A longitudinal study of substance use and abuse in a single class of medical students.

PURPOSE: A longitudinal study to ascertain the attitudes toward, and habits of, substance use among a single class of medical students. METHOD: A single class from a northeastern medical school was surveyed in both its first year (February 1991, 176 students) and its third year (May 1993, 170 students). The students were asked to report how frequently during the prior year they had used drugs or alcohol, and whether their use of each substance had increased, decreased, or remained the same since entering medical school; to identify any family members with histories of alcohol or drug problems; and to report any incidence during the prior year of ten behaviors associated with substance dependence. The students were also asked to indicate their agreement or disagreement with 11 attitudinal statements. Additional attitudinal items asked the students to identify three major deterrents to the abuse of drugs and alcohol, and what they had done if they had become aware of a classmate with a drug or alcohol problem. Chi-square analysis and two-tailed t-tests were used to compare data from the two surveys. RESULTS: The response rates in the first and second surveys were 96.9% and 81.8%, respectively. Use of licit and illicit substances was comparable to that of chronological peers and prior national studies of medical trainees. Most of the students admitted to using alcohol at least once in the prior year (91.8% and 95%, respectively). In both years marijuana was the illicit drug used most often. Although there was a slight increase over time in the use of benzodiazepines (2.4% to 5.8%) and a decrease in the use of marijuana (29.4% to 21.7%), these changes were not significant. Few of the students in their third year reported using any substance other than alcohol more than once a month. In general, a greater percentage of the students reported a decrease rather than an increase in the use of a substance since entering medical school; the primary exception was for wine. As they progressed in their training, the students became less concerned about the effect of substance use on their performance and more likely to be embarrassed about admitting to an addiction. Although in each year a few of the students appeared to be at risk for substance dependence (8.9% and 3.5%, respectively), no student came to the attention of the administration because of problems related to substance use. While most of the students were unaware of any classmate who had a problem, half of those who were aware had done nothing, and the balance had rarely sought assistance from the faculty or administration. CONCLUSION: Although there was no evidence that substance use was a major problem, a few of the students appeared to be at risk for drug or alcohol dependence. Appropriate intervention, support, and referral systems should be identified for the few who may be at risk, and increased educational efforts are needed to help all students address this issue with their peers and, ultimately, with their patients.

Pilot-testing a holistic approach to scoring performance on standardized-patient examinations.

BACKGROUND: Scoring protocols for most standardized-patient (SP) examinations have not received extensive scrutiny and their validity has not been well established. METHOD: A holistic method (i.e., one based on raters' overall impressions) of scoring performance on an SP examination was pilot-tested in the spring of 1992 by administering an examination to two cohorts of fourth-year students at the Albert Einstein College of Medicine at Yeshiva University. The examination consisted of eight SP stations, representing a range of medical problems. Two to three experienced clinical teachers independently reviewed all the written material for each encounter. In Phase I of the study, holistic ratings of outstanding, competent, marginal, or inadequate were given for overall clinical competence for a cohort of 16 students; in Phase II, holistic ratings were given separately for data-gathering and communication skills for a cohort of 26 students. Intercase and interrater reliability analyses were performed. RESULTS: Adequate reliability coefficients were obtained on a two-hour test; total scores (i.e., students' scores across all eight cases) discriminated between groups of examinees; and, on average, less than two minutes were required to score an encounter. CONCLUSION: Although based on a small sample, the study's results suggest that this holistic method of scoring performance may be useful in some situations. Since experienced clinical teachers know and agree about clinical competence when they see it, developers of scoring protocols for SP examinations need to establish that the results obtained are congruent with the judgments of expert teachers.

A performance-based method for early identification of medical students at risk of developing academic problems.

The authors studied three classes at the Albert Einstein College of Medicine and found that students' performances on examinations administered during the third month (November) of medical school were highly predictive of their subsequent performances during the first two years of medical school. The investigation had two components: (1) a retrospective study of the classes of 1988 and 1989, which found that students' November grades from three first-year courses predicted 76% of the variance in the year-one weighted aggregate score and 41% for the year-two score, and (2) a prospective study of the class of 1992, in which three November of year one examination scores of the students in the lowest quarter of the class were highly predictive of their encountering substantial academic problems, with a sensitivity of .77 and a specificity of .99. This performance-based method was found to be more powerful than using the scores on the 1977 version of the Medical College Admission Test or the students' undergraduate grade-point averages, or both, in identifying individual students who were academically at risk.

Integrating basic science and clinical teaching for third-year medical students.

A two-month program for third-year students at the Albert Einstein College of Medicine of Yeshiva University provides a model for integrating basic sciences and clinical training. Entitled The Scientific Basis of Clinical Medicine, the course involves more than 100 basic science instructors and clinical instructors and is designed to foster recognition that good patient care requires physicians to evaluate the latest evidence of medical researchers. It also demonstrates the importance of lifelong learning in a field that constantly changes. Since 1978, the course has been offered in the spring of the third year after students as demonstrating "the continuum from basic science to clinical medicine" and as moderately successful in achieving its other objectives. Students view both its content and its less pressured environment after an intense year of clinical training as its major strengths.

Attitudes towards cancer. Development of the cancer attitudes questionnaire.

A questionnaire evaluating attitudes towards cancer (the Cancer Attitudes Questionnaire) was constructed to compare the attitudes of first-year medical students before and after taking a clinical oncology program with those of students who did not participate in the program. A factor and reliability analysis revealed five underlying factors that explained 42% of the variance and reliabilities ranging from 0.55 to 0.79. An analysis of covariance revealed that students who participated in the clinical oncology program were more positively predisposed toward the outpatient functioning of cancer patients (P less than 0.04) at the conclusion of the year than students who did not take the course; the participating students were also somewhat less pessimistic toward the disease (P less than 0.07). Women (regardless of whether they had taken the course) assigned significantly greater importance to the patient's and family's attitudes in relation to outcome of disease (P = 0.03) than did male students. It appears that an early medical educational oncology experience emphasizing contact with ambulatory cancer patients can appreciably alter the attitudes of first-year medical students towards cancer.

Evaluating self-help support groups for medical students.

Self-help support groups for medical students represent one strategy for dealing with the emotional stresses of medical training and the diminished human sensitivity of students that often accompanies that experience. Support groups at the Albert Einstein College of Medicine were evaluated by 26 students who completed a nine-part questionnaire. The respondents indicated that they were primarily drawn to these groups because of a desire for social affiliation and an opportunity to express their feelings in a "safe" environment. Members shared in the leadership responsibilities of the group and dealt with external personal problems of the students rather than with the internal group dynamics. The gains derived from participation in these groups included opportunities for nonprofessional contact with faculty members, getting help and support from fellow students, and participation in stimulating discussions about the medical field. Students rated the groups as "meaningful" and expressed a desire for more frequent meetings.

Interdisciplinary training for medical and nursing students: learning to collaborate in the care of geriatric patients.

A medicine clerkship for students at the Albert Einstein College of Medicine provided the setting for a pilot program in interdisciplinary geriatric training with nursing students from the College of Mount Saint Vincent. The program's objectives were to provide opportunities for interdisciplinary collaboration and to increase appreciation for the role of each discipline in caring for the aged. Additionally, it sought to foster a holistic approach to the aging and a recognition of the psychosocial influences on their lives. Teams of one medical and two nursing students conducted patient work-ups and presented cases to an interdisciplinary group of health care professionals. Analysis of pretest-posttest responses of ten medical and ten nursing students to a Role Assessment Questionnaire (RAQ) found that the program significantly increased medical students' perceptions of the nurse's role in caring for hospitalized elderly patients (P less than 0.05). Despite this gain, however, there continued to be substantial discrepancies between medical and nursing students' perceptions of the extent to which nurses are "essential" in caring for the elderly. In evaluating the program, all participants concurred that working with students in another health profession was a valuable learning experience. While nursing students felt that the program achieved all its goals, responses of medical students were more variable, with volunteers having more positive perceptions of program impact than those who were assigned. The program demonstrated both the need for and the effect of interdisciplinary training, and that teaching and clinical experiences centering around the hospitalized older person can provide a natural setting for such training.

A content validity analysis of neoplastic items of the National Board of Medical Examiners Part II Examination.

As part of its evaluation of the Clinical Cancer Education Program (CCEP) at the Albert Einstein College of Medicine, the Office of Educational Research and Evaluation analyzed student performance on neoplastic items of the National Board of Medical Examiners (NBME) Examination Part II. The evaluation provided a successful application of the American Association for Cancer Education (AACE) coding schema for analysis of neoplastic items. Two examinations were analyzed in order to determine the frequency with which specific disease sites, treatment modalities, and question emphasis items appeared. With reference to disease site, the greatest number of questions on both examinations dealt with gynecological issues while the fewest dealt with lung and hematologic-related disease. A breakdown of questions into various treatment modalities indicated that of items that could be categorized, most dealt with surgical treatment, while other therapeutic modalities were given little or no emphasis. Looking at question emphases, the most frequently asked questions referred to diagnostic tests and stratagems, whereas the least amount of emphasis was placed on rehabilitative and psychosocial aspects of the disease. These findings corroborate those reported by Ruckdeschel and his associates and point out several limitations to the content validity of the neoplastic items on NBME Part II.