy. Tobacco curricula characteristics assessed included amount and type of classroom instruction, frequency of tobacco treatment observation, instruction, and perception of preceptors as role models. RESULTS: Greater tobacco treatment knowledge, self-efficacy, and curriculum-specific variables were associated with 5A intentions, while younger age, tobacco treatment self-efficacy, intentions, and each curriculum-specific variable were associated with greater 5A behaviors. When controlling for important student variables, greater frequency of receiving 5A instruction (OR=1.07; 95%CI 1.01-1.12) and perception of preceptors as excellent role models in tobacco treatment (OR=1.35; 95%CI 1.04-1.75) were significant curriculum predictors of 5A intentions. Greater 5A instruction (B=.06 (.03); p<.05) and observation of tobacco treatment (B=.35 (.02); p<.001) were significant curriculum predictors of greater 5A behaviors. CONCLUSIONS: Greater exposure to tobacco treatment teaching during medical school is associated with both greater intentions to use and practice tobacco 5As. Clerkship preceptors, or those physicians who provide training to medical students, may be particularly influential when they personally model and instruct students in tobacco dependence treatment.

Tobacco dependence treatment teaching by medical school clerkship preceptors: survey responses from more than 1,000 US medical students.

OBJECTIVE: To determine factors associated with tobacco cessation counseling in medical school clerkships. METHODS: Third-year medical students at 10 medical schools across the United States completed a 100-item survey, measuring the frequency with which they experienced their preceptors providing clinical teaching components: clear instruction, feedback, modeling behavior, setting clear objectives, and responding to questions about tobacco dependence counseling as well as frequency of use of tobacco prompts and office systems. Our primary dependent measure was student self-reported skill level for items of tobacco dependence treatment (e.g. "5As"). RESULTS: Surveys were completed by 1213 students. For both family medicine and internal medicine clerkships, modeling and providing clear instruction on ways to provide tobacco counseling were reported most commonly. In contrast, providing feedback and clear objectives for tobacco dependence treatment lagged behind. Overall, students who reported preceptors' provision of optimal clinical teaching components and office system prompts in both family medicine and internal medicine clerkships had higher self-reported skill (P<0.001) than students with no exposure or exposure during only one of the clerkships. CONCLUSIONS: Future educational interventions intended to help students adopt effective tobacco dependence treatment techniques should be engineered to facilitate these critical precepting components.

Influences on older women's adherence to a low-fat diet in the Women's Health Initiative.

OBJECTIVE: Most studies of dietary change during aging have focused on maintaining adequate intake by impaired elderly, and little is known about factors affecting dietary change for preventive purposes in older individuals. The purpose of this exploratory study was to determine the major behavioral influences on older women's adherence to a dietary fat reduction intervention. METHOD: A diverse sample of 92 women aged 55 to 80 was recruited from two East Coast sites of the Women's Health Initiative. All the women were participating in the dietary modification arm of WHI, had received the same dietary instruction, and were in the maintenance phase of the intervention. The women were classified by nutritionists as adherent or nonadherent to a diet limiting fat intake to <20% of total calories. Focus groups and telephone interviews were conducted, and textual data were coded and sorted using content analysis techniques within the four categories of the Stimuli-Organismic Factors-Response Repertoire-Consequences (SORC) behavioral model. Frequencies of responses within categories were tabulated and compared qualitatively. RESULTS: Adherent women were more likely to report assertiveness, a lifelong commitment to reduced dietary fat, satisfaction with their lifestyle changes, and having applicable knowledge and skills. Nonadherent women reported more difficulty resisting negative emotions and prior food preferences and habits; they were also more concerned about negative responses from others. CONCLUSIONS: Enhancing adherence of older women to a dietary fat reduction program will require shifting priorities away from conforming to social pressure and using high-fat foods for personal satisfaction and moving toward enhancing motivation and commitment to long-term health.