Sexual Health Curriculum in Medical Schools

Transcription

1 o r i g i n a l c o m m u n i c a t i o n Medical School Sexual Health Curriculum and Training in the United States Sheetal Malhotra, MBBS, MS; Anjum Khurshid, PhD, MPAff; Katherine A. Hendricks, MD, MPH, TM; and Joshua R. Mann, MD, MPH Financial support: This article was supported by Cooperative Agreement #H75CCH from the Centers for Disease Control and Prevention (CDC). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the CDC, the Department of Health and Human Services or the U.S. government. The study was approved by the Sterling Institutional Review Board, Atlanta, GA. Background: With 19 million new sexually transmitted infections (STIs) annually and poor screening and counseling by physicians, there is a need to improve medical training in sexual health topics in the United States. Purpose: To assess medical school sexual health curricula through student and faculty descriptions of training content, methods and effectiveness. Methods: Nationwide telephone survey of 500 fourth-year medical students (M4s) and medical school curriculum offices. Results: Many U.S. medical schools (41/92, 44%) lack formal sexual health curricula. Many medical students are uncomfortable taking sexual histories from year olds (87/499, 17.4%) and from adults >75 years (119/498, 23.8%). Students who learned history-taking on patients were more likely (OR=3.22) to be comfortable taking histories from year-olds than those who did not. Risk reduction counseling was considered appropriate by more students than was risk avoidance counseling (99.4% vs. 74.2%, P<0.001). Conclusion: There are significant deficiencies in medical students training on sexual health. Key words: sexual history n sexually transmitted diseases n education From Medical Institute for Sexual Health, Austin, TX (Malhotra, epidemiologist; Hendricks, vice president, science); Department of Health Management & Informatics, University of Missouri Columbia School of Medicine, Columbia, MO (Khurshid, assistant professor and director); and Department of Family and Preventive Medicine, University of South Carolina School of Medicine, Columbia, SC (Mann, associate professor). Send correspondence and reprint requests for J Natl Med Assoc. 2008;100: to: Sheetal Malhotra, Epidemiologist, Medical Institute for Sexual Health; phone: (512) ext. 206; fax: (512) ; smalhotra@medinstitute.org INTRODUCTION Sexually transmitted infections (STIs) are a major health problem in the United States; most people who have STIs are asymptomatic. Few physicians routinely offer recommended STI screening or counseling. Medical training on sexual health is inadequate and needs to be enhanced and standardized. The purpose of this study was to assess sexual health training in U.S. medical schools from the perspective of both the students and curriculum directors; particular emphasis was placed on sexual history-taking and STI counseling. Each year, an estimated 19 million new STIs 1 costing $9.3 $15.5 billion 2 occur in the United States. Since most STIs are asymptomatic 3-6 and often go undiagnosed and untreated, sequelae such as ectopic pregnancy, premature birth, congenital infections and cancer may result. 7 Consequently, it is of paramount importance to screen asymptomatic patients for STIs. Both poor physician screening for STIs and inadequate prevention counseling contribute to the endemic nature of STIs in the United States. Physicians are more likely to screen for STIs if patients report symptoms, high-risk sexual behaviors or sex with infected partners. 8 Screening of asymptomatic patients and emphasis on prevention counseling are often overlooked. Fewer than one-half of physicians (including ob/gyns) profess to screen asymptomatic patients for chlamydia or other common STIs Prevention counseling by physicians can positively influence patient behavior. 12 Effective sexual health messages can change behaviors the most notable example being the reversal of the Uganda HIV epidemic during the early 1990s. 13 Although data on sexual health counseling by physicians are not available, U.S. medical student HIV prevention counseling is perfunctory. 14 Studies have found medical school training on sexual health issues to be lacking. 15,16 Only about a third (9/25, 36%) of Canadian physicians felt that they had received adequate training on sexual health topics; most lacked knowledge on sexually transmitted disease (STD) prevention. 17 Currently, 123 U.S. medical schools include some human sexuality education as part of a required course; 38 schools include it as part of an elective. 18 Mul- JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 100, NO. 9, SEPTEMBER

2 tidisciplinary curriculum enhancement to identify deficiencies in sexual health education has been attempted in a few schools. However, consensus has yet to be achieved regarding what elements to include in a sexual health curriculum and when and how to incorporate them. 19,20 Poor sexual health awareness among British medical students 21 was addressed recently by the adoption of a consensus document on core genitourinary topics for medical school curricula. 22 Sexual health curriculum guidelines are also needed for U.S. medical schools. METHODS Data Collection We conducted a telephone survey of 500 fourth-year medical students (M4s) and a telephone survey of curriculum offices at each medical school in the United States. The surveys assessed: 1) students self-reported knowledge, attitudes and practices regarding a) sexual health histories and physicals, and b) STI screening, diagnosis, reporting and counseling as well as 2) student and faculty descriptions of training content, methods and effectiveness. Approval for the project was granted by the Sterling Institutional Review Board. From February through August 2005, telephone interviews were conducted; telephone numbers from a nationwide American Medical Association database were available for 6,884 students who were supposed to be enrolled in the fourth year of accredited allopathic medical schools in the United States. Three different activities were involved in data collection: focus groups, student surveys and curriculum office surveys. Focus groups were conducted in San Francisco, CA; Gainesville, FL; and Houston, TX. Each of the three groups comprised of 8 10 M4s. Findings from these groups were used to draft the questionnaires for both the student and curriculum office telephone interviews. The instruments were piloted with medical students and medical education curriculum directors, respectively. Student interviews were conducted using Computer-Assisted Telephone Interview (CATI). Each telephone number was called 3 times. The second time an answering machine was encountered, a scripted message was left that provided a toll-free call-back number for scheduling an interview. All respondents were assured complete confidentiality of their responses. Students who completed the survey received a $25 incentive. From May through October 2005, the curriculum directors of 122 accredited allopathic medical schools in the continental United States were surveyed by telephone and . Specifics of each school s sexual health curriculum were elicited from the directors or a designee. Data obtained from the interviews were supplemented, when possible, with information from the Association of American Medical Colleges (AAMC) Curriculum Management and Information Tool (CurrMIT). Survey Instruments Student survey development was guided by information obtained during focus group discussions. The student questionnaire comprised 53 items which sought information about training on sexual history-taking and physical examination, clinical rotations, STI screening and reporting, and attitude toward and practice of counseling. The curriculum office interview comprised 7 items on sexual health training on topics such as sexual history taking, sexually transmitted infections and counseling. M4 Student Survey Instrument Sexual history-taking and physical examination. We collected information on all methods used to teach sexual history-taking, and male and female physical examination. Possible methods included textbooks, lectures, videotapes, actors, actual patients and others. Students were asked to choose which 1 method was most effective. They were also asked how often they were evaluated on their history-taking and physical examination skills (most of the time, some of the time, rarely, never) as well as their comfort levels when taking sexual histories from various age groups. The comfort level was recorded on a 5-point Likert scale (ranging from 1=very uncomfortable to 5=very comfortable). They were also asked if they had ever observed a resident or faculty member performing male and female examinations, and whether they had ever been observed by a resident or faculty member while performing these types of examinations. Videos on sexual activity. In 1 focus group, students mentioned that, as part of their sexual health training, they had been asked to view videos of people engaging in sexual intercourse. In response to this information, we queried the M4s about whether their training included watching videos of people engaging in sexual activity. For those who had, we asked whether they felt that this helped them to improve their history-taking, physical examination or counseling skills. Clinical rotations. Students were asked whether they had rotated through STD, family planning, ob/gyn, adolescent and prenatal clinics. They were also asked to specify if they had rotated through any other clinic setting that had STI patients. Open-ended questions were used to ascertain the number of days spent in each setting. Diagnosis, screening and reporting of STIs. Respondents were asked whether they had ever observed any patients with chlamydia, HIV or syphilis being diagnosed and, if they had, how many of each. The approximate number of patients with asymptomatic STIs who had been diagnosed by their medical team was ascertained. Respondents were then asked whether they had ever personally diagnosed HIV or other STIs in asymptomatic patients. Respondents were presented with case scenarios (a sexually active 20-year-old female, a JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 100, NO. 9, SEPTEMBER 2008

3 year-old male who has had oral sex with another male, and a 31-year-old pregnant female) and asked whether they would recommend chlamydia screening for each. In an open-ended question, respondents were also asked to name reportable STIs in their home states. Prevention counseling. Participants were asked to use a 5-point Likert scale (ranging from 1=very inappropriate to 5=very appropriate) to describe their attitudes toward counseling patients about risky behaviors such as multiple sexual partners, anal intercourse or sexual intercourse with an intravenous (IV) drug user. They were also asked about their attitudes toward physicians providing patients with risk avoidance and risk reduction counseling on topics such as monogamy, abstinence, delay of sexual debut and consistent condom use. Finally, respondents were asked whether they themselves had ever counseled patients on multiple sexual partners, anal intercourse, sexual intercourse with an IV drug user, monogamy, abstinence and consistent condom use. Condom effectiveness for preventing STI transmission. Respondents were asked whether consistent condom use was effective in reducing HIV and chlamydia risk and how much risk reduction it afforded for each. Curriculum Office Survey Instrument The curriculum office survey instrument included items on the presence of a formal sexual health curriculum and its source; how many preclinical and clinical hours were devoted to sexual health education; and the time devoted as well as the methods used to teach 1) pathophysiology, microbiology, STI epidemiology, sexual history-taking and physical examination; and 2) STI screening, diagnosis, treatment and counseling. The emphasis placed on sexual health as part of a complete history and physical was assessed. The year during which condom and contraceptive information were provided was recorded. Data Analysis Data were entered into SPSS 13.0 (SPSS Inc., Chicago, IL), the student and curriculum office data sets were merged and descriptive statistics were run on the variables. Chi-squared tests were performed to detect associations among variables. Associations and odds ratios between the reported presence of a formal sexual health curriculum (from the curriculum office data set) and the student rotations, training, comfort levels and diagnostic and counseling skills, were calculated using Chi-squared tests and multinomial logistic regression. After controlling for student sex and ethnicity, odds ratios were calculated for comfort levels during sexual history-taking from patients in different age groups. Independent variables used in regressions included presence of sexual health curriculum in medical school, methods used to teach history-taking, clinical rotations attended and evaluation of history-taking skills. RESULTS Study Population The sample size needed for a national 2005 M4 population of 15,760 was calculated to be n=460. To ensure an adequate number of complete responses for data analysis, interviews were conducted with 500 M4 students. To obtain 500 completed student interviews, all of the available 6,884 telephone numbers were called at least once. Of the 1,267 medical students who were reached, 314, or 24.8%, refused to participate. This left 953 M4s amenable to participating. Interviews were stopped after 500 had been completed, since 500 had been selected a priori as an adequate sample size (Table 1). Our sample was similar in age and gender distribution to the 2005 M4 national population and differed slightly in ethnicity (Table 1). 23 Participant age ranged from years (mean=28.8 years, SD=3.86). Our sample had more white and fewer Asian or Pacific Islander students (P<0.001) than the national population. Table 1. Demographic characteristics of the study sample and national M4 population Study Sample (n=500) Mean Age (Years) Gender Male 269 (53.8) 8,348 (52.9) Female 231(46.2) 7,412 (47.1) Ethnicity White 375 (75) 10,086 (64) Asian or Pacific islander 61 (12.2) 3,120 (19.8) African American 25 (5) 1,103 (7) Hispanic 20 (4) 993 (6.3) Other 10 (2) 457 (2.9) National Population (N=15,760) JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 100, NO. 9, SEPTEMBER

4 Sexual History & Physical Examination: Teaching Methods and Evaluation Students, particularly females, reported discomfort taking sexual histories from patients in some age groups (Table 2). Far more students reported discomfort when taking sexual histories from very young (87, 17.4%) or elderly (119, 23.8%) patients than from patients aged (P=0.015 and P<0.001, respectively). Males were more comfortable than females taking histories from patients aged years (OR=1.77, 95% CI: ) and >75 years (OR=2.12, 95% CI: ). Teaching method and evaluation affected sexual history-taking skills. Compared to other sexual history teaching methods, those employing patients (45.5%) or actors (34.9%) were perceived as most effective by students (Table 3). Students who had learned historytaking on patients were more likely (OR=3.22, 95% CI: ) to be comfortable taking histories from year-olds than those who had not. Many students reported that their instructors rarely (47.6%) or never (4.2%) evaluated their sexual history-taking skills. Compared to those whose skills were never evaluated, students whose skills were evaluated were more likely to be comfortable taking sexual histories from patients aged years (OR=1.82, 95% CI: ) and >75 years (OR=5.38, 95% CI: ). Teaching method and evaluation also affected skills pertaining to physical examination of the male and female reproductive systems (Table 3). As for the method used to teach both male and female examinations, students preferred actors (194/492, 39.4%; 242/500, 48.4%) and actual patients (234/492, 49.6%; 224/500, 44.8%). Students were significantly more likely (P<0.001) to have observed a resident or faculty member performing a female (497/500, 99.4%) than a male (451/500, 90.4%) genital examination. Although all the students had been observed by a resident or faculty member while performing a female genital examination, far fewer (412/500, 82.4%) had been observed while performing a male genital examination (P<0.001). Of the 112 (22.4 %) students who had been shown Table 2. M4 comfort levels taking sexual histories from patients in different age groups Comfort Level* Age Group (Years) >75 Uncomfortable 87 (17.4) 11(2.2) 8 (1.6) 53 (10.6) 119 (23.8) Neutral 129 (25.8) 35 (7) 27 (5.4) 117 (23.4) 126 (25.2) Comfortable 283 (56.6) 154 (90.8) 265 (93) 330 (66) 253 (50.6) *Response categories were collapsed so that comfortable = very comfortable and comfortable, and uncomfortable = very uncomfortable and uncomfortable. Table 3. Sexual history-taking and physical examination teaching methods and evaluation Sexual History-Taking Male Genital Examination Female Genital Examination Teaching Method Used Textbook 369 (73.8) 452 (90.4) 462 (92.4) Lecture 484 (96.8) 476(95.2) 490 (98.0) Videotape 279 (55.8) 258 (51.6) 314 (62.8) Actors 428 (85.6) 322 (64.4) 433 (82.6) Actual patients 405 (81.0) 430 (86.0) 461 (92.2) Other* 37 (7.4) 46 (9.2) 58 (11.6) Most Effective Method Textbook 5 (1.0) 3 (0.6) 9 (1.8) Lecture 42 (8.5) 8 (1.6) 20 (4.1) Videotape 15 (3.0) 7 (1.4) 14 (2.8) Actors 173 (34.9) 242 (48.4) 194 (39.4) Actual patients 225 (45.5) 224 (44.8) 234 (49.6) Other * 35 (7.1) 16 (3.2) 21 (4.3) *Other methods include role playing, small group discussions, dummies, standardized patients, and plastic or anatomic models JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 100, NO. 9, SEPTEMBER 2008

5 videos of people engaging in sexual activity as part of their medical training, only about a third (34, 30.1%) said that the videos helped them improve their historytaking, examination or counseling skills. Clinical Rotations Of the rotations where students are most likely to encounter patients with STIs, most students reported rotating through ob/gyn (93.6%) and prenatal (83.4%) clinics (Table 4 and Figure 2). Fewer had rotated through adolescent (49.2%), family planning (35.2%) and STD (31%) clinics. About half (248/461, 53.8%) of the students stated that most of their experience managing STI patients was gained in ob/gyn or women s health clinics. Screening, Diagnosis and Reporting of Sexually Transmitted Infections When asked if they would recommend chlamydia screening for various scenarios, 471 (94.2%) students stated that they would screen a 31-year-old pregnant woman, 371 (74.2%) a sexually active 20-year-old female, and 234 (46.8%) a 20-year-old male who had oral sex with another male. Students had little experience observing or diagnosing STIs, particularly in asymptomatic patients. Most (387/500, 77.4%) had observed the diagnosis of an asymptomatic patient with chlamydia, about half (247/500, 49.4%), with HIV infection, and less than a third (146/500, 29.2%) with primary or secondary syphilis. Most students had observed the diagnosis of <5 cases of chlamydia, HIV, and primary or secondary syphilis. Three-hundred-twenty-nine (65.8%) students had themselves diagnosed asymptomatic patients with non-hiv STIs and 95 (19%) with HIV. With the exception of HIV and syphilis, few students reported knowing which STIs are reportable in their home states. When asked about reportable STIs in their state, 419 (83.8%) mentioned HIV, 412 (82.4%) syphilis, 279 (55.8%) gonorrhea and 258 (51.6%) chlamydia. Fewer than 10% mentioned chancroid, hepatitis A, hepatitis B and hepatitis C. Counseling Attitudes and Practices Almost all students felt it was appropriate to counsel patients about risky behaviors, e.g., multiple sexual partners (496, 99.4%) and risk reduction strategies, e.g., condom use (497, 99.4%). Fewer (P<0.001) thought it was appropriate to counsel patients about risk avoidance, e.g., monogamy (371, 74.2%). Female students were more likely than males (184/231, 79.5% vs. 187/269, 69.5%) to believe in the appropriateness of counseling patients to delay sexual debut (c 2 =16.19, df=4, P=0.003). A large majority of M4s considered consistent condom use to be effective for reducing transmission of HIV (496, 99.2%) and chlamydia (487, 97.4%), with median perceived risk reduction of 90% for both. Almost all students had counseled patients about condom use, a Table 4. Medical student clinical rotations Had Rotation Clinic Setting STD 155 (31.0) Family Planning 176 (35.2) Ob/gyn 498 (93.6) Adolescent 246 (49.2) Prenatal care 417 (83.4) Other** 364 (72.8) Most Experience Gained in Managing Patients with STDs (Excluding HIV) in Clinical Setting Adolescent 20 (4.3) Ambulatory medicine 10 (2.2) Community health center 31 (6.7) STD 15 (3.3) ER 31 (6.7) Family medicine 75 (16.3) Medicine/infectious disease 15 (3.3) Health department 2 (0.4) Gynecology/women s health 248 (53.8) Other** 14 (3) ** Other sites include family practice, primary care, infectious disease, HIV/AIDS, ambulatory care, and women s health clinics as well as the emergency department. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 100, NO. 9, SEPTEMBER

6 majority had discussed multiple sexual partners, and about half had ever counseled a patient about monogamy or abstinence (Figure 3). Student attitudes and practices were concordant for risk reduction counseling, Figure 1. Flowchart for M4 survey responses 6,884 telephone num bers contacted 41 respond ents not in 4 th year 934 phone numbers disconn ected, 332 not wo rking, 87 nonresidential nu mbers, 78 beepers/fax numbers 317 stud ents mo ved 5095 eligible students contacted 2639 answering m achine 950 no a nswe r 239 busy 1267 eligible students reached 953 stud ents am enable to participation 314 refused to participate 500 final sam ple (interviews stopped at com pletion of 500 th interview) Table 5. When and how are sexual health topics addressed in medical schools? STI/Sexual Health Topic Schools Preclinical Years Clinical Years Lecture Small Groups Actors Patients Other* Pathophysiology (95.7%) 33 (35.9%) 87 (94.6%) 45 (48.9%) 7 (7.6%) 11 (12.0%) 24 (26.1%) Microbiology (96.6%) 21 (23.6%) 84 (94.4%) 39 (43.8%) 4 (4.5%) 5 (5.6%) 24 (27.0%) Epidemiology (87.3%) 32 (40.5%) 69 (87.3%) 34 (43.0%) 6 7.6%) 9 (11.4%) 19 (24.1%) Sexual history taking (96.6%) 40 (44.9%) 52 (58.4%) 52 (58.4%) 52 (58.4%) 20 (22.5%) 30 (33.7%) Physical examination (87.1%) 46 (54.1%) 42 (49.4%) 34 (40.0%) 62 (72.9%) 22 (25.9%) 30 (35.3%) Screening (63.9%) 60 (72.3%) 61 (73.5%) 41 (49.4%) 8 (9.6%) 20 (24.1%) 25 (30.1%) Diagnosis (71.9%) 67 (74.3%) 68 (76.4%) 48 (53.9%) 12 (13.5%) 30 (33.7%) 25 (28.1%) Treatment (67.0%) 74 (84.1%) 71 (80.7%) 45 (51.1%) 13 (14.8%) 31 (35.2%) %) Prevention counseling (68.3%) 61 (74.4%) 47 (57.3%) 45 (54.9%) 23 (28.0%) 22 (26.8%) 31 (37.8%) * Other methods include videotapes, CDs, case-based learning, problem-based learning, seminars, conferences, web-based teaching, anatomic models, mannequins and role playing JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 100, NO. 9, SEPTEMBER 2008

7 but were often discordant when it came to counseling about either risky behaviors or risk avoidance strategies (P<0.001 and P=0.03). Curriculum Office Survey Eighty-six of the 122 U.S. medical schools contacted sent complete responses to the curriculum office survey (Table 5). Seven other schools provided partial responses, and information from CurrMIT was used to supplement these answers where possible, for a response rate of 71.3%. Fifty-one out of ninety-two (55.4%) schools reported having a sexual health curriculum; 47 (92.2%) had developed it internally. The median number of preclinical a contact hours for sexual health education was 12 (range 3 40), and median number of clinical contact hours was 8 (range 0 35). Table 5 shows when various topics were taught and the methods used to teach them. Most schools addressed STI screening, diagnosis, treatment, and counseling in both the preclinical and clinical years. Medical School Sexual Health Curriculum/Training According to the curriculum office directors, clinical faculty at their schools would always (20%), usually (34.1%), sometimes (30.6%) or rarely (4.7%) consider a history and physical incomplete if it lacked a sexual history. Condom and contraceptive effectiveness for STI and pregnancy risk reduction were covered in 82% (82/86) and 95% (88/89) of the schools, respectively. DISCUSSION Physicians have an important role in reducing the STI rates in the United States. Current physician practices related to STI screening, reporting and risk avoidance, as well as risk reduction counseling, are inadequate. Better sexual health training in medical schools can significantly improve physician practices. Findings from this study identify deficiencies pertaining to sexual health training. The lack of emphasis and consistency in instructional approaches to sexual health are striking. Only about half of U.S. medical schools have formal sexual health curri- a For the purposes of this survey, years 1 and 2 of medical school were grouped into preclinical, and years 3 and 4 were grouped into clinical years. Figure 2. Days spent by medical students in various clinical settings STD Family planning OB/GYN Adolescent Prenatal care Other* * Other clinical sites include family practice, primary care, infectious disease, HIV/AIDS, ambulatory care and women s health clinics, as well as the emergency department. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 100, NO. 9, SEPTEMBER

8 cula. Having a formal sexual health curriculum appears to improve student comfort, while taking sexual histories and increase the proportion of students who believe it is appropriate to counsel patients in at least some circumstances (data not shown). Sexual history-taking can be influenced by medical school training. 15,24 It is also influenced by embarrassment, 25 belief in relevancy of sexual history, attitudes toward sexual orientation, 26 and patient and physician gender. 8,11 It is therefore not surprising that many students in our sample reported being uncomfortable taking sexual histories, particularly from the young and the elderly. Didactic training is often used in medical schools for teaching sexual history-taking. However, teaching methods that employ patients or actors and are accompanied by formal evaluation 27 can more effectively impart these critical communication skills to students. More importantly, these methods can inculcate the professionalism necessary to elicit sensitive information in a confidential and nonjudgmental manner. The value of formal evaluation cannot be overemphasized, since its presence indicates that it is important and its absence, that it is not. There appear to be disparities in the training on female and male physical examinations. It is noteworthy that almost a fifth of the students had not been observed while performing a male genital examination, and about 10% had never even seen one performed by a resident or faculty member. Just as for history-taking, students prefer learning how to perform a physical examination in settings that employ patients or actors. According to the CDC STD Treatment Guidelines 28 all of the patients in the case scenarios presented to the M4s in our study should have been screened for chlamydia. Yet only half of the students would have screened a young male who has had oral sex with another male, and three-fourths would have screened a young sexually active female. These findings confirm those of previous studies, 8 emphasizing the importance of STI screening. Since most STIs are asymptomatic, testing recommendations cannot be limited to patients who recognize and report symptoms. Sexual health curricula also need to address STI screening of asymptomatic patients with demographic or behavioral risks. Given the high prevalence of STIs such as chlamydia and gonorrhea in the United States, it is surprising that one-third of the participants had never personally diagnosed asymptomatic STIs other than HIV. It is even more surprising that 4 in 5 M4s had never personally diagnosed an HIV infection in an asymptomatic patient. Additional rotation time spent in family medicine, community health, adolescent, and STD clinics or emergency departments as well as greater emphasis on screening during these rotations could increase student exposure to STI diagnosis and treatment. STI incidence could be decreased if medical professionals counseled patients on risk avoidance and risk Figure 3. Risk avoidance and risk reduction counseling: attitudes and practices of medical students 1104 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 100, NO. 9, SEPTEMBER 2008

9 reduction strategies. Because physicians are viewed as credible information sources, they are uniquely positioned to promote behavior change to patients. Our M4 focus groups showed that many were reluctant to counsel patients on sexual behaviors for fear of seeming preachy or judgmental. Survey findings also highlighted substantial discrepancies in students attitudes toward and actions in counseling about different aspects of STI prevention. Students were much more likely to endorse risk reduction (e.g., partner reduction or condom use) than risk avoidance (e.g., abstinence or monogamy) strategies. Similarly, they were more likely to counsel on risk reduction than risk avoidance. Students would be better prepared to counsel patients if they were more knowledgeable about the risks associated with various behaviors or intervention strategies. For example, although most evidence suggests that consistent condom use decreases chlamydia risk by about 50%, 29 students in our sample estimated the risk reduction to be about 90%. Physicians do a poor job of reporting notifiable conditions. 9 Very few students were aware of STI reporting requirements in their home states. Although most students listed HIV and syphilis as reportable, only about half mentioned gonorrhea and chlamydia, and only a handful mentioned other important reportable conditions. 30 While the relatively low M4 response rate could limit the generalizability of the data, our sample comprised M4s from 115 schools in 45 states and was demographically similar to the national population. Our decision to interview only 500 of 953 amenable M4s makes the response rate (39.5%) appear artificially low. Although student attributes such as attitudes and biases, interest and personal experiences may have influenced their responses, such considerations were beyond the scope of this study. The location of a student s medical school undoubtedly affects the patient mix they encounter, and influences what they learn about STI screening, diagnosis and treatment. We did not include this factor in our analysis. Information from the students and medical school curriculum offices may be affected by response bias. Curriculum offices who responded to the survey may be better equipped to handle inquiries regarding curricula, more interested in the topic of sexual health, or they may have specific curriculum guidelines in place. Conclusion Our findings suggest that all medical schools should have a formal sexual health curriculum. Students need to be given the opportunity to learn history-taking and physical examination in settings that use real patients or actors. All students must be shown how to perform a male genital examination. History and examination skills must be formally evaluated. The asymptomatic nature of STIs should be stressed, and students must be familiarized with screening guidelines. Sexual health curricula should include information on reportable STIs and reporting requirements. Students should be provided with evidence-based information on STI risk avoidance and risk reduction strategies so that they can effectively counsel patients about behavior change. Schools in areas of low endemicity should make special efforts to provide students with clinical opportunities to care for patients with STIs. From sexual history-taking to STI risk avoidance counseling, medical students appear ill equipped to address the increasing STI incidence and prevalence in the United States. If we are to reverse the STI epidemic, a knowledgeable, confident and motivated physician workforce is needed. Better education of medical students is an important first step toward this goal. Acknowledgements The authors conceived and designed the study collaboratively. SM was responsible for data analysis and initial drafting of the manuscript. AK, KH and JM contributed to the data analysis and critical revisions of the manuscript. SM had full access to all the data in the study and takes responsibility for the integrity and accuracy of the data analysis. The authors wish to thank the medical students and curriculum directors who participated in the study. We would also like to thank Population Research Systems Inc. for collecting M4 survey data using computerassisted telephone interviews. We also thank the CurrMIT branch of AAMC for providing us with selected information on the sexual health-related curricula in U.S. medical schools. Finally, we wish to thank Drs. Patricia Thickstun and Harold Thiele for their assistance with the preparation of this manuscript. References 1. Weinstock H, Berman S, Cates W Jr. Sexually transmitted diseases among American youth: incidence and prevalence estimates, Perspect Sex Reprod Health. 2004;36: Chesson HW, Blandford JM, Gift TL, et al. The estimated direct medical cost of sexually transmitted diseases among American youth, Perspect Sex Reprod Health. 2004;36: Koutsky L. Epidemiology of genital human papillomavirus infection. Am J Med. 1997;102(5A): Hook EW, III, Handsfield HH. Gonococcal infections in the adult. In: Holmes KK, Sparling PF, Mardh P, et al, eds. Sexually Transmitted Diseases. 3rd ed. New York: McGraw-Hill; 1999: Centers for Disease Control and Prevention. Chlamydia Fact Sheet. Atlanta, GA: Accessed 01/16/ Ambroziak J, Levy JA. Epidemiology, natural history, and pathogenesis of HIV infection. In: Holmes KK, Sparling PF, Mardh P, et al. Sexually Transmitted Diseases. 3rd ed. New York: McGraw-Hill; 1999: Westrom L, Eschenbach D. Pelvic inflammatory disease. In: Holmes KK, Sparling PF, Mardh P, et al, eds. Sexually Transmitted Diseases. 3rd ed. New York: McGraw-Hill; 1999: St Lawrence JS, Kuo W, Hogben M, et al. STD care: Variations in clinical care associated with provider sex, patient sex, patients self-reported symptoms or high-risk behaviors, partner STD history. Soc Sci Med. 2004;59(5): JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 100, NO. 9, SEPTEMBER

10 9. St. Lawrence JS, Montano DE, Kasprzyk D, et al. STD screening, testing, case reporting, and clinical and partner notification practices: a national survey of US physicians. Am J Public Health. 2002;92: Torkko KC, Gershman K, Crane LA, et al. Testing for chlamydia and sexual history taking in adolescent females: results from a statewide survey of Colorado primary care providers. Pediatrics. 2000;106(3):E Cook RL, Wiesenfild HC, Ashton MR, et al. Barriers to screening sexually active adolescent women for chlamydia: a survey of primary care physicians. J Adolesc Health. 2001;28(3): Kreuter MW, Chheda SG, Bull FC. How does physician advice influence patient behavior? Evidence for a priming effect. Arch Fam Med. 2000;9(5): Stoneburner RL, Low-Beer D. Population-level HIV declines and behavioral risk avoidance in Uganda. Science Apr 30;304(5671): Cook RL, Steiner BD, Smith AC III, et al. Are medical students ready to provide HIV-prevention counseling? Acad Med. 1998;73(3): Kurth AE, Holmes KK, Hawkins R, et al. A national survey of clinic sexual histories for sexually transmitted infection and HIV screening. Sex Transm Dis. 2005;32(6): Merill JM, Laux LF, Thornby JI. Why doctors have difficulty with sex histories. South Med J. 1990; 83(6): Langille DB, Mann KV, Gailiunas PN. Primary care physicians perceptions of adolescent pregnancy and STD prevention practices in Nova Scotia county. Am J Prev Med. 1997;13(4): AAMC. Hot topics in medical education. Liaison Committee on Medical Education. Part II Annual Medical School Questionnaire for Accessed 01/16/ Kingsberg SA, Malemud CJ, Novak T, et al. A comprehensive approach to enhancing sexual health education in the Case Western Reserve University School of Medicine. Int J Impot Res. 2003;15(3): S51-S Ferrara E, Pugnaire MP, Jonasses JA, et al. Sexual health innovations in undergraduate medical education. Int J Impot Res. 2003;15(3): S46-S Fayers T, Crowley T, Jenkins JM, Cahill DJ. Medical student awareness of sexual health is poor. Int J STD AIDS. 2003;14(6): The Medical Society for the Study of Venereal Diseases. National consensus document on essential topics in genito-urinary medicine that should be included in the undergraduate core curriculum of all medical schools Accessed 01/16/ AAMC. FACTS-Applicants, matriculants and graduates www. aamc.org/data/facts/start.htm. Accessed 01/16/ Merill JM, Laux LF, Thornby JI. Why doctors have difficulty with sex histories. South Med J. 1990; 83(6): Weerakoon P, Jones MK, Pynor R, et al. Allied health professional students perceived level of comfort in clinical situations that have sexual connotations. J of Allied Health. 2004;33(3): Vollmer SA, Wells KB. How comfortable do first year medical students expect to be when taking sexual histories? Med Educ. 1988;22 (5): Hastings AM, McKinley, RK, Fraser RC. Strengths and weaknesses in the consultation skills of senior medical students: identification, enhancement and curricular change. Med Educ. 2006;40(5): Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines MMWR 2006;55 (RR-11): gov/std/treatment/2006/toc.htm. Accessed 01/16/ Holmes. KK, Levine R, Weaver M. Effectiveness of condoms in preventing sexually transmitted infections. Bull World Health Organ. 2004;82(6): Nationally Notifiable Infectious Diseases. Washington, DC: U.S. Dept. of Health and Human Services. Centers for Disease Control and Prevention. Accessed 01/16/08. n 1106 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 100, NO. 9, SEPTEMBER 2008