Tobacco Education and Counseling in Obstetrics and Gynecology Clerkships: A Survey of Medical School Program Directors
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- Powers, C.A., Zapka, J., Phelan, S. et al. Matern Child Health J (2011) 15: 1153. doi:10.1007/s10995-010-0679-3
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The 16,000 medical students completing OB/GYN clerkship programs each year provide a unique opportunity to motivate and mentor students in facilitating tobacco cessation. To determine the scope of current tobacco teaching in obstetrics/gynecology (OB/GYN) education at US medical schools and to assess opportunities for including new tobacco teaching, a 28-question survey was administered to directors and assistant directors at US medical school OB/GYN clerkship programs. Surveys were completed at 71% of schools. Only 9% reported having at least 15 min of dedicated teaching time for improving tobacco cessation skills. Nearly three-fourths of respondents reported teaching students how to intervene to reduce smoking during a work-up in the OB/GYN clinic, but only 43% reported that students would know where to refer someone wishing to quit. Only a third of respondents reported teaching students both to intervene with and refer OB/GYN patients who smoke. These findings suggest that although medical students see many OB and GYN patients who smoke, they have few opportunities to learn comprehensive cessation skills during their clerkships.
KeywordsTobaccoCounselingMedical educationOBGYNClerkship education
An estimated 18% of pregnant women ages 18–44 in the US smoke . The US Surgeon General and the American College of Obstetricians and Gynecologists (ACOG) have determined that smoking during pregnancy is the most modifiable risk factor for poor birth outcomes , and ACOG includes tobacco use on its list of gender-specific risks . The impact of smoking during pregnancy, including increased rates of fetal mortality and morbidity, has been well documented . Intrauterine exposure to maternal smoking accounts for 20% of low birth-weight babies, 8% of pre-term deliveries, and 5% of prenatal deaths nationwide . Women who use tobacco are also twice as likely to be diagnosed with cervical cancer and 40% more likely to be diagnosed with breast cancer [6–9]. Smoking rates during pregnancy are estimated as high as 25% overall, with rates exceeding 35% for women on Medicaid [10, 11]. Relapse rates range from 70 to 85% among women who smoke but quit at some time during their pregnancy .
With an estimated 23.3 million prenatal visits being made annually, there are ample opportunities for providers to intervene and counsel pregnant patients who smoke . The epidemiologic evidence correlating smoking with increased risk for cervical and breast cancer is a compelling reason to include tobacco cessation counseling and education in standard care, especially since obstetric and gynecologic (OB/GYN) specialists often serve as the primary healthcare provider for women. Because nearly all pregnant smokers in the US will see an obstetric health care provider during their pregnancy, and many women receive primary care screening from their OB/GYN practitioners , ACOG recommends that obstetric health care providers screen all patients for tobacco dependence . In addition, several professional organizations associated with women’s health, including ACOG and Association of Professors of Gynecology and Obstetrics (APGO) have made tobacco treatment a top priority [3, 14].
ACOG has identified three key foci for tobacco cessation, including medical school curricula.
In addition, ACOG and APGO are collaborating to revise the learning objective on tobacco use during pregnancy for graduating medical students . In response to the Healthy People 2010 goals, moreover, several national organizations have collaborated to form the National Partnership to Help Pregnant Smokers Quit, which has influenced research as well as state and federal funding policies and has fostered strategies to utilize the health care system, media, and communities to encourage cessation .
Numerous tobacco training curricula are also available for integration into OB/GYN clerkship programs. For example, The US Public Health Service’s updated Clinical Practice Guidelines, available via the internet provide both clinician and consumer materials , and ACOG offers an evidence-based clinician’s guide that includes information on integrating tobacco cessation into routine prenatal care . In addition, Dartmouth Medical School’s on-line “virtual practicum” features interactive virtual patient tobacco cessation counseling , and The Legacy Foundation’s internet-based program for pregnant and postpartum smokers, although created for smokers, provides clinicians with tools for motivating smokers to quit .
Practice, however, has been suboptimal . In particular, despite widespread calls to integrate tobacco cessation and referral skills into the OB/GYN medical school clerkship, efforts to include tobacco education in OB/GYN medical clerkships have generally been minimal. Many physicians do not consistently counsel OB/GYN patients about smoking cessation, with rates ranging from 19 to 83% [21–25]. Providers treating pregnant patients have cited a lack of time and training among the reasons for not providing cessation counseling [26, 27]. Furthermore, despite general consensus that successful tobacco cessation interventions for the public include patient, education, pharmacotherapy, and behavioral intervention [28–30], tobacco training in medical schools is limited , particularly in OB/GYN clerkships where in one recent study only 41% of the students reported receiving instruction for assisting patients with smoking cessation .
OB/GYN rotations are an excellent clinical setting to learn smoking cessation skills given that the obstetric population is generally a motivated receptive population for such education, thus the student may commonly experience a positive impact with their intervention.
To elucidate the nature and extent of tobacco teaching in US OB/GYN clerkship programs, we administered a survey to US medical school clerkship directors and assistant directors. This survey was designed to assess the current status of tobacco cessation teaching in OB/GYN clerkships and identify co-existing conditions that might be conducive to comprehensive educational interventions.
We obtained a list of current clerkship directors and assistant directors from the Association of Professors of Gynecology and Obstetrics (hereafter directors and assistant directors will be referred to as directors).
In 2007, we mailed a 28-question survey to directors at US medical school OB/GYN clerkship programs. Initial surveys were sent via mail. Non-respondents received email surveys. We made a maximum of four attempts via mail and email to reach participants. The research procedures and survey were approved by Institutional Review Boards at Boston University and the Harvard School of Public Health.
Instruments and Measures
After ascertaining the respondent’s current position (e.g., clerkship director or assistant clerkship director), years of service, duration of each OB/GYN clerkship block (in weeks), number of clerkship sites, and number of OB/GYN patients seen by medical students during a rotation, we divided the survey into sections representing five domains traditionally used to assess and plan for new programs in substance abuse and tobacco for physicians-in-training, including medical students and residents [31–35].
Tobacco Cessation Teaching and Tobacco Control Policies
Tobacco curriculum questions included whether there was dedicated teaching time of at least 15 min for improving tobacco cessation skills, and if so, what methods were used: didactic, skills training (role-plays, etc.), applied (supervised clinical training), or web-based. We queried if curricula included: the 5A’s (Ask, Advise, Assess, Assist, Arrange), the high rate of post-partum recidivism, and a list of expected skills to be learned during clinical rotations as well as whether that list included smoking cessation skills. Respondents were also asked if there were institutional tobacco policies such as a smoke-free campus, restriction on tobacco industry-funding for research, designated smoking areas on campus, or prohibition on the sale of tobacco products on campus.
Office Systems and Clinic Environment
Respondents estimated the smoking rate for OB/GYN patients as <10%, 11–20%, or 21+%, and estimated the number of OB/ GYN patients students typically see during a rotation using a scale of <10, 11–20 and 21+. We assumed that students saw one patient per day, seven days per week, so that at the end of 6 weeks they would have seen 42 patients (21 OB and 21 GYN). Referring to the hospital or clinic in which most students clerked, respondents were asked if there were reminders (e.g., vital signs, chart stickers, and checklists) to encourage patients not to smoke and if these reminders asked if smoking history was assessed, follow-up arranged, and hospitals had tobacco cessation clinics for patient referral.
Professional Development and Training
Respondents indicated if their hospital had ever offered any in-service training, workshop or continuing medical education for tobacco cessation, or related pharmacotherapy. They also rated level of faculty support for tobacco workshops and for integrating tobacco cessation into the clerkship.
Medical Student Skills
We used a four-point Likert scale to assess students’ skill level after completing the OB/GYN clerkship in the following areas: counseling patients about environmental tobacco smoke; asking about smoking at every visit; advising all smokers to quit; assessing patient willingness to quit; assisting patients with quit plans; arranging follow-up contact; recommending nicotine replacement therapy (NRT); talking with pregnant patients about smoking effects, and, the major outcome, having learned to intervene to reduce smoking or where to refer patients wishing to quit.
Clerkship Director/Assistant Director Practice
Using a 4-point Likert scale, respondents described their own practice in convincing patients to quit smoking, discussing smoking when patients have multiple health problems, advising OB/GYN patients about NRT, and demonstrating familiarity with state reimbursement/Medicaid options for cessation counseling.
Data Management and Analysis
We de-identified survey data and entered it into a secure project database. Using SAS and Excel, we analyzed the data by calculating the proportion of students who had been taught to intervene with patients and knew how to make a referral from other students who did not have these clinical experiences. We then analyzed all other study variables to determine predictors related to students who had been taught to intervene with patients and to make a referral.
Of the 129 US medical schools with an OB/GYN clerkship program, surveys were completed by OB/GYN clerkship directors at 70% (90/129) of the schools, with 57 returned via regular mail and 33 via e-mail. Eighty-eight percent of respondents were clerkship directors and the rest were assistant clerkship directors.
Respondents’ Position and Years of Service
On average, respondents had served 5 years in their current capacity with a range of <1–23 years.
Clerkship Program Structure and Setting
Sixty-one percent of the clerkships lasted 6 weeks, 26% 8 weeks, 7% 4 weeks and 6 % “other.” Seventy-three percent of programs had at least 2–4 clinical rotation sites. Respondents reported that 74% of students see at least 21 gynecology patients and 88% see at least 21 obstetrics patients during a rotation.
Tobacco Cessation Teaching and Tobacco Control Policies
Students trained to intervene with and/or refer smokers
Two-thirds of the medical campuses were smoke-free, and more than one-third had restrictions on tobacco industry-funding for research. Sixteen of the universities prohibited the sale of tobacco products on campus.
Office Systems and Clinic Environment
Clerkship directors estimated the following rates of smoking at their clinic: less than 10% (36%), between 11 and 20% (42%), and over 20% (21%). Fifty-six percent noted that vital signs, chart stickers, and checklists prompting providers to encourage patients not to smoke were available in the hospital or clinic for which the largest number of students completed clerkships. Seventy-three percent of respondents noted that their charts assessed smoking history, while 52% noted that follow-up was arranged, and 48% reported that their hospitals had tobacco cessation clinics for patient referral.
Professional Development and Training
Less than one-third of respondents reported that their faculty had ever offered an in-service training on tobacco cessation; 23% provided continuing medical education credits (CME) for tobacco education, and only 8% had workshops on pharmacotherapy. Forty-eight percent of respondents felt that there was a high level of support for faculty workshops on integrating tobacco cessation into the OB/GYN clerkship.
Medical Students’ Skills
Smoking Cessation Practices of Clerkship Directors
Ninety-three percent of clerkship directors reported that they were able to convince some patients to quit smoking, and 74 and 72%, respectively, reported that they routinely advise OB/GYN patients about the use of NRT. However, while most respondents reported that they routinely advise GYN patients about the use of nicotine replacement (70%), significantly fewer clerkship directors routinely advise OB patients about nicotine replacement (31%). Sixty-eight percent of respondents also reported that they were unfamiliar with state reimbursement/Medicaid options for cessation counseling, and 12% reported that they were less inclined to talk about smoking with a patient who has multiple health problems.
With 16,000 medical students completing OB/GYN clerkship programs each year, a unique opportunity exists to motivate students to become skilled in facilitating tobacco cessation in the OB/GYN setting. This survey of over 70% of US OB/GYN clerkship directors indicates that although medical students appear to have many OB/GYN patients who smoke, they have few opportunities to learn comprehensive cessation skills during their clerkships. In fact, fewer than 10% of clerkship programs provided at least 15 min of cessation teaching during the entire clerkship, and only 20% provided training in the US Public Health Service’s 5A’s for tobacco cessation. The fact that only 43% of clerkship directors felt that students would know where to refer patients who smoke is distressing, although it is consistent with other studies that show “arranging follow-up care” as the least commonly employed of the basic 5A’s .
Clerkship directors in our survey also reported that only 33% of medical students are taught both to intervene with a smoker and provide information about referrals for smokers who wish to quit. One disincentive for timely referrals can be attributed to the fact that nearly half of the reporting sites did not have cessation clinics on campus. In fact, lack of cessation clinics are oft-cited reasons for sub-optimal cessation counseling during the clinical encounter . Physician referrals to tobacco quit lines have improved patient quit rates, suggesting that medical students should be routinely provided with quit line numbers as part of their educational packets .
While we found that nearly 70% of programs have an expected list of clerkship competencies, only 14% of these programs included tobacco counseling on their list. This omission undermines the importance of the skill. With the ever competing demands of undergraduate medical education, a skill that is not formally graded or observed will be marginalized or omitted altogether. To remedy this, clerkship directors should formally include tobacco counseling among the expected clinical skills and observe students as they do with clinical examination skills. Successfully integrating tobacco teaching in the clerkship experience requires preceptor participation. The need for curricular change related to tobacco teaching in OB/GYN clerkships provides APGO and ACOG, who have already developed many relevant materials of instruction, with an opportunity to take on a leadership role in the effort.
Interestingly, our findings about clerkship directors’ less than optimal use of NRT for pregnant smokers may reflect their own lack of training in tobacco cessation in medical school and continuing medical education. ACOG recommends using NRT if all other therapies fail, and OB/GYNs have been shown to recommend NRT when they believe it is safe and effective for use in pregnancy, and if colleagues are prescribing it . Periodic CME training in smoking cessation and the use of NRT would provide practicing OB/GYNs with current clinical guidelines and best practices and, presumably, increase exposure of medical students to these practices. Formally integrating smoking cessation training, including the safe usage of NRT, in clerkship programs would ensure that the next generation of obstetricians and gynecologists has the necessary training to provide optimal care to their patients who smoke. Continuing medical education (CME) about Medicaid reimbursement may also be useful, since lack of awareness of reimbursements for tobacco cessation treatment programs for pregnant smokers may hinder physicians’ decisions to recommend cessation treatments as well. According to a 2008 report on Medicaid coverage for tobacco cessation, 39 states, including the District of Columbia, provided at least some coverage for smoking-cessation treatments .
On a more encouraging note, our results suggest that the environmental context of the medical school and clerkship sites already contain numerous opportunities for promoting policy and systems change conducive to promoting effective counseling. Although only 18% of respondents said their schools prohibited the sale of cigarettes on campus, two-thirds of campuses were smoke-free. Furthermore, most clerkship directors routinely advise their own patients about the use of nicotine replacement, more than half of clinics had prompts to remind faculty and students to counsel patients, and 73% had smoking history assessments. These characteristics represent opportunities for mentoring, role-modeling, and education.
At the same time, our findings confirm the need for further research, both on the current state of cessation training and on the most effective methods for teaching tobacco cessation in OB/GYN clerkship settings. In particular, because responses on student skill level provided by clerkship directors are subjective, they should be corroborated with objective evaluations of student performance. That nearly 30% of clerkship directors did not respond to our survey despite numerous attempts to reach them also suggests some degree of non-response bias, although this particular concern is mitigated by the sub-optimal rates of cessation teaching reported by respondents. To better understand effective approaches, short case studies on the evolution of formal cessation teaching during the clerkship in the eight programs that already offer at least 15 min of instruction in this subject might be fruitful. Future studies might also investigate factors influencing both the integration and retention of tobacco cessation training, such as dedicated funding, influential faculty members, or a department-wide commitment to preventive teaching.
In conclusion, given the convincing need and potential opportunity for intervention, it is imperative that medical students understand the importance of timely intervention for smokers in the OB/GYN setting. In fact, most patients report that they are expecting providers to intervene, and there is evidence that these interventions are successful . Our findings confirm ample opportunities within the OB/GYN clerkship for students to provide counseling and referrals to patients who smoke. Emerging literature as well as the support, new resources and practical tools already available from organizations such as ACOG and APGO suggests that integrating tobacco education into the OB/GYN clerkship need not require an entire curricular overhaul. Individuals interested in integrating preventive education, such as tobacco education, into the OB/GYN curriculum can already learn from successful models used with physicians-in-training [21–25]. They can also draw on suggestions from this study about the potential efficacy of a series of small but concrete tasks. These include adding smoking cessation skills to the expected skill set, periodic CME training or in-service teaching for smoking cessation skills, and chart space for arranging follow-up care and providing information to students on where to refer patients who wish to quit.