MAJOR ARTICLE
Medical Students’ Perceptions and Knowledge About Antimicrobial Stewardship: How Are We Educating Our Future Prescribers? Lilian M. Abbo,1 Sara E. Cosgrove,2 Paul S. Pottinger,3 Margaret Pereyra,4 Ronda Sinkowitz-Cochran,5 Arjun Srinivasan,5 David J. Webb,6 and Thomas M. Hooton1 1
Downloaded from http://cid.oxfordjournals.org/ by guest on October 27, 2015
Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Florida; 2Division of Infectious Diseases, Department of Medicine, Johns Hopkins University, Baltimore, Maryland; 3Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle; 4Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, New York; 5 Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia; and 6Queen's Medical Research Institute, University of Edinburgh, United Kingdom
Background. Better understanding of medical students’ perceptions, attitudes, and knowledge about antimicrobial prescribing practices could facilitate more effective education of these future prescribers. Methods. A 24-item electronic survey on antimicrobial prescribing and education was administered to fourthyear medical students at the University of Miami, the Johns Hopkins University, and the University of Washington ( January–March 2012). Results. Three hundred seventeen of 519 (61%) students completed the survey; 92% of respondents agreed that strong knowledge of antimicrobials is important in their careers, and 90% said that they would like more education on appropriate use of antimicrobials. Mean correct knowledge score (11 items) was 51%, with statistically significant differences between study sites and sources of information used to learn about antimicrobials. Only 15% had completed a clinical infectious diseases rotation during medical school; those who had done so rated the quality of their antimicrobial education significantly higher compared to those who had not (mean, 3.93 vs 3.44, on a 5-point scale; P = .0003). There were no statistically significant associations between knowledge scores and having had an infectious diseases clinical elective. Only one-third of respondents perceived their preparedness to be adequate in some fundamental principles of antimicrobial use. Conclusions. Differences exist between medical schools in educational resources used, perceived preparedness, and knowledge about antimicrobial use. Variability in formative education could frame behaviors and prescribing practices in future patient care. To help address the growing problem of antimicrobial resistance, efforts should be undertaken to ensure that our future doctors are well educated in the principles and practices of appropriate use of antibiotics and antimicrobial stewardship. Keywords.
antimicrobial stewardship; education; medical students.
Antimicrobial-resistant organisms are spreading worldwide, and the pipeline for new antimicrobials remains meager. The next generation of doctors must be better
Received 28 March 2013; accepted 14 May 2013; electronically published 31 May 2013. Correspondence: Lilian Abbo, MD, Division of Infectious Diseases, University of Miami Miller School of Medicine, 1120 NW 14th St, Ste 851, Miami, FL 33136 (
[email protected]). Clinical Infectious Diseases 2013;57(5):631–8 © The Author 2013. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail:
[email protected]. DOI: 10.1093/cid/cit370
prepared to use antimicrobials more sparingly and appropriately. According to the World Health Organization, education of healthcare workers and medical students on rational antimicrobial prescribing or “antimicrobial stewardship” is an integral part of all antimicrobial resistance containment activities [1, 2]. The inclusion of education about appropriate use of antimicrobials in medical school curricula and continuing education on new developments in the field of antimicrobial therapy have been achieved to varying extents in different countries [3–6]. However, in the United States, there are few data on the content and effectiveness of
Medical Students and Antimicrobial Stewardship
•
CID 2013:57 (1 September)
•
631
among a total of 10 medical students at the 3 medical schools for readability, length, and relevance of specific items. Institutional review boards approved the study at all 3 participating institutions. Participation was voluntary and responses were anonymous. The survey was available online for a period of 6 weeks between January and March 2012. No attempts were made to alter course material or teaching methods before or during the survey. As an incentive, each student received a $10 iTunes electronic gift card upon completion of the questionnaire. Information collected included age, sex, medical specialty that the student was considering, previous research experience with antimicrobials prior to medical school, attitudes and perceptions about antimicrobials, awareness of the problem of antimicrobial-resistant diseases, sources of antimicrobial education, and self-confidence in antimicrobial prescribing. Knowledge was assessed using 11 clinical vignettes that had been pilot tested for content validity. Students reported their perceptions about the quality of their education regarding appropriate use of antimicrobials and their preparedness to prescribe antimicrobials upon graduation. Prior to analyses, sites were de-identified and recoded as “A,” “B,” and “C.” Answers to questions that used a 5-point Likert scale were condensed into 3 categories (agree/strongly agree, neutral, and disagree/strongly disagree). Nonparametric tests were used to assess differences between groups and correlations between variables. Specifically, the Kruskal-Wallis test was used to test for differences in means, χ2 tests, or McNemar test (in the case of comparing opinions) for differences in proportions, and Spearman rank correlations for correlations between ordinal-level variables. Not all respondents answered each question, and thus numbers were adjusted as appropriate for each item. An overall knowledge score was assessed by calculating the total percentage of correct answers for the 11 vignette-based questions. Analyses were performed using SAS, version 9.2.
METHODS
Three hundred seventeen (61%) of the 519 fourth-year medical students who were emailed the survey invitation completed the survey. Response rates by institution were 65% for A, 61% for B, and 57% for C. Overall, 57% of respondents were female and the mean age was 27 years (SD, 2.65); 48% reported that they expected to pursue a career in either internal medicine, family medicine, or pediatrics, 27% a surgical specialty, 20% another field (eg, emergency medicine, ophthalmology, dermatology, pathology, obstetrics and gynecology, physical medicine and rehabilitation, or psychiatry), and 5% other areas of interest or undecided. Only 26 (8%) respondents had research experience or pharmacology education regarding antimicrobials prior to entering medical school. All 3 medical schools in this study were affiliated with at least 1 hospital with established antimicrobial stewardship programs,
We conducted a cross-sectional multicenter electronic survey evaluating fourth-year medical students’ perceptions, attitudes, and knowledge about antimicrobial use and resistance, and the quantity and perceived quality of education about antimicrobials in 3 US medical schools: the University of Miami Miller School of Medicine, the Johns Hopkins University School of Medicine, and the University of Washington School of Medicine. The University of Miami served as the coordinating site. A multidisciplinary team of investigators including 5 infectious diseases physicians, 3 medical students, a behavioral scientist, a pharmacologist, and a statistician developed a 24-item electronic survey instrument. The questionnaire was pilot tested
632
•
CID 2013:57 (1 September)
•
Abbo et al
RESULTS
Downloaded from http://cid.oxfordjournals.org/ by guest on October 27, 2015
the education of medical students regarding appropriate antimicrobial prescribing and antimicrobial resistance. In spite of the severe consequences and global spread of antimicrobial resistance, effective dissemination of information to healthcare professionals about adverse outcomes associated with antimicrobial misuse remains challenging [7]. Although it is recognized that skill is required to optimally prescribe antimicrobials, the prescribing decision is often left to junior staff who may or may not receive instruction from their seniors, and who themselves may not have the expertise to optimally prescribe antimicrobials [7]. Often, only patients with complicated or severe infections are referred to infectious diseases consultants. Unlike many other drugs whose use is generally limited to well-trained specialists (eg, antipsychotics or chemotherapeutic agents), antimicrobials are prescribed by virtually all doctors and allied healthcare practitioners, regardless of training or knowledge, across a wide spectrum of practice [8–10]. To address the development of antimicrobial resistance and to support prescribers in their efforts to treat patients effectively, antimicrobial stewardship programs have been developed worldwide [11–16]. Thus far, most antimicrobial stewardship efforts in the United States have sought to understand and modify perceptions and behaviors of healthcare practitioners during residency training or thereafter [8–10, 17–22]. Less attention has been given to future doctors during medical school [23]. To date, there have been no multicenter studies evaluating US medical students’ perceptions, attitudes, and knowledge about antimicrobial use and resistance. Likewise, there are no data on whether medical students believe they receive adequate education on appropriate antimicrobial use, or the degree to which they feel prepared to prescribe these medications appropriately. This study aims to identify gaps in knowledge and to understand medical students’ perceptions in order to implement appropriate remedies in medical school curricula that will subsequently affect behavioral change and lead to more appropriate use of antimicrobials.
Table 1. Medical Students’ Perceptions and Attitudes About Antimicrobial Prescribing and Resistance—Percentage Who Agree/ Strongly Agree With Each Statement School A
B
C
n = 311
n = 120
n = 66
n = 125
P Valuea
Inappropriate use of antimicrobials can harm patients
97%
95%
100%
98%
.148b
Inappropriate use of antimicrobials causes antimicrobial resistance Prescribing broad-spectrum antimicrobials when equally effective narrower spectrum antimicrobials are available increases antimicrobial resistance Better use of antimicrobials will reduce problems with antimicrobial-resistant organisms
97%
94%
100%
98%
.071b
95%
94%
100%
93%
.092
94%
93%
99%
94%
.23
Antimicrobials are overused nationally Strong knowledge of antimicrobials is important in my medical career
94% 92%
91% 88%
99% 94%
94% 94%
.109 .175
I would like more education on the appropriate use of antimicrobials Poor infection control practices by healthcare professionals cause spread of antimicrobial resistance
90%
92%
89%
88%
.637
83%
85%
82%
82%
.749
I would like more education on antimicrobial resistance Appropriate use of antimicrobials can cause antimicrobial resistance
79% 70%
80% 63%
77% 64%
78% 79%
.902 .012
Antimicrobials are overused at the hospitals where I have rotated New antimicrobials will be developed in the future that will keep up with the problem of “resistance”
65%
70%
62%
62%
.334
20%
22%
15%
21%
.541
Antimicrobial resistance is not a significant problem at the hospitals where I have rotated
3%
4%
2%
2%
.623b
Antimicrobial resistance is not a significant problem nationally
2%
3%
0%
2%
.271b
Perceptions and Attitudes
a
χ2test.
b
Fisher exact test.
although not all the affiliated hospitals where students who participated in this study had rotated had such a program. We found that 115 of 288 (40%) respondents were familiar with the term “antimicrobial stewardship” with significant differences between medical schools (43% A, 51% B, 80% C; P < .001).
Perceptions and Attitudes About Antimicrobial Use and Antimicrobial Education
Respondents’ perceptions about antimicrobial prescribing and antimicrobial resistance by medical school are summarized in Table 1. More than 90% of respondents agreed that knowledge of antimicrobials is important in their careers and that inappropriate use of antimicrobials causes antimicrobial resistance and can harm patients. A higher proportion agreed that antimicrobials are overused nationally (94%) compared with hospitals where they had rotated (65%; P < .001). Respondents reported they would like more education on appropriate use of antimicrobials (90%) and on antimicrobial resistance (79%).
Ninety-eight percent of respondents perceived that medical schools should spend more time teaching students about the appropriate use of antimicrobials: 152 (51%) would like that education to occur during the third year and 72 (24%) during all 4 years. One hundred seventy-seven (58%) students rated their education regarding appropriate use of antimicrobials as useful, with statistically significant differences between the 3 schools (42% A, 67% B, 70% C; P < .001). Regarding curricula, of 305 respondents, 219 (72%) recalled having lecture(s) about the rational use of antimicrobials, 150 (49%) about when to start antimicrobials, 86 (28%) about how to select the right duration of treatment for specific infections, and 57 (19%) about how to select the correct doses of antimicrobials. Forty-six of 305 (15%) respondents had completed a clinical infectious diseases rotation during medical school (14% A, 9% B, 19% C). Students who had rotated on a clinical infectious diseases service were more likely to rate their antimicrobial education as useful or very useful (83%) compared with those who had not completed such a rotation (54%) (P = .0002).
Medical Students and Antimicrobial Stewardship
•
CID 2013:57 (1 September)
•
633
Downloaded from http://cid.oxfordjournals.org/ by guest on October 27, 2015
All
Table 2. Medical Students’ Perceptions About Antimicrobial Stewardship Education and Preparedness—Percentage Who Feel Their Medical Education Has Been Good/Very Good School
Perceptions
All
A
B
C
n = 300
n = 113
n = 64
n = 123
P Valuea
Find reliable sources of information to treat infections
63%
78%
60%
58%
.016
Basic mechanisms of antimicrobial resistance Handle patients demanding unnecessary antibioticsb
61% 54%
72% 59%
58% 54%
58% 50%
.132 .486
When to start antimicrobial therapy
54%
43%
67%
58%
.004
Select the best antimicrobial for a specific infection Spectrum of therapy for different antibiotics
39% 34%
56% 53%
36% 34%
32% 22%
.004
