Objective

The primary purpose of the study was to assess the prevalence of adverse childhood experiences (ACEs) in a cohort of third-year medical students and characterize their childhood protective factors.

Methods

The authors developed a web-based anonymous survey distributed to all third-year medical students in one school (N = 98). The survey included the 10-item ACE Study questionnaire, a list of childhood protective factors (CPF) and questions to assess students' perception of the impact of ACEs on their physical and mental health. The medical school's IRB approved the student survey as an exempt study. The authors computed descriptive and comparative statistical analyses.

Results

Eighty-six of 98 students responded (88% response rate). Forty-four students (51%) reported at least one ACE exposure and 10 (12%) reported ≥ 4 exposures. The latter were all female. The average difference in the ACE score between male and female medical students was - 1.1 (independent t test with unequal variances t(57.7) = - 2.82, P = .007). Students with an ACE score of ≥ 4 were significantly more likely to report a moderate or significant effect on their mental health, compared with students with scores ≤ 3 (chi-square test, P = < .0001). Most students reported high levels of CPF (median score = 13 of a maximum score = 14). ACEs and CPF were inversely associated (Pearson correlation = - 0.32, P = .003).

Conclusions

A sizeable minority of medical students reported exposure to multiple ACEs. If replicated, findings suggest a significant vulnerability of these medical students to health risk behaviors and physical and mental health problems during training and future medical practice.

Background

Many primary care physicians (PCPs) are ill-equipped to provide screening and counseling for inherited breast cancer.

Objective

To evaluate the outcomes of an interactive web-based genetics curriculum versus text curriculum for primary care physicians.

Design

Randomized two-group design.

Participants

121 California and Pennsylvania community physicians.

Intervention

Web-based interactive genetics curriculum, evaluated against a control group of physicians who studied genetics review articles. After education, physicians interacted with an announced standardized patient (SP) at risk for inherited breast cancer.

Main measures

Transcripts of visit discussions were coded for presence or absence of 69 topics relevant to inherited breast cancer.

Key results

Across all physicians, history-taking, discussions of test result implications, and exploration of ethical and legal issues were incomplete. Approximately half of physicians offered a genetic counseling referral (54.6%), and fewer (43.8%) recommended testing. Intervention physicians were more likely than controls to explore genetic counseling benefits (78.3% versus 60.7%, P = 0.048), encourage genetic counseling before testing (38.3% versus 21.3%, P = 0.048), ask about a family history of prostate cancer (25.0% versus 6.6%, P = 0.006), and report that a positive result indicated an increased risk of prostate cancer for male relatives (20.0% versus 1.6%, P = 0.001). Intervention-group physicians were less likely than controls to ask about Ashkenazi heritage (13.3% versus 34.4%, P = 0.01) or to reply that they would get tested when asked, "What would you do?" (33.3% versus 54.1%, P = 0.03).

Conclusions

Physicians infrequently performed key counseling behaviors, and this was true regardless of whether they had completed the web-based interactive training or read clinical reviews.

Background: Gender plays a significant role in the selection of medical specialty. Few studies have been conducted to explore the impact of gender differences on specialty choosing among Chinese medical students. Methods: The specialty choices of 648 students from six consecutive classes in an 8-year MD program were collected and compared between male and female students. A total of 110 students from one graduating class were surveyed by a questionnaire covering 22 career influencing factors. Each factor has a scale of zero to three (zero = no influence, one = mild influence, two = moderate influence, and three = strong influence). Results: Statistically significant gender differences were observed in 10 out of 16 specialties. Most male students limited their specialty choices to surgery (64%), internal medicine (12%), and orthopedics (12%), compared with a relatively diversified pattern in female students. For male students, the top three influencing factors were personal interest, future job prospects for the chosen specialty, and job opportunity in academic medicine. The strongest influencing factors of females were personal interest, specialty-specific knowledge and skills, and the sense of achievement. The expected salary was ranked among the top 10 influencing factors in male but not in females, while the work-life balance was ranked among the top 10 factors in females but not in males. Conclusion: There is a significant gender difference regarding specialty choices among Chinese medical students. Career coaching is needed to help students in their specialty choosing process.

BACKGROUND:Injection drug use is on the rise in the USA, and skin and soft tissue infections (SSTI) are a common complication, resulting in significant morbidity and mortality. Due to structural barriers to care-seeking, many people who inject drugs avoid formal care and resort to self-care techniques, but little is known about the nature of these techniques, or more generally about the accuracy or breadth of this population's knowledge of SSTIs. METHODS:Semi-structured qualitative interviews were conducted with 12 people who inject heroin in two metropolitan areas: Sacramento and Boston, USA. RESULTS:These interviews reveal a robust and accurate knowledge base regarding skin infections, including the progression from simple cellulitis to an abscess, and acknowledgment of the possibility of serious infections. Nonetheless, there remains a reticence to seek care secondary to past traumatic experiences. A step-wise approach to self-care of SSTI infections was identified, which included themes of whole-body health, topical applications, use of non-prescribed antibiotics, and incision and drainage by non-medical providers. CONCLUSIONS:The reported SSTI self-care strategies demonstrate resilience and ingenuity, but also raise serious concerns about inappropriate antibiotic consumption and complications of invasive surgical procedures performed without proper training, technique, or materials. Harm reduction agencies and health care providers should work to obviate the need for these potentially dangerous practices by improving healthcare access for this population. In the absence of robust solutions to meet the needs of this population, education materials should be developed to optimize the efficacy and minimize the harms of these practices, while empowering and supporting the autonomy of people who use drugs and providing clear guidance on when self-care should be abandoned in favor of formal medical care.

Purpose

Few studies have compared the effect of Web-based eLearning versus small-group learning on medical student outcomes. Palliative and end-of-life (PEOL) education is ideal for this comparison, given uneven access to PEOL experts and content nationally.

Method

In 2010, the authors enrolled all third-year medical students at the University of California, Davis School of Medicine into a quasi-randomized controlled trial of Web-based interactive education (eDoctoring) compared with small-group education (Doctoring) on PEOL clinical content over two months. Students participated in three 3-hour PEOL sessions with similar content. Outcomes included a 24-item PEOL-specific self-efficacy scale with three domains (diagnosis/treatment [Cronbach alpha=0.92; CI: 0.91-0.93], communication/prognosis [alpha=0.95; CI: 0.93-0.96], and social impact/self-care [alpha=0.91; CI: 0.88-0.92]); 8 knowledge items; 10 curricular advantage/disadvantages; and curricular satisfaction (both students and faculty).

Results

Students were randomly assigned to Web-based eDoctoring (n=48) or small-group Doctoring (n=71) curricula. Self-efficacy and knowledge improved equivalently between groups (e.g., prognosis self-efficacy, 19%; knowledge, 10%-42%). Student and faculty ratings of the Web-based eDoctoring curriculum and the small-group Doctoring curriculum were equivalent for most goals, and overall satisfaction was equivalent for each, with a trend toward decreased eDoctoring student satisfaction.

Conclusions

Findings showed equivalent gains in self-efficacy and knowledge between students participating in a Web-based PEOL curriculum in comparison with students learning similar content in a small-group format. Web-based curricula can standardize content presentation when local teaching expertise is limited, but it may lead to decreased user satisfaction.

Background

Screening and counseling for genetic conditions is an increasingly important part of primary care practice, particularly given the paucity of genetic counselors in the United States. However, primary care physicians (PCPs) often have an inadequate understanding of evidence-based screening; communication approaches that encourage shared decision-making; ethical, legal, and social implication (ELSI) issues related to screening for genetic mutations; and the basics of clinical genetics. This study explored whether an interactive, web-based genetics curriculum directed at PCPs in non-academic primary care settings was superior at changing practice knowledge, attitudes, and behaviors when compared to a traditional educational approach, particularly when discussing common genetic conditions.

Methods

One hundred twenty one PCPs in California and Pennsylvania physician practices were randomized to either an Intervention Group (IG) or Control Group (CG). IG physicians completed a 6 h interactive web-based curriculum covering communication skills, basics of genetic testing, risk assessment, ELSI issues and practice behaviors. CG physicians were provided with a traditional approach to Continuing Medical Education (CME) (clinical review articles) offering equivalent information.

Results

PCPs in the Intervention Group showed greater increases in knowledge compared to the Control Group. Intervention PCPs were also more satisfied with the educational materials, and more confident in their genetics knowledge and skills compared to those receiving traditional CME materials. Intervention PCPs felt that the web-based curriculum covered medical management, genetics, and ELSI issues significantly better than did the Control Group, and in comparison with traditional curricula. The Intervention Group felt the online tools offered several advantages, and engaged in better shared decision making with standardized patients, however, there was no difference in behavior change between groups with regard to increases in ELSI discussions between PCPs and patients.

Conclusion

While our intervention was deemed more enjoyable, demonstrated significant factual learning and retention, and increased shared decision making practices, there were few differences in behavior changes around ELSI discussions. Unfortunately, barriers to implementing behavior change in clinical genetics is not unique to our intervention. Perhaps the missing element is that busy physicians need systems-level support to engage in meaningful discussions around genetics issues. The next step in promoting active engagement between doctors and patients may be to put into place the tools needed for PCPs to easily access the materials they need at the point-of-care to engage in joint discussions around clinical genetics.

Two decades ago, the genocide against the Tutsis in Rwanda led to the deaths of 1 million people, and the displacement of millions more. Injury and trauma were followed by the effects of a devastated health system and economy. In the years that followed, a new course set by a new government set into motion equity-oriented national policies focusing on social cohesion and people-centred development. Premature mortality rates have fallen precipitously in recent years, and life expectancy has doubled since the mid-1990s. Here we reflect on the lessons learned in rebuilding Rwanda's health sector during the past two decades, as the country now prepares itself to take on new challenges in health-care delivery.