Lisa Elon

Changes in U.S. Medical Students’ Specialty Interests over the Course of Medical School

Studies have examined factors affecting medical students’ specialty choice, but little research exists on stability of these specialty interests. To describe patterns of change in specialty interests during medical school and examine associations between specialty change patterns and gender, desire for a high-prestige career, and interest in prevention. Medical students (Class of 2003) at 15 representative US schools were invited to complete surveys during freshman orientation, entry to wards, and senior year. This analysis used data from 942 students who completed all 3 surveys. In addition to a number of other items, students were asked to choose the 1 specialty they were most interested in pursuing. The most common specialty choices among freshman students were pediatrics (20%) and surgery (18%); least common choices were psychiatry and preventive medicine (1% each). General internal medicine was the initial specialty choice for 8%. Most students changed their specialty choices, regardless of initial interest. Only 30% of those initially interested in primary care (PC) remained interested at all 3 time points, compared to 68% of those initially interested in non-PC. Female versus male students were more commonly interested in PC at all 3 time points. Senior students interested in non-PC specialties were more likely to desire a high-prestige career (48%) than those interested in PC (31%). Medical students may benefit from more intensive introduction to some specialties earlier in pre-medical and medical education. In addition, increasing the prestige of PC fields may shape the physician workforce.BackgroundStudies have examined factors affecting medical students’ specialty choice, but little research exists on stability of these specialty interests.ObjectiveTo describe patterns of change in specialty interests during medical school and examine associations between specialty change patterns and gender, desire for a high-prestige career, and interest in prevention.DesignMedical students (Class of 2003) at 15 representative US schools were invited to complete surveys during freshman orientation, entry to wards, and senior year.ParticipantsThis analysis used data from 942 students who completed all 3 surveys.MeasurementsIn addition to a number of other items, students were asked to choose the 1 specialty they were most interested in pursuing.ResultsThe most common specialty choices among freshman students were pediatrics (20%) and surgery (18%); least common choices were psychiatry and preventive medicine (1% each). General internal medicine was the initial specialty choice for 8%. Most students changed their specialty choices, regardless of initial interest. Only 30% of those initially interested in primary care (PC) remained interested at all 3 time points, compared to 68% of those initially interested in non-PC. Female versus male students were more commonly interested in PC at all 3 time points. Senior students interested in non-PC specialties were more likely to desire a high-prestige career (48%) than those interested in PC (31%).ConclusionsMedical students may benefit from more intensive introduction to some specialties earlier in pre-medical and medical education. In addition, increasing the prestige of PC fields may shape the physician workforce.

Alcohol consumption and alcohol counselling behaviour among US medical students: cohort study

Objective To determine which factors affect alcohol counselling practices among medical students. Design Cohort study. Setting Nationally representative medical schools (n=16) in the United States. Participants Medical students who graduated in 2003. Interventions Questionnaires were completed (response rate 83%) at the start of students’ first year (n=1846/2080), entrance to wards (typically during the third year of training) (n=1630/1982), and their final (fourth) year (n=1469/1901). Main outcome measures Previously validated questions on alcohol consumption and counselling. Results 78% (3777/4847) of medical students reported drinking in the past month, and a third (1668/ 4847) drank excessively; these proportions changed little over time. The proportion of those who believed alcohol counselling was highly relevant to care of patients was higher at entrance to wards (61%; 919/1516) than in final year students (46%; 606/1329). Although students intending to enter primary care were more likely to believe alcohol counselling was highly relevant, only 28% of final year students (391/1393) reported usually or always talking to their general medical patients about their alcohol consumption. Excessive drinkers were somewhat less likely than others to counsel patients or to think it relevant to do so. In multivariate models, extensive training in alcohol counselling doubled the frequency of reporting that alcohol counselling would be clinically relevant (odds ratio 2.3, 95% confidence interval 1.6 to 3.3) and of reporting doing counselling (2.2, 1.5 to 3.3). Conclusions Excessive drinking and binge drinking among US medical students is common, though somewhat less prevalent than among comparably aged adults in the US general population. Few students usually discussed alcohol use with patients, but greater training and confidence about alcohol counselling predicted both practising and believing in the relevance of alcohol counselling. Medical schools should consider routinely training students to screen and counsel patients for alcohol misuse and consider discouraging excessive drinking.

Health effects of long-term mercury exposure among chloralkali plant workers

BACKGROUND Inorganic mercury is toxic to the nervous system, kidneys, and reproductive system. We studied the health effects of mercury exposure among former employees of a chloralkali plant that operated from 1955 to 1994 in Georgia. METHODS Former plant workers and unexposed workers from nearby employers were studied. Exposure was assessed with a job-exposure matrix based on historical measurements and personnel records. Health outcomes were assessed with interviews, physical examinations, neurological and neurobehavioral testing, renal function testing, and urinary porphyrin measurements. Exposure-disease associations were assessed with multivariate modeling. RESULTS Exposed workers reported more symptoms, and tended toward more physical examination abnormalities, than unexposed workers. Exposed workers performed worse than unexposed subjects on some quantitative tests of vibration sense, motor speed and coordination, and tremor, and on one test of cognitive function. Few findings remained significant when exposure was modeled as a continuous variable. Neither renal function nor porphyrin excretion was associated with mercury exposure. CONCLUSIONS Mercury-exposed chloralkali plant workers reported more symptoms than unexposed controls, but no strong associations were demonstrated with neurological or renal function or with porphyrin excretion.

Alcoholism Causes Alveolar Macrophage Zinc Deficiency and Immune Dysfunction

RATIONALE Alcohol use disorders cause oxidative stress in the lower airways and increase susceptibility to pneumonia and lung injury. Currently, no therapeutic options exist to mitigate the pulmonary consequences of alcoholism. OBJECTIVES We recently determined in an animal model that alcohol ingestion impairs pulmonary zinc metabolism and causes alveolar macrophage immune dysfunction. The objective of this research is to determine the effects of alcoholism on zinc bioavailability and alveolar macrophage function in human subjects. METHODS We recruited otherwise healthy alcoholics (n = 17) and matched control subjects (n = 17) who underwent bronchoscopy for isolation of alveolar macrophages, which were analyzed for intracellular zinc, phagocytic function, and surface expression of granulocyte-macrophage colony-stimulating factor receptor; all three of these indices are decreased in experimental models. MEASUREMENTS AND MAIN RESULTS Alcoholic subjects had normal serum zinc, but significantly decreased alveolar macrophage intracellular zinc levels (adjusted means [SE], 718 [41] vs. 948 [25] RFU/cell; P < 0.0001); bacterial phagocytosis (adjusted means [SE], 1,027 [48] vs. 1,509 [76] RFU/cell; P < 0.0001); and expression of granulocyte-macrophage colony-stimulating factor receptor β subunit (adjusted means [SE], 1,471 [42] vs. 2,114 [35] RFU/cell; P < 0.0001]. Treating alveolar macrophages with zinc acetate and glutathione in vitro increased intracellular zinc levels and improved their phagocytic function. CONCLUSIONS These novel clinical findings provide evidence that alcohol abuse is associated with significant zinc deficiency and immune dysfunction within the alveolar space and suggest that dietary supplementation with zinc and glutathione precursors could enhance airway innate immunity and decrease the risk for pneumonia or lung injury in these vulnerable individuals.

Methodologic Concerns in Defining Lesbian for Health Research

A recent report from the Institute of Medicine recommends more methodologic and substantive research on the health of lesbians. This study addresses one methodologic topic identified in the Institute of Medicine report and by a subsequent scientific workshop on lesbian health: the definition and assessment of sexual orientation among women. Data are from the Women Physicians’ Health Study, a questionnaire-based U.S. probability sample survey (N = 4,501). The two items on sexual orientation (current self-identity and current sexual behavior) had a high response rate (96%), and cross-tabulation of responses indicated several combinations of identity and behavior. Three conceptually different definitions of “lesbian” are compared on the basis of (1) identity only, (2) sexual behavior only, and (3) both identity and sexual behavior. Suggestions and cautions are given to researchers who will add items on sexual orientation to new or ongoing research on women’s health.

Successful Enrollment in Text4Baby More Likely With Higher Health Literacy

Adequate health literacy is vital for understanding and using health information. The authors assessed the health literacy of pregnant women and mothers of children under the age of 1 year and their success in self-enrolling in the Text4Baby health message program: 468 pregnant women and mothers of children under the age of 1 year completed an in-person baseline survey, including the Newest Vital Sign health literacy assessment, at 2 Metro-Atlanta Women, Infants, and Children clinics. They were asked to self-enroll in the Text4Baby message program and were later contacted by phone to see whether they had attempted to enroll in the program and whether they were successful. Of the 333 women contacted by phone to assess enrollment efforts, 21% had a high likelihood of limited literacy (a score of 0–1 on the Newest Vital Sign assessment), 48% had a chance of limited literacy (a score of 2–3), and 31% had adequate literacy (a score of 4–6). Attempting to self-enroll was not associated with health literacy (p = .70), but successful enrollment was more likely with higher literacy (p = .01). Results suggested a positive association between health literacy skills and successful self-enrollment in the Text4Baby program, which suggests the need for additional outreach efforts to assure enrollment by women with low health literacy skills.

Sex-Related Knowledge, Attitudes, and Behaviors of U.S. Medical Students

OBJECTIVE: To understand the personal and clinical safe-sex–related knowledge, attitudes, and practices of U.S. medical students. METHODS: Sixteen medical schools were selected to survey the class of 2003 based on their characteristics similar to the national average. Students were surveyed at freshman orientation, at entrance to wards, and during their senior year. The primary personal outcome was the response to the question, “Are you currently trying to practice safe sex when sexually involved? (no, not applicable/no, not trying/yes, low priority/yes, high priority).” The primary professional outcomes were answers to: 1) “How relevant do you think talking to patients about safe sex will be in your intended practice? (not at all/somewhat/highly),” and 2) “With a typical general medicine patient, how often do you actually talk about safe sex? (never-rarely/sometimes/usually-always).” RESULTS: A total of 2,316 students provided data, and the response rate was 80%. Personally practicing safe-sex habits was a high priority for 75% of the sexually active, single medical students, especially for women, African Americans, and those earlier in their medical education. Among seniors, 41% reported extensive training in discussing safe sex with patients, and 57% were highly confident about conducting such discussions. Overall, 55% of students believed it would be highly relevant to counsel patients about safe sex (59% of freshmen, 62% of those at entry to wards, and 41% of seniors); 73% answered all four true/false questions on human papillomavirus correctly. CONCLUSION: About half of U.S. medical students believed that counseling their patients about safe sex will not be highly relevant to their practice. These findings should be considered by those trying to interest a new generation of physicians in helping patients have safe-sex practices. LEVEL OF EVIDENCE: III

A Randomized Prospective Trial of a Worksite Intervention Program to Increase Physical Activity

Purpose. To evaluate the effectiveness of addressing multiple barriers to physical activity (PA) using interventions at the workplace. Design. The Physical Activity and Lifestyle Study used a randomized controlled trial in which 60 university departments were randomized into five groups. Setting. Large Southeastern university. Subjects. Physically inactive nonfaculty employees in the participating departments (n = 410) were interviewed five times over 9 months, with 82% completing all surveys. Intervention. Departments were randomly assigned to (1) control, (2) gym membership, (3) gym + PA education, (4) gym + time during the workday, and (5) gym + education + time. Measures. PA intensity and quantity were measured using the 7-day Physical Activity Recall instrument, with PA then classified as the number of days meeting Centers for Disease Control and Prevention guidelines. Analysis. The outcome was modeled with generalized linear mixed model methodology. Results. There was no significant improvement when a group received gym alone compared to the control (Rate Ratio [RR]) 1.22 [.90, 1.67]). However, gym + education, gym + time, and gym + education + time were significantly better than the control (RR 1.51 [1.15, 1.98], RR 1.46 [1.13, 1.88], RR 1.28 [1.01, 1.62]), with improvements sustained over the 9 months. Conclusion. Among sedentary adults who had access to indoor exercise facilities, addressing environmental and cognitive barriers simultaneously (i.e., time and education) did not encourage more activity than addressing either barrier alone.

Bone density in haemophilia: a single institutional cross-sectional study.

Haemophilia has been associated with low bone mineral density (BMD). However, prior clinical studies of this population have neither clearly elucidated risk factors for development of low BMD nor identified who may warrant screening for osteoporosis. The aim of the study was to evaluate the relationship between BMD and haemophilic arthropathy and other demographic and clinical variables. We undertook a cross‐sectional study of BMD in adult men with haemophilia. Measures of predictor variables were collected by radiographic studies, physical examination, patient questionnaires and review of medical records. Among 88 enrolled subjects, the median age was 41 years (IQR: 20); median femoral neck BMD (n = 87) was 0.90 g cm−2 (IQR: 0.24); and median radiographic joint score was 7.5 (IQR: 18). Among subjects <50 years (n = 62), after controlling for BMI, alcohol, HIV and White race, BMD decreased as radiographic joint score increased (est. β = −0.006 mg cm−2; 95% CI −0.009, −0.003; partial R2 = 0.23). Among subjects ≥50 years (n = 26), 38% had osteoporosis (T score less than or equal to −2.5) and there was no association between BMD and arthropathy. Risk factors for low BMD in men with haemophilia <50 years include haemophilic arthropathy, low or normal BMI and HIV. Men with haemophilia over age 50 years should have routine screening for detection of osteoporosis.

Measuring social contacts in the emergency department.

Background Infectious individuals in an emergency department (ED) bring substantial risks of cross infection. Data about the complex social and spatial structure of interpersonal contacts in the ED will aid construction of biologically plausible transmission risk models that can guide cross infection control. Methods and Findings We sought to determine the number and duration of contacts among patients and staff in a large, busy ED. This prospective study was conducted between 1 July 2009 and 30 June 2010. Two 12-hour shifts per week were randomly selected for study. The study was conducted in the ED of an urban hospital. There were 81 shifts in the planned random sample of 104 (78%) with usable contact data, during which there were 9183 patient encounters. Of these, 6062 (66%) were approached to participate, of which 4732 (78%) agreed. Over the course of the year, 88 staff members participated (84%). A radiofrequency identification (RFID) system was installed and the ED divided into 89 distinct zones structured so copresence of two individuals in any zone implied a very high probability of contact <1 meter apart in space. During study observation periods, patients and staff were given RFID tags to wear. Contact events were recorded. These were further broken down with respect to the nature of the contacts, i.e., patient with patient, patient with staff, and staff with staff. 293,171 contact events were recorded, with a median of 22 contact events and 9 contacts with distinct individuals per participant per shift. Staff-staff interactions were more numerous and longer than patient-patient or patient-staff interactions. Conclusions We used RFID to quantify contacts between patients and staff in a busy ED. These results are useful for studies of the spread of infections. By understanding contact patterns most important in potential transmission, more effective prevention strategies may be implemented.