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AAMC Reporter: November 2007
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Ronald M. Davis, M.D.,
President, American Medical Association;
Director, Center for Health Promotion and Disease Prevention,
Henry Ford Health System
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Viewpoint:
"Pushing Prevention in Medical Training"
About half of all deaths in the United States are caused by a
few largely preventable behaviors, exposures, and conditions,
such as obesity and diabetes. The U.S. Preventive
Services Task Force has issued more than 90 evidence-based
recommendations for clinical preventive services in the categories
of screening, counseling, immunization, and preventive
medication.
Unfortunately, with time and reimbursement constraints,
health education is relegated to posters, waiting room
media, and group teaching in the community. And
although these are important adjuncts, the role of the
physician is crucial; patients cite their physician most
often as the one who influenced them most to make a
health behavior change.
Medical students express in focus groups that lifestyle counseling
is an important societal and personal obligation. But
as they move from the basic science to the clinical years and
face more time constraints and stress, they are less willing to
attend lifestyle classes.With a tight curriculum, students
and residents may perceive that prevention is less important
than traditional basic science and clinical education.
They also admit to having less time for their own wellness;
and physicians' own health behaviors affect their likelihood
of conducting, and capacity to conduct, successful lifestyle
counseling. This trend continues or may worsen in the
graduate medical education years.Hence unhealthy personal
behaviors and practice styles that deemphasize prevention
are built early in their medical careers. This may
lead to lack of credibility with patients.
In view of these challenges, the current level of prevention
education in both medical schools and primary care residencies
falls far short of what is needed. Based on the
2006-2007 Liaison Committee on Medical Education
(LCME) Annual Medical School Questionnaire, sent to
125 LCME-accredited medical schools with a 100 percent
response, 124 schools reported requiring one or more
courses in prevention/health maintenance (one school did
not respond to the item). The average number of hours
offered on the topic was 23, with a range of 1 to 127.
This allocation of time to the teaching of prevention is not
only inadequate to cover the science behind the preventive
guidelines—including intervention on tobacco and alcohol
dependence, nutrition, and exercise—but is also woefully
inadequate to cover skills-building in motivational interviewing
and other counseling techniques for health behavior
change. The large variability in the number of hours
offered on the topic demonstrates the lack of standardization
across medical schools. It is no surprise that medical
students report that they feel ill-prepared to counsel
patients about smoking cessation, problem drinking, diet,
and exercise, and are pessimistic about their ability to learn
the skills needed to address these issues.
A minimum prevention curriculum that includes didactic
as well as interactive skills-building sessions (with role-playing
and patient scenarios) should be required for every
medical school to increase students' self-efficacy (their perceived
ability to succeed) in delivering preventive services
and the likelihood that they will offer these services routinely
in their practices. Both undergraduate and graduate
medical education need to boost emphasis on prevention
knowledge and skills.Graduate medical education for every
specialty should be included, since prevention is a cross-specialty
issue.
Strategies to make the necessary changes in medical education
include strong leadership, faculty development programs,
curriculum development awards, a formal curriculum
change process, and student skills assessments.
Innovative curricula and case-based teaching have been
developed and tested at some schools; and medical education
leaders need to spearhead the dissemination of such
curricula. Our medical education system needs leaders who
will overcome the challenge of competing topics in the curriculum,
the cross-specialty nature of prevention, and the
perception that prevention is less important than traditional
curriculum topics. These leaders also need to serve
as role models for wellness in their personal health.
The successful integration of prevention into practice that
results in improved health behavior outcomes also can benefit
from a different practice model—such as the chronic
care model, which includes a practice team, appropriate
information systems, decision supports, and linkages to the
community that support the patient beyond the office visit.
Medical students and residents need training in this type of
setting to develop comfort in implementing and participating
in a system that supports tangible prevention outcomes.
Instilling the prevention mindset early in the hearts and
minds of medical students and young physicians is crucial
in building sustainable prevention-oriented physician practices.
Often the patient drives attention to acute problems,
but prevention gets relegated to the end of the visit with a
cursory progress note that might mention smoking status
and the most recent mammogram.
Successful preventive services demand much more.Medical
faculty need to role model the appropriate attention to prevention
screening, intervention, and follow-up. As we advocate
for appropriate payment for prevention in our health
care system, we need to develop an incoming physician
workforce that is competent and confident in prevention.
If we put these strategies into place, unprecedented numbers
of patients will receive prevention and healthy lifestyles
counseling, and the health of individuals and communities
will be measurably improved.
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