Study examines residency's influence in doctors' decisions to use smoking cessation methods

07/08/04



Dr. Katherine E. Hartmann
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CHAPEL HILL -- Primary-care doctors who use smoking cessation methods while training as residents are twice as likely to continue doing so in their medical practice more than eight years later, new research at the University of North Carolina at Chapel Hill shows. The study, which appears in the July issue of Preventive Medicine, is believed to be the first to take a long-term look at the influence of residency education - specifically, preventive-care skills - on the behavior of physicians.

"Our study shows that training through exposure alone, albeit exposure to very robust smoking cessation intervention methods and materials, is almost worthless unless you managed to put it into play when you were a resident," said study principal author Dr. Katherine E. Hartmann, assistant professor of obstetrics and gynecology as well as epidemiology in UNC's schools of medicine and public health.

"It's important we do more than just provide deluxe teaching and put charts, prompts and other materials into the learning environment. There must be serious expectations that residents use this training and are supervised while doing it during their residency."

U.S. residency education is based on the belief that it influences long-term practice, Hartmann said. But until now, follow-up studies assessing the influence of specialized components of residency education, such as smoking cessation intervention training, have been short-term, measured in weeks or months.

Hartmann, also a member of the UNC Lineberger Comprehensive Cancer Center, said she is not aware of other publications on any topic in behavioral intervention training, including smoking cessation intervention, that have extended the follow-up of former residents "into the timeframe in which they have an established and mature practice style."

Study results were based on 291 doctors' responses to a three-page, 20-question written survey. All had been in residency training between 1986 and 1996 and are now primary-care practitioners in internal medicine, family medicine, obstetrics and gynecology, or pediatrics. The national group studied had been in practice an average of 8.5 years at the time of follow-up.

Half of these doctors had received smoking cessation intervention training and half had not. Such training included formal, uniform instruction from teachers trained in the National Cancer Institute's "Train the Trainer" workshops, the gold standard for smoking cessation intervention training, Hartmann said.

The primary study outcome was based on responses to an item that gave study participants a list of 16 possible smoking cessation interventions, including "best" or ideal practices such as identifying smokers, advising cessation, assisting with a plan and arranging for follow-up.

Overall, 42 percent of respondents were using best practices. But prior training alone was not associated with current use of best practices. Moreover, those who reported use of best practices in residency were twice as likely to currently use them, even after more than eight years and in a wide range of clinical practice settings, Hartmann said.

"Our findings are compatible with educational theory: Imparting knowledge alone is not as powerful as knowledge coupled with experience," she said.

"To change future practice patterns, we will need to give resident physicians training, tools, time and guidance to become comfortable and experienced in conducting smoking cessation intervention.

"While 23 percent of adults in the U.S. population are smokers, there is ample reason to continue to assure that the next generation of physicians is optimally equipped to take on the challenge of promoting cessation."

Doctors perform a central role in reducing unhealthy behaviors including smoking, said Dr. Barbara K. Rimer, Alumni distinguished professor in the department of health behavior and health education at UNC's School of Public Health and deputy director of population sciences at UNC Lineberger.

"This important study reconfirms what we've long suspected: It takes more than classroom training to make sure a doctor will give the best help to smokers," she said. "It takes supervised experience with patients and always having the right resources on hand, and that is something that medical schools, public health officials and health-care administrators can do something about."

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