MICROBIAL DRUG RESISTANCE Volume 16, Number 4, 2010 ª Mary Ann Liebert, Inc. DOI: 10.1089/mdr.2010.0009
A Survey of Knowledge, Attitudes, and Beliefs of Medical Students Concerning Antimicrobial Use and Resistance Mia T. Minen,1 Damon Duquaine,2 Melissa A. Marx,3 and Don Weiss 4
Physicians who are insufficiently prepared to make choices on antibiotic selection may use antibiotics inappropriately. We surveyed medical students’ perceptions and attitudes about their training on antimicrobial use to identify gaps in medical education. Medical students at an urban medical school in the northeast were e-mailed a link to an online survey. The survey was online for 1 week, after which time the survey responses were downloaded and analyzed. Thirty percent of medical students responded to the survey (n ¼ 304). The majority of third- and fourth-year medical students believe that antibiotics are overused in the hospital and in outpatient areas. Over three quarters of the students would like more education on antibiotic selection, and 83% wanted this education to be during the third year of medical school. The resources they used the most for antibiotic selection included other physicians and handheld programs such as Epocrates, but no clear resource emerged as the dominant preference. Medical students recognized the importance of judicious antibiotic use and would like greater instruction on how to choose antibiotics appropriately. Medical school curricula should be expanded in the third year of medical school to provide students with additional training timed with their clinical rotations.
Introduction
A
ntimicrobial resistance continues to challenge healthcare workers in both the treatment of multidrug resistance and preventing the spread of resistant organisms. Unnecessary and inappropriate antibiotic use is widely believed to increase antibiotic resistance, and the Centers for Disease Control and Prevention and infectious disease organizations have called for reducing unnecessary and inappropriate antimicrobial use.6 However, many physicians are not trained in proper antimicrobial prescribing. It is difficult in the setting of busy clinical practice to deliver education on inappropriate antimicrobial use. Further, the urge to use empiric therapy to treat all infectious organism possibilities is sometimes at odds with public health efforts to reduce antimicrobial resistance. A previous study by Srinivasan et al. reported that less than a quarter of house staff physicians felt very confident that they were using antimicrobials optimally outside of the ICU. They also found that 90% of those surveyed wanted more antimicrobial education. On an antimicrobial quiz, upper-level residents performed as poorly as interns.6 A
study by Humphreys et al. also concluded that recent medical graduates’ knowledge of how to treat infections with antibiotics was poor; 25% of them correctly answered how to treat a urinary tract infections, cellulitis, or Neisseria gonorrhoeae.2 Few published studies have investigated medical students’ opinions about their education and knowledge of antibiotic use. A study by Ibia et al. concluded that senior medical students do not choose antibiotics appropriately in various clinical settings.3 The study by Eyal and Cohen reported that 80% of medical students and recent graduates thought that a basic science pharmacology course prepared them well for work in a clinical setting. However, 84% believed that there was inadequate time spent on clinical pharmacology.1 Thus, there appears to be a discord between basic science pharmacology and the emphasis given to antibiotic use in the clinical rotations. We surveyed medical students to examine their knowledge, attitudes, and beliefs concerning antimicrobial use and resistance. Our goals were to determine how prepared medical students felt to prescribe antibiotics and where they acquired knowledge about antimicrobial agents.
1
Department of Neurology, Columbia Presbyterian Medical Center, New York, New York. Antibiotic Resistance Unit, Bureau of Communicable Disease, New York City Department of Health and Mental Hygiene, New York, New York. 3 Global AIDS Program, Centers for Disease Control and Prevention, Lusaka, Zambia. 4 Bureau of Communicable Disease, New York City Department of Health and Mental Hygiene, New York, New York. 2
285
286
Total enrollment ¼ 999; respondents ¼ 304 (34%) What type of specialty are you considering or pursuing? Surgery Primary care Other Undecided Do you anticipate that strong knowledge of antibiotics will be important to you in your medical career? Please indicate how often you use the sources below to inform you about appropriate antimicrobial treatment: Infectious disease attendings and fellows Noninfectious disease attendings and fellows Other house staff physicians Education from pharmaceutical representative Sanford guide Other pocket guide Palm or other handheld application Internet Medical journals The medical letter Webcasts Audio podcasts Textbooks
Year of medical school
Question
Most of the time 47 84 74 74 36 11 73 65 19 8 3 3 40
17 7 12 12 7 6 36 19 2 3 0 0 16
No 12 (4%)
75 (25%)
2nd
All of the time
51 (17%) 68 (22%) 29 (10%) 156 (51%) Yes 292 (96%)
71 (23%) N (%)
1st
115 97 107 107 58 39 47 99 96 46 12 10 106
Some of the time
86 (28%)
3rd
118 106 102 102 190 235 140 111 176 236 276 278 130
None of the time
72 (24%)
4th
Table 1. Medical Student Responses to a Survey of Knowledge, Attitudes, and Beliefs Concerning Antibiotic Use and Resistance
287
Includes all respondents.
Please tell us how strongly you agree or disagree with the following statements on antibiotics: Antibiotics are overused in general in inpatient medicine Antibiotics are overused in general in outpatient medicine Antibiotics are overused at hospitals I have worked in Hospitals in general face serious problems with antibiotic-resistant organisms I get useful feedback on my antibiotic selections I would like more feedback on my antibiotic selections I would like more ongoing education on antibiotics When should the education be entered into the curriculum? (multiple responses accepted) Please rank the following challenges to healthcare in the United States in order of importance: Uninsured Americans Medical errors and long-term drug side effects Antibiotic resistance Malpractice litigation and the cost of insurance Low reimbursement from HMOs, Medicaid, and Medicare Which organism do you feel presents the greatest resistance challenge to drug treatment? (200 students replied, multiple choices possible) 81 121 50 96 126 2nd
27 148 12 31 70 1st
139
Staphylococcus aureus
171 18 11 59 38
26
Enterococcus faecalis
41 44 61 84 71
146 Somewhat important
151
89
50 Most important
101
Somewhat agree
43
Strong agree
11
Mycobacterium tuberculosis
36 57 81 55 62
221 Neutral
91 3rd
182 155
28
157
43
110
Neutral
7
Pseudomonas aeruginosa
21 69 91 45 50
148 Somewhat unimportant
10 4th
41 8
3
28
16
44
Somewhat disagree
5
Clostridium difficile
19 88 48 35 76
6 Least important
1 Not needed
8 2
1
3
3
4
Strong disagree
288
MINEN ET AL.
Methods
Medical student beliefs about antibiotic resistance
Setting and survey instrument
Nearly all medical students (99%, 269/273) agreed that hospitals face serious problems with antibiotic resistance, while fewer (36%, 108/296) reported that antibiotics are overused in hospitals that they have worked in. Of the five challenges to U.S. Healthcare presented, antibiotic resistance received the fewest ‘‘most important’’ votes (Table 1).
A link to a 35-question, anonymous, self-administered Web survey was sent via e-mail to all medical students (N ¼ 999) at an urban medical school in the northeast United States. The instrument was modified from one developed by Srinivasan et al. and included questions about demographics, medical school year and specialty being considered.6 Students were asked about antimicrobial use, including whether they thought a strong knowledge of antibiotics would be important to them in their medical career. The survey asked about which resources (e.g., physicians, Internet, and pocket guides) medical students utilize to determine appropriate antimicrobial treatment and included questions on how often they receive feedback on their antibiotic selections and their perceptions about antibiotic use in the hospital. We also asked students which organism they believed posed the greatest challenge to drug treatment. Responses were single answer, multiple response, scaled (both 4- and 5-level scales were used), or free text. Survey distribution The study received exemption from the medical school’s International Review Board (IRB) committee. The survey was available online for a period of 7 days. After the initial e-mail was sent asking students to complete the survey, two e-mail reminders were also sent, on days 3 and 5. Students were not given any compensation for completing the survey. Statistical methods The results from the online survey were downloaded and analyzed using SPSS 13.0 (SPSS, Inc. Chicago, IL). Scaled items were analyzed both as multilevel responses and collapsed into dichotomous variables as follows: all of the time and most of the time; some of the time and none of the time; strong agreement and agreement; neutral, disagree, and strong disagreement. Analyses of questions on antibiotic prescribing practices were restricted to third- and fourth-year students, as the questions referred to clinical experiences. Chi-square was used to compare proportions and statistical significance was set at p < 0.05. Results Demographics Of the 999 medical students e-mailed, 30% (N ¼ 304) completed the entire survey, including 146 first- and secondyear medical students (response rate 28%) and 158 third- and fourth-year medical students (response rate 33%). The medical students who completed the survey were representative of the medical school student body with respect to age and sex (44.1% were male compared with 50% of the student body and the mean age of respondents and the medical school student body was 25.6 years). Of the third- and fourth-year medical students, 43.0% reported that they expected to pursue a career in primary care (internal medicine, pediatrics, and family medicine), 32.3% reported that they expected to pursue a career in a surgical area, 18.4% reported that they expected to pursue a career in another area of medicine such as psychiatry, neurology, and radiology, and 6.3% were undecided (Table 1).
Senior medical student attitudes toward resistance and antimicrobial use in clinical settings Over half (53%) of the third- and fourth-year medical students reported agreeing that antibiotics are overused in inpatient medicine and 84% agreed that antibiotics are overused in outpatient medicine (Table 1). Nearly all students (92%) reported agreeing with the statement, ‘‘Hospitals face serious problems with antibiotic resistant organisms,’’ but only 53% reported agreeing with the statement, ‘‘Antibiotics are overused in the hospitals I’ve worked in.’’ Compared to students pursuing surgical specialties, students going into primary care specialties were 2.1 times more likely (95% CI ¼ 1.0, 4.4) to respond that antibiotics are overused in hospitals in which they have worked. Antimicrobial education Ninety-three percent of third- and fourth-year students anticipate that strong knowledge of antibiotics will be important to them in their medical careers, while 63% indicated that they did not receive useful feedback on their antibiotic selections. Students pursuing surgical residencies were 2.1 times more likely (95% CI ¼ 1.0, 4.5) to feel that they did not get useful feedback on their antibiotic selections compared to their classmates in primary care, other, and undecided specialties. Seventy-one percent of students reported that they would like more feedback on antibiotic selection, and responses did not vary across specialties. Seventy-eight percent of third- and fourth-year students agreed with the statement, ‘‘I would like more ongoing education about antibiotics,’’ while students interested in primary care specialties were 2.7 times more likely (95% CI ¼ 1.2, 6.0) to agree than all others. Ten percent of respondents indicated that additional education should occur in the first year, 39% during the second year, 83% in the third-year clinical rotations, and 61% in the fourth year as preparation for the internship course (multiple responses were allowed). When asked how often they used specific types of resources to inform them about antibiotic choices, third- and fourth-year students reported using physicians (infectious disease trained and noninfectious disease trained) and handheld devices, ‘‘most,’’ or ‘‘all of the time.’’ No third- or fourth-year student reported using information from pharmaceutical representatives, pocket guides (other than the Sanford Guide), the Medical Letter, Webcasts, or audio mp3s. When asked which electronic programs they used for obtaining antimicrobial information, respondents most frequently cited the following personal digital assistant and Internet applications (N ¼ 126): Epocrates (n ¼ 55), UpToDate (n ¼ 32), Micromedex (n ¼ 24), and the John Hopkins Antibiotics Guide (n ¼ 16). Additional resources students found useful included Grand Rounds, noontime conferences, and lectures.
MEDICAL STUDENT EDUCATION ON ANTIBIOTIC USE Seventy percent of the medical student respondents named Staphylococcus aureus as the organism presenting the greatest resistance challenge to drug treatment. The other most frequently cited organisms included Enterococcus faecalis, Mycobacterium tuberculosis, Pseudomonas aeruginosa, and Clostridium difficile. Discussion Medical students who participated in the survey believe that hospitals face serious problems with antibiotic-resistant organisms, specifically S. aureus, and that antibiotics are overused. Students also responded that they believe that there is more antibiotic overuse in the outpatient setting than in the inpatient setting. Placed in the context of other problems facing the U.S. Healthcare System, antibiotic resistance was not viewed as more important than insurance coverage, reimbursement, or the cost of malpractice insurance. Nearly two-thirds of students in their clinical rotation years reported a desire for greater feedback on their antimicrobial selections, and 78% would like additional education. Srinivasan et al. found that upper-level residents did not perform better than interns on an antimicrobial quiz.6 This suggests that instruction about appropriate and judicious antibiotic selection should occur before residency, the time when newly graduated physicians assume responsibility for patient care decisions. The final 2 years of medical school therefore may be the optimal time to focus education on appropriate use of antimicrobials, and a concerted effort to include feedback is warranted. One project on sensible prescribing practices developed a guide to assist students and residents with antibiotic prescribing decisions, which may be a useful addition to medical school curricula.5 We asked students which resources they used to obtain continuing education regarding antimicrobials. While students rely heavily upon more senior colleagues and handheld devices to obtain information about antibiotic usage, no clear resource emerged as the most useful. Further, previous studies have found that physicians, including infectious disease physicians, do not always prescribe antimicrobials judiciously, suggesting the need for continuing education and feedback, such as ‘‘report cards’’ on antimicrobial prescribing practices throughout a physician’s career.4 This study has several limitations. The response rate among third- and fourth-year medical students was 30%, in part because of the timing of the survey. While the survey was conducted at a time when both classes had experienced inpatient and outpatient settings, some third-year students were occupied with time-intensive rotations and many of the fourth-year students had already completed their course requirements and were away on elective. Due to the low response rate, we cannot exclude the possibility that those who were more motivated to respond may have experiences and opinions that differ from the rest of student body. The survey was conducted at a single medical school where the secondyear medical school curriculum included a pharmacology course and an infectious disease course that included antimicrobial treatment selection. We cannot easily generalize these findings to all institutes of medical education, partic-
289 ularly those outside the United States. However, our findings are consistent with the published literature and support the conclusion that the core elements of antimicrobial prescribing practices deserve greater attention. Our survey indicates that there is a perceived need by medical students for both education and feedback on antimicrobial prescribing. It seems prudent to incorporate additional antimicrobial education into the medical school curriculum during the third- and fourth-year clinical rotations. Additional data are needed to determine the optimal format of the education and content to provide future practitioners with the information needed to use antibiotics judiciously. Acknowledgment The authors wish to acknowledge Dr. Arjun Srinivasan for his assistance with questionnaire design. Disclosure Statement The authors report no financial or other conflicts of interest. References 1. Eyal, L., and R. Cohen. 2006. Preparation for clinical practice: a survey of medical students’ and graduates perceptions of the effectiveness of their medical school curriculum. Med. Teacher 28:162–170. 2. Humphreys, H., T. Dillane, B. O’Connell, and L.C. Luke. 2006. Survey of recent medical graduates’ knowledge and understanding of the treatment and prevention of infection. Ir. Med. J. 99:58–59. 3. Ibia, E., M. Sheridan, and R. Schwartz. 2005. Knowledge of the principles of judicious antibiotic use for upper respiratory infections: a survey of senior medical students. South. Med. J. 98:888–894. 4. Metlay, J.P., J.A. Shea, L.B. Crossette, and D.A. Asch. 2002. Tensions in antibiotic prescribing: pitting social concerns against the interests of individual patients. J. Gen. Intern. Med. 17:87–94. 5. Paterson Davenport, L.A., P.G. Davey, and J.S. Ker. 2005. An outcome-based approach for teaching prudent antimicrobial prescribing to undergraduate medical students: report of a Working Party of the British Society for Antimicrobial Chemotherapy. J. Antimicrob. Chemother. 56:196–203. 6. Srinivasan, A., X. Song, A. Richards, R. SinkowitzCochran, D. Cardo, and C. Rand. 2004. A survey of knowledge, attitudes, and beliefs of house staff physicians from various specialties concerning antimicrobial use and resistance. Arch. Intern. Med. 164:1451–1456.
Address correspondence to: Don Weiss, M.D., M.P.H. Bureau of Communicable Disease New York City Department of Health and Mental Hygiene 125 Worth St., Box 22a New York, NY 10013 E-mail:
[email protected] 