Review Board of the University of Pittsburgh approved ... A 54-year-old woman with no previous history of coronary artery disease presents to your practice.
Experiential Learning Influences Residents Knowledge About Hormone Replacement Therapy Rachel Hess Division of General Internal Medicine University of Pittsburgh and Center for Health Equity Research and Promotion VA Pittsburgh Health Care System Pittsburgh, Pennsylvania, USA
Chung Chou Joyce Chang Division of General Internal Medicine University of Pittsburgh Pittsburgh, Pennsylvania, USA
Joseph Conigliaro Division of General Internal Medicine University of Pittsburgh and Center for Health Equity Research and Promotion VA Pittsburgh Health Care System Pittsburgh, Pennsylvania, USA
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D. Michael Elnicki
Division of General Internal Medicine University of Pittsburgh Pittsburgh, Pennsylvania, USA
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Melissa McNeil
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Division of General Internal Medicine University of Pittsburgh Pittsburgh, Pennsylvania, USA
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Background: Knowledge concerning hormone replacement therapy (HRT) is rapidly changing. Purpose: We sought to understand the factors that influence how residents assimilate this knowledge. Methods: We conducted an anonymous survey of residents in an internal medicine residency. Questions included personal demographic information and aspects of training (didactic and experiential) regarding and knowledge about HRT. Data were analyzed using univariable and multivariable linear regression. Results: Sixty-nine of 92 residents (75%) completed the survey. The gender and race of respondents did not differ significantly from the overall group. Knowledge scores were higher among residents in nontraditional (Women’s Health, Primary Care, and Internal Medicine–Pediatrics) training tracks (p = .04) and among residents with patient population of ≥ 30% postmenopausal women (p = .049). Demographic characteristics and didactic training about HRT did not influence knowledge. Conclusions: Nontraditional residency track and higher proportion of postmenopausal women in a practice (experiential learning) improve knowledge about HRT. Didactic training has no effect. Teaching and Learning in Medicine, 16(3), 240–246
Copyright © 2004 by Lawrence Erlbaum Associates, Inc.
Correspondence may be sent to Rachel Hess, M.D., 230 McKee Place, Suite 600, Pittsburgh, PA 15213, USA. E-mail: hessr@umpc.edu
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Educating residents about rapidly changing areas of knowledge is challenging. Because the use of hormone replacement therapy (HRT) in postmenopausal women has become increasingly controversial in recent years, teaching residents about menopause management presents a daunting task for faculty in residency training programs. Over the last 5 years, the indications for the use of HRT have dramatically changed. Before 1998, several studies found a cardio-protective benefit with HRT. Among large cohorts of postmenopausal women observed for up to 20 years, HRT demonstrated a 40–60% reduction in cardiovascular mortality1,2 Additional randomized controlled trials indicated that HRT had a beneficial effect on lipid profiles.3,4 Together these results provided a basis for the belief that estrogen, alone or in combination with progesterone, was helpful to postmenopausal women who were at risk for, or had, ischemic heart disease. In addition, randomized studies showed that HRT had beneficial effects on bone density and markers of bone turnover.5 These findings, along with the cardio-protective findings, led to the practice of offering HRT to the majority of postmenopausal women. Nonetheless, there were risks and concerns to be considered, including an increase in the incidence of breast cancer, endometrial cancer in women with an intact uterus, and thromboembolic complications.3,6–8 Subsequently, in 1998, the Heart Estrogen/progestin Replacement Study called into question the use of HRT for the secondary prevention of cardiac disease.9 Additionally, a reanalysis of data from the Nurses’ Health Study, also questioned the benefits of HRT in women with preexisting cardiac disease.10 Thus, guidelines for menopause management have undergone scrutiny and change. Research concerning the education of physicians has indicated that different training experiences have an impact on physicians’ feelings of preparedness in dealing with common outpatient problems, including problems related to alcohol and tobacco use.11 To our knowledge, however, research has not focused on feelings of preparedness concerning issues and problems related to the topic of menopause management. Therefore, to determine whether residents’ understanding of this topic and preparedness to offer menopause guidance are affected by potentially modifiable factors, we conducted a survey of resident physicians at a large urban medical center. We hypothesized that increased contact with postmenopausal female patients and increased exposure to didactic teaching about HRT would improve residents’ knowledge scores about menopause management. We further hypothesized that residents with higher knowledge scores would feel better prepared to counsel women regarding the use of HRT. We designed and implemented our survey prior to the release of the Women’s Health Initiative.6
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Methods Participants Between February and April 2002, we invited each of the 92 University of Pittsburgh Medical Center (UPMC) 2nd-, 3rd-, and 4th-year internal medicine residents to participate in our study. The Institutional Review Board of the University of Pittsburgh approved our study. Because of its anonymous nature, the survey was exempt from informed consent. We approached residents either in person prior to outpatient clinics or sent them a survey via the UPMC internal mail system. We provided them with written information about the study, as well as a copy of the survey instrument to complete either during the clinic session or within one week of receipt by mail. There was no monetary incentive for completion of the survey and the respondents remained anonymous. We asked them to return the completed survey either at the site of administration or at a designated office location. Study Site
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UPMC has two internal medicine residency programs, one based at a university teaching program affiliated with a large urban medical center and a Veteran’s Administration hospital and the other at a smaller community hospital. Residents in both programs spend time at all hospitals. Within these two programs, the University of Pittsburgh offers various residency training tracks, some of which are nontraditional (e.g., women’s health, primary care, and a combined medicine-pediatrics track) and some of which are traditional (i.e., categorical). There are categorical and primary care residents at both the University and Community hospitals, whereas women’s health residents are located at the University hospital and medicine-pediatrics residents are at the Community hospital. Residents in the women’s health and primary care tracts spend extra time in the outpatient setting and participate in specific educational programs on topics such as contraception and menopause management.
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Study Instrument The survey contained three domains: (a) questions eliciting demographic data, including characteristics of the resident and his or her chosen residency track; (b) questions concerning the types of didactic training that the resident received about menopause management, such as lectures, workshops, clinic rotations, self-directed study, and detailing by pharmaceutical representatives; and (c) questions allowing for the assessment of the resident’s knowledge about menopause management and HRT (Table 1). Before writing the knowledge-assessment portion of the survey, we reviewed the current literature (as of 241
Table 1. Knowledge-Based Questions Alternative therapies have been used to treat menopausal symptoms in women who cannot or choose not to take HRT. Which of the following classes of antihypertensive agents has been used in the treatment of vasomotor symptoms associated with menopause? • • • •
Calcium channel blockers Angiotensin converting enzyme inhibitors Beta-blockers Alpha-blockers
Women on hormone replacement therapy have an increased risk of thromboembolic disease including deep venous thrombosis and pulmonary embolism. • True • False A 54-year-old woman with no previous history of coronary artery disease presents to your practice. She has not had a period for about 9 months and is having hot flashes and vaginal dryness. She had been toughing it out but a friend who was on HRT suggested she might want to consider it. She has a family history remarkable for a father who died at the age of 55 from an MI and a mother who was recently hospitalized with a hip fracture. She has no personal history of CAD or diabetes mellitus. She smokes about a half a pack of cigarettes per day and exercises regularly. Assuming she has no other relevant history and a normal baseline ECG, what would you choose to do? • Discuss the risks and benefits of HRT. If she is agreeable, you feel she is a good candidate and would initiate therapy. • Discuss the risks and benefits of HRT. If she agrees and she has a normal exercise treadmill test, you feel she is a good candidate and would initiate therapy. • Discuss the risks and benefits of HRT. Because of her family history of early CAD, you do not feel she is an appropriate candidate for HRT and would offer her other options for the management of her menopausal symptoms. • Discuss the risks and benefits of HRT. Because of her current smoking, you do not feel she is an appropriate candidate for HRT and would offer her other options for the management of her menopausal symptoms. HRT has been shown to improve the lipid profile in postmenopausal women who take it. Which of the following is most correct? • • • •
HRT results in a decrease in serum triglyceride levels. HRT both increases serum HDL and decreases serum LDL levels. HRT decreases serum LDL levels. HRT raises serum HDL levels.
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Symptoms of menopause, which may be improved by using HRT, include all of the following except: • • • •
Hot flashes Vaginal dryness Insomnia Breast tenderness
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In women who smoke, HRT leads to a greater improvement in bone mineral density compared with placebo, than in women who do not smoke. • True • False
Women in the following groups have an absolute contraindication to the use of HRT (please choose one): • • • • •
Factor V leiden positive Hypertriglyceridemia Chronic liver disease Migraines Seizure disorder
Hormone replacement therapy has been shown to increase the incidence of breast cancer in women: • • • •
With any duration of use. After 5 years of use. After 10 years of use. Not at all. There is no increase in breast cancer incidence compared with age-matched controls.
In 1998, the Heart and Estrogen/progesterone Study (HERS) was published and challenged our thinking about the role of hormone replacement therapy. A summary of the overall results is best stated as: • Over the length of the study, women with a history of coronary artery disease had an increased risk of cardiac death if they received HRT during the study. • All women, with or without preexisting cardiac disease, had an increased risk of cardiac death if they received HRT over the length of the study. • Women who received HRT during the HERS trial had a decrease in cardiac events over the length of the study. • Over the length of the study, there was no difference in the number of cardiac events in women who received HRT compared with those who received placebo. Note. HRT = hormone replacement therapy; MI = myocardial infarction; CAD = coronoary artery disease; ECG = electrocardiogram; HDL = high density lipoprotein; LDL = low density lipoprotein.
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December 2001) on HRT use, HRT benefits, HRT risks, contraindications to HRT use, and alternatives to HRT use.1–3,5,7,9,10,12–19 Each of our questions was based on one or more of these topics and required a single best answer. Questions followed a true–false or multiple-choice format. Multiple choice questions included questions around a clinical vignette. Members of the Section on Women’s Health (a section of the Division of General Internal Medicine in the Department of Medicine) at the University of Pittsburgh reviewed the questions for content and clarity. Additional faculty with expertise in survey design gave us suggestions concerning question structure and layout. Statistical Analysis
attended additional didactic training (see Table 2), only 26% of residents reported feeling adequately prepared to counsel women regarding menopause management and HRT. The mean knowledge score of residents was 47 ± 16% SD. As knowledge increased, residents tended to feel more prepared to counsel patients about the use of HRT (p = .058). Residents in a traditional residency track cared for fewer postmenopausal women than did residents in nontraditional residency tracks. Indeed, only 30% of residents in traditional tracks reported that their patient population consisted of 30% or more postmenopausal women. In contrast, 75% of residents in the combined medicine–pediatrics track, 67% in the women’s health track, and 33% in the primary care track reported that
We used descriptive statistics to examine the data concerning demographics and didactic training about menopause management. To calculate knowledge scores, we divided the number of correctly answered questions by the total number of answered questions for a percent correct score. Knowledge scores were normally distributed. A score of greater than 50% was considered “knowledgeable.” To examine the relationship of knowledge scores to demographic characteristics, training characteristics, and didactic training, we used univariable and multivariable linear regressions. For cases in which we found a univariable significance of .25 or less, we included the variable in the multivariable model. We constructed the final multivariable model using both backward and forward stepwise linear regression. For covariates, we included gender, time since medical school graduation, and postgraduate year in training. A result was considered significant if the associated p-value was ≤ 0.05. The analysis was conducted using STATA, version 7.0 (STATA Corp., College Station, Texas).
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Table 2. Characteristics and Responses of the Surveyed Residents (N = 69) Category
Results Sixty-nine of the 92 eligible residents (75%) completed the survey. Respondents did not differ significantly from nonrespondents with respect to gender and race (62% men and 42% White residents in the respondent group; 58% men and 39% White residents in the larger group; p = .55 and p = .71 for differences in gender and race, respectively). As expected by the composition of the UPMC residency programs, more of the surveyed residents were in traditional than nontraditional residency tracks (79% vs. 21%), and more were in university than community hospitals (59% vs. 41%; Table 2). Because of the survey’s anonymous nature, we were unable to calculate difference in response rate based on site of administration (clinic vs. mail). Although nearly all residents had attended at least one lecture on menopause management and many had
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Gender Male Female Race White Black Hispanic Asian/Pacific Islander Other Postgraduate year in training Second Third Fourth Type of residency track* Traditional Nontraditional Location of training University hospital Community hospital Time spent in clinic ≤ 1 half-day per week > 1 half-day per week Patient population* Postmenopausal women < 30% Postmenopausal women ≥ 30% Future plans Subspecialty Primary care Type of didactic training about menopause Management and hormone replacement therapy (HRT) Lecture (one or series) Half-day workshop or seminar Clinic rotation in women’s health, obstetrics/gynecology, or endocrinology Self-directed study Detailing by pharmaceutical representatives Preparedness to counsel women about HRT Feel adequately prepared Feel inadequately prepared
Responses 43 (62%) 26 (38%) 29 (42%) 3 ( 4%) 3 ( 4%) 28 (41%) 6 ( 9%) 35 (51%) 31 (45%) 3 ( 4%) 54 (79%) 14 (21%) 41 (59%) 28 (41%) 43 (62%) 26 (38%) 45 (65%) 33 (35%) 44 (65%) 24 (35%)
68 (99%) 15 (22%) 52 (75%) 49 (71%) 20 (29%) 18 (26%) 51 (74%)
*n = 68, question left blank
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their patient population consisted of 30% or more postmenopausal women. When we used univariable linear regressions to examine factors that could influence the HRT-related knowledge of residents (Table 3), we found a statistically significant association between a resident’s knowledge score and the percentage of postmenopausal women that the resident reported seeing in the patient population (score of 44% for those seeing < 30% postmenopausal women vs. score of 54% for those seeing ≥ 30% postmenopausal women; p = .02). We also found that residents in nontraditional tracks trended toward higher knowledge scores (54% for nontraditional vs. 45% for traditional; p = .08). Subgroup analysis of individual tracks (traditional or nontraditional) shows that knowledge tends to be improved in each track among residents with a patient population consisting of more than 30% postmenopausal women. Given the observational nature of the study, however, cause and effect cannot be definitively stated. We found no statistically significant association between the knowledge score and the training location or between the knowledge score and the type of didactic training about menopause management and HRT.
Table 3. Univariable Association of Knowledge Scores with Resident Training Variables
Category (n) Patient population Postmenopausal women < 30% (35) Postmenopausal women ≤ 30% (33) Type of residency track Traditional (54) Nontraditional (14) Location of training University hospital (41) Community hospital (28) Type of didactic training about menopause management and hormone replacement therapy (HRT) Lecture (one or series) Yes (68) No (1) Half-day workshop or seminar Yes (15) No (54) Clinic rotation in women’s health, obstetrics/gynecology, or endocrinology Yes(53) No(16) Self-directed study Yes (49) No (20) Detailing by pharmaceutical representatives Yes (20) No (49)
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Knowledge Score (M ± SD) 44% ± 15% 54% ± 16%
P Value
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45% ± 15% 54% ± 19%
.08
47% ± 16% 46% ± 18%
.80
47% ± 16% 29%
.27
43% ± 15% 48% ± 17%
.33
48% ± 17% 43% ± 13%
.26
47% ± 17% 46% ± 16%
.75
51% ± 16% 45% ± 16%
.14
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.02
Using multivariable analysis, we found that both the percentage of postmenopausal women seen by the resident and the type of residency track were significant factors in predicting knowledge (p = .049 and p = .04, respectively, for these factors; overall R2 = .14). After we controlled for the resident’s gender, time since medical school graduation, and postgraduate year in training, we found that the percentage of postmenopausal women seen by residents trended toward significance whereas the type of residency track remained significant (p = .13 and p = .01, respectively). There was no significant interaction between the percentage of postmenopausal patients seen and the residency track (p = .61). We controlled not only for time since medical school graduation but also for postgraduate year because approximately 40% of the residents were international graduates who did not begin their residency in the United States immediately after their graduation. The multivariable model explained approximately 25% of the variance in knowledge scores (R2 = .25). There was no significant relationship between feeling prepared to counsel patients about menopause management and either the percentage of postmenopausal patients seen or the type of residency track (p = .21 and p = .44, respectively) separate from knowledge.
Discussion
Our study shows that fewer than one-half of residents are knowledgeable (have greater than 50% correct on a knowledge assessment) about the rapidly changing field of HRT and menopause management and that fewer than one third of residents feel adequately prepared to counsel women about it. We found mixed results with regards to our primary hypotheses, that residents with more didactic and experiential learning would have higher knowledge scores about menopause management. Residents in nontraditional residency training tracks (women’s health, primary care, and a combined medicine–pediatrics track) have higher knowledge scores about menopause management than residents in traditional tracks. Moreover, the knowledge scores of residents are significantly improved by increased contact with postmenopausal women. In contrast, neither training location (community vs. university hospital) nor extensive didactic training about menopause management significantly affects knowledge scores. Our secondary hypothesis was born out. As knowledge about menopause management increases, residents tend to feel more prepared to counsel women about the use of HRT. These findings suggest two points concerning the residency tracks worth examining further to improve resident knowledge and preparedness about meno-
EXPERIENTIAL LEARNING INFLUENCES KNOWLEDGE ABOUT HRT
pause management. First, we should examine whether the factors accounting for the differences associated with nontraditional and traditional residency tracks are modifiable. These differences may be attributable to the characteristics of residents who choose to enter traditional tracks (i.e., characteristics of a self-selected group). Alternatively, the differences may be attributable to differences in the design or implementation of HRT and menopause management education within tracks, in which case providing the same educational experience to all tracks could improve knowledge and preparedness in the entire group of residents. Second, we should take measures to increase the percentage of postmenopausal women seen by residents. The Accreditation Council for Graduate Medical Education states that residents in internal medicine training programs “should receive instruction and clinical experience in the prevention counseling, detection, and diagnosis and treatment of gender-specific diseases of women and men” (p. 14).20 Moreover, it states, “There must be patients of both sexes, with a broad range, including geriatric patients (Note: The resident’s panel of patients must included at least 25% of patients of each gender)” (p. 3).20 At our institution, about 50% of residents have their continuity experience at a Veterans Affairs (VA) hospital where the number of female patients is small. Beginning with the intern class entering in 2001, our institution initiated a program to increase the exposure of VA residents to a larger population of female patients. Residents in this program spend one clinic session per month with a mentor in the Division of General Internal Medicine Faculty Practice. During this session, the resident sees primarily female patients and discusses, as they arise, issues of gender-specific medicine. We will explore whether this type of exposure is equivalent to a continuity panel with adequate numbers of female patients. Our study has several limitations. First, it was conducted in a single training program with a core group of physicians dedicated to women’s health. This may have increased knowledge across the groups and our study may underestimate knowledge differences and/or overestimate overall knowledge. We plan to replicate the study over multiple institutions. Second, it utilizes a new instrument. Although content validity was assessed by the Section of Women’s Health at the University of Pittsburgh, the knowledge-based questions had not been previously utilized. It is observational and cross-sectional in design, which does not allow us to determine cause and effect. For example, residents who see more postmenopausal women may be gaining increased knowledge from the encounters or, alternatively, their increased knowledge may be attracting more postmenopausal women to their practices. Finally, it does not provide longitudinal follow-up of how knowledge evolves over the years of training or how training influences future practice pat-
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terns. Further research is needed to determine whether our findings are robust in other topical areas and in other resident populations. Nevertheless, our study provides insight into how residents learn and develop a body of knowledge. Experiential learning in the form of exposure to a diverse patient population with the resident as primary manager appears to have an impact above and beyond that of common types of sporadic didactic instruction (e.g., single lectures, half-day workshops, and detailing by pharmaceutical representatives) and beyond that of the traditional month-long rotation focusing on a particular topic. Ensuring adequate exposure to women’s health issues, specifically menopause management and HRT, during residency programs is critical to building knowledge that translates into a greater feeling of preparedness to discuss these issues effectively with patients.
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Received 28 May 2003 Final revision received 6 of January 2004
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