- Email: [email protected]
Medical student intrauterine device knowledge and attitudes: an assessment of clerkship training
Contraception 88 (2013) 257 – 262
Original research article
Medical student intrauterine device knowledge and attitudes: an assessment of clerkship training☆,☆☆ Deborah Bartz a, b,⁎, Jennifer Tang a, b, 1 , Rie Maurer b, c , Elizabeth Janiak a a
Department of Obstetrics, Gynecology, and Reproductive Biology, Brigham and Women's Hospital, Boston, MA 02115, USA b Harvard Medical School, Boston, MA 02115, USA c Center for Clinical Investigation, Brigham and Women's Hospital, Boston, MA 02115, USA Received 9 July 2012; revised 23 October 2012; accepted 26 October 2012
Abstract Background: Studies demonstrate that many clinician populations have poor knowledge of and harbor negative attitudes towards intrauterine devices (IUDs). We set out to assess the impact of the clinical clerkship in obstetrics and gynecology on medical student IUD knowledge and attitudes. Study Design: In this prospective cohort study, students at seven diverse US medical schools were surveyed at the start and completion of their obstetrics and gynecology clinical clerkships regarding IUD exposure, knowledge and attitudes. Subject responses were compared preand postclerkship. Results: One hundred six students returned completed paired surveys (response rate 82%). The preclerkship mean knowledge percent correct (54%, SD 17%) increased significantly at postclerkship assessment (72%, SD 18%) (pb.0001). The mean attitudes score also increased significantly from pre- (34%, SD 31%) to postclerkship (59%, SD 26%) (pb.0001). Conclusions: US medical student IUD knowledge and attitudes are significantly improved through the obstetrics and gynecology clerkship. However, significant gaps in knowledge persist postclerkship. © 2013 Elsevier Inc. All rights reserved. Keywords: Intrauterine device; Medical students; Educational assessment
1. Introduction The unintended pregnancy rate in the United States is higher than other developed countries [1,2], with 49% of the 6.3 million annual pregnancies being unintended [3]. With a failure rate of less than 1% [4], the intrauterine device (IUD)
☆
Presentation information: These findings were presented as a poster presentation at the Association of Reproductive Health Professionals 2010 Annual Meeting in September 2010. ☆☆ Disclosure: Full financial support for this study was provided through the American College of Obstetricians and Gynecologists/Bayer HealthCare Pharmaceuticals Research Award in Contraceptive Counseling. ⁎ Corresponding author. Department of Obstetrics, Gynecology, and Reproductive Biology, Brigham and Women's Hospital, OBC-3, Boston, MA 02120. Tel.: + 1 617 525 7744; fax: + 1 617 525 7746. E-mail address: [email protected] (D. Bartz). 1 At the time of submission, Jennifer Tang's affiliation has changed to the Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC 27599, USA. 0010-7824/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.contraception.2012.10.028
is highly effective at preventing unintended pregnancies. However, IUD utilization rates in the United States remain low, having reached their nadir in the mid-1990s subsequent to adverse events associated with IUD technology since removed from clinical practice. In 1995, only 0.8% of US women of reproductive age were using an IUD, a proportion which increased to 2.0% in 2002 and to 5.5% in 2006–2008 [5,6]. The IUD's potential to reduce unintended pregnancy has prompted the American College of Obstetricians and Gynecologists and other reproductive health experts to champion expanded use of these methods [2,7–11] and inspired the development of guidelines for medical student learning objectives related to their mechanism of action, risks and benefits [12]. However, there are several reasons to suspect accurate IUD knowledge is not being promulgated to medical students. In a recent survey of 68 US medical school preclinical reproductive health curricula, only 76% covered the topic of IUDs in their contraception lecture [13]. An
258
D. Bartz et al. / Contraception 88 (2013) 257–262
examination of textbooks commonly used by medical students on women's health rotations found the information about the safety of IUDs inaccurate and outdated [14]. Surveys of practicing health care providers, many of whom work in academic medical facilities, frequently endorse exaggerated safety concerns and outdated perceptions about appropriate patient candidates for IUDs [15–23]. These findings suggest that medical students are at risk for learning misinformation about the IUD, which may encourage IUD underutilization in future practice. In this prospective cohort study, we used pre- and postrotation survey measures of IUD knowledge and attitudes as a proxy measure of whether students at seven diverse US medical schools learn scientifically accurate information regarding failure and continuation rates, mechanism of action and contraindications of use of the IUD during their obstetrics and gynecology clerkship.
2. Materials and methods We followed a cohort of third-year medical students starting their clinical clerkship in obstetrics and gynecology at seven US medical schools sampled on geographic and curricular diversity, as follows: (a) Northeast: Harvard Medical School, Boston; (b) South: Duke University Medical School, Durham, and Baylor College of Medicine, Houston; (c) Midwest: Indiana University School of Medicine, Indianapolis, and Loyola University–Stritch School of Medicine, Chicago; (d) West: University of New Mexico School of Medicine, Albuquerque, and University of Washington School of Medicine, Seattle. Schools were also selected for diversity on factors that may impact curricular inclusion of contraception. Among the schools sampled, two had Ryan Residency Training Programs in Abortion and Family Planning at their affiliated hospitals, one is a Catholic institution affiliated with a Catholic hospital, and the remaining four were neither Ryan nor Catholic institutions. Institutional Review Board protocol approval was granted by all seven medical schools prior to recruitment. All students starting their obstetrics and gynecology clinical clerkship for the first time at participating institutions in the spring of 2009 (n= 129) were eligible and asked to participate. Participants completed identical pre- and postclerkship paper surveys, which were paired by an anonymous identifier created by subjects and never linked to identifying information. A single obstetrics and gynecology faculty or staff member from each of the seven institutions assisted in subject recruitment and survey implementation. At all schools except the University of Washington, students were approached as a group during their didactic time during the first week of the clerkship and given the preclerkship survey and accompanying cover letter by the on-site faculty member. Due to the dispersed locations of third-year University of Washington students who rotate through hospitals throughout Alaska and the Pacific Northwest, the
study materials and instructions for that institution were mailed with other clerkship paperwork before the start of the rotation. Study participation was anonymous and voluntary, and consent was implied when students read the cover letter and completed the survey. The postclerkship survey was administered in a similar fashion during the last week of the clerkship. The survey instrument included 39 items representing the following: (a) demographic questions; (b) intended future medical specialization; (c) recall questions about prior IUD training and experience, including an assessment of the medical school basic science lectures; (d) items to capture a self-assessment of knowledge and comfort performing comprehensive IUD counseling; (e) 10 equally weighted questions to assess IUD knowledge, including failure and continuation rates, mechanism of action and contraindications for use; and (f) 14 equally weighted clinical vignettes to assess attitudes toward IUD use in a variety of patient populations. The knowledge and attitude questions were used or modified with author permission from survey questions previously published in the literature to assess IUD knowledge and attitudes in provider populations [17,19]. The clinical vignettes represented management of a wide range of contraceptive counseling scenarios encountered frequently in obstetrics and gynecology and primary care. All patient scenarios presented in the clinical vignettes lacked contraindication to IUD use. Response choices for the vignettes were “recommend routinely,” “recommend only if other methods are unacceptable,” “never recommend” or “not sure.” “Recommend routinely” was considered a correct response to the clinical vignette items. Each survey was designed to take approximately 10–15 min to complete. Analysis was restricted to participants who completed pre- and postclerkship surveys that could be accurately paired. Descriptive analyses were performed on the demographic data and previous IUD exposure data to look for trends in responses. Fisher's Exact Tests and χ 2 were used to compare demographic data between the survey responders and nonresponders. The paired t test was used to assess the difference in the IUD knowledge score and IUD attitudes score as a mean percent correct from before to after the obstetrics and gynecology clerkship. The McNemar test was used to assess marginal homogeneity of the correct responses before and after the clerkship. Student's t test, Wilcoxon rank sum and analysis of variance were performed on items relating to prior and clerkship IUD exposure to assess their impact on IUD knowledge and attitudes over the course of the clerkship. All statistical tests were performed with SAS statistical software, release 9.2 (SAS Institute, Inc., Cary, NC, USA).
3. Results Of the 129 students beginning their obstetrics and gynecology clerkships at the time of the survey, 123
D. Bartz et al. / Contraception 88 (2013) 257–262
completed some of the study procedures for a total response rate of 96%, with high rates of participation (89%–100%) at all schools. One-hundred six subjects returned two completed surveys that could be accurately paired for an 82% final completed response rate. The age and gender distribution of this final cohort was not different from those who submitted incomplete data. Sample demographics and preclerkship IUD training and exposure are detailed in Table 1. Among the 106 subjects included in the analysis, the majority were 22–25 years old (62%), with a small majority (53%) being male. Six subjects (6%) reported an interest in specializing in obstetrics and gynecology, and 49 subjects (46%) reported interest in an adult and/or pediatric primary care specialty that may include contraceptive care as part of the practice. Seventy-four percent of subjects reported that IUD information was taught in the basic sciences portion of their medical school curriculum, most frequently (67%) by obstetrics and gynecology faculty. Forty-two percent of subjects had Table 1 Participant characteristics and IUD exposure prior to the obstetrics and gynecology clerkship (N=106) n (%) Age, years 22–25 26–29 30–34 35–39 Gender Male Female Future specialty plans a Obstetrics and gynecology Adult and/or pediatric primary care specialty Other Undecided Prior IUD exposure a Prior to medical school Medical school My own physician Job/volunteer work Reading/investigation apart from school curriculum Other Gained IUD exposure in preclinical medical school classes Yes No Departments of IUD teaching faculty Obstetrics and gynecology faculty Other faculty Gained IUD exposure in other clinical rotations b Yes No Clinical rotations with prior IUD exposure a Internal medicine Pediatrics Family medicine Radiology a
66 (62) 27 (26) 10 (9) 3 (3) 56 (53) 50 (47) 6 (6) 49 (46) 47 (44) 11 (10) 33 (31) 88 (83) 12 (11) 4 (4) 27 (25) 13 (12) 78 (74) 28 (26) 71 (67) 35 (33) 44 (42) 60 (57) 7 (7) 5 (5) 37 (35) 1 (1)
Respondents could mark more than one answer. b Two respondents did not report on IUD exposure in other clinical rotations.
259
learned about the IUD in prior medical school clerkships, primarily through family medicine (35%). As displayed in Table 2, 21% of subjects reported seeing an IUD placement prior to their obstetrics and gynecology clerkship, and another 44% gained this experience during the rotation. Of those students who had observed any IUD placements, most reported having observed one to four procedures, both before and after the clerkship. Prior to the obstetrics and gynecology rotation, 7% of subjects felt they had sufficient knowledge to counsel patients about the Copper T380A IUD, while 9% felt they could counsel about the levonorgestrel IUD. These proportions increased to 69% and 76%, respectively, following the rotation. Respondents scored 54% (SD ± 17%) mean percent correct on the 10 IUD knowledge items prior to the rotation and 72% (SD ± 17%) at the end of the rotation, a significant improvement in mean knowledge score (18%, SD ± 20%, pb.0001). As displayed in Fig. 1, the greatest proportion of subjects responded correctly both pre- and postclerkship to questions that pertain to IUD mechanism of action and failure rate. Students scored the lowest both pre- and postclerkship on questions about IUD discontinuation rates, IUD use for emergency contraception and return to fertility following IUD discontinuation. The mean percent correct for the 14 IUD attitude clinical vignettes was 34% (SD ± 31%) at the start of the rotation and 59% (SD ± 26%) at the rotation's conclusion, representing a significant improvement in overall IUD attitude scores (25%, SD ± 34%, pb.0001). As displayed in Fig. 2, the greatest proportions of favorable attitudes toward IUD use were reported in scenarios with women with at least two previous deliveries, aged 30–39 and with one sexual partner. The smallest proportions of subjects had favorable attitudes towards IUD use in women b 19 years of age, with more than one sexual partner and with a history of a sexually transmitted infection, pelvic inflammatory disease or ectopic Table 2 IUD experience throughout the obstetrics and gynecology clerkship (N= 106) Before the clerkship
After the clerkship
Number of IUD placements seen 0 IUD 84 (79) 39 (37) 1–2 IUDs 12 (11) 36 (34) 3–4 IUDs 6 (6) 22 (21) ≥ 5 IUDs 4 (4) 9 (8) Do you think you have sufficient knowledge to counsel patients about the Paragard (Copper T380A) IUD? a Yes 7 (7) 73 (69) No 99 (93) 32 (30) Do you think you have sufficient knowledge to counsel patients about the Mirena (levonorgestrel) IUD? a Yes 10 (9) 81 (76) No 96 (91) 24 (23) Data are n (%). a One respondent felt unprepared to counsel patients about Copper T380A IUD or levonorgestrel IUD preclerkship but did not respond to these questions following the rotation.
260
D. Bartz et al. / Contraception 88 (2013) 257–262
Fig. 1. Proportion of correct responses to knowledge questions. The topics covered in the 10 knowledge questions are listed (x-axis) with the proportion of correct responses (y-axis) from all subjects (N= 106) both preclerkship (gray) and postclerkship (black).
pregnancy. Reported attitudes improved the most regarding IUD use by a family member or friend. Univariate analysis was used to assess subject characteristics and aspects of training environment that may influence IUD knowledge and attitudes. Subjects who were taught about IUDs by obstetrician–gynecologists during their preclinical training in medical school had more favorable attitudes (mean attitudes score 39%, SD ± 30%) than those who were taught by instructors outside of obstetrics and gynecology (mean attitudes score 12%, SD ± 22%, p=.009); no difference was noted in IUD knowledge with respect to instructor specialty. Compared to those with no prior IUD placement exposure, subjects who had previously seen one or more IUD placements started their obstetrics and gynecology rotation with significantly higher knowledge (64%, SD ± 17% vs. 51%, SD ± 16%, p=.001) and attitude scores (48%, SD ± 32% vs. 30%, SD ± 29%, p= .013). There was no difference in preclerkship knowledge or attitude scores between students who had learned about IUDs prior to medical school compared to those who first learned about IUDs in medical school, or between subjects who had learned about IUDs in medical school preclinical lectures or in prior clinical rotations and those who had not. There was no difference in postclerkship IUD knowledge or attitude scores when controlling for age, gender or medical specialty interest.
4. Discussion This study assessed whether previously captured provider IUD misinformation and misperception are replicated among medical school students rotating through the obstetrics and gynecology clerkship. Our study subjects consistently had improvement in IUD knowledge and attitudes at the conclusion of the clerkship, although their scores for both were low at the start of the rotation and demonstrated only modest improvement. Our findings suggest that clinical training by obstetrics and gynecology providers on the wards and in clerkship didactics has a favorable effect on US medical students’ knowledge of IUDs. This finding is reassuring and may reflect the renaissance that the IUD appears to be having in the United States. Since the nadir in IUD use in the mid1990s, there has been a consistent, but slow increase in IUD utilization [5,6]. The findings of our study may reflect the contraceptive advances that have contributed to increased IUD utilization in the last decade: the Food and Drug Administration (FDA) approval of the levonorgestrel-containing IUD in 2000, the FDA-approved product label changes to the Copper T380A IUD in 2005 that expanded IUD candidate criteria and new medical research that consistently demonstrates the safety of modern IUDs in many patient populations.
D. Bartz et al. / Contraception 88 (2013) 257–262
261
Fig. 2. Proportion of correct responses to clinical vignettes. The clinical scenarios presented in the 14 clinical vignettes are listed (x-axis) with the proportion of respondents (N=106) who would recommend an IUD routinely (y-axis) both preclerkship (gray) and postclerkship (black).
Previous research provides possible evidence that the effect of these IUD advances may trickle down to training physicians and student physicians. Notably, a greater number of practicing clinicians may currently be trained and feel comfortable performing IUD insertion and removal techniques. At the time that IUD utilization was dismally low in the United States, residents reported minimal exposure to IUD training due to lack of opportunity [25]. Following the devastating effects of the Dalkon Shield IUD — patient and provider fear surrounding the safety of all IUDs, provider fear of IUD litigation and removal of several IUDs from the US market — modern IUD practice has had a difficult time breaking free of the cycle of barriers that may limit its use. It is reassuring that several recent provider surveys consistently demonstrate that younger doctors [15,23,24] and doctors in academic training centers [15,23] report more accurate IUD knowledge and improved IUD provision than older doctors and doctors in private practice. These findings are likely a result of older doctors having personal experience with the devastating effects of the Dalkon Shield in their patients and being less familiar with the newer research of the last two decades that demonstrates improved safety of the modern IUD. In addition, younger doctors have likely had more training opportunities in IUD insertion. Educational activities that directly target IUD insertion, such as increased pelvic model simulation training and the Kenneth J. Ryan Residency Training Program in Abortion and Family
Planning curriculum, may be helping to break the cycle of poor IUD provision due to poor IUD insertion skill. Our study demonstrates that this improved training environment is likely trickling down to medical students. This study had several key strengths and limitations. Through the use of in-person recruitment, we were able to elicit a high response rate from a large sample of students from seven geographically diverse institutions with substantial variation in training environments. As a result, we were able to collect detailed information regarding previous and clerkship-related IUD training. However, our sample is too small to permit analysis with respect to training characteristics that vary by school (e.g., religious affiliation, faculty specialty in family planning) without compromising the anonymity of participating institutions. Another limitation of this study is the potential for recall bias as we relied on subjects’ recollection of detailed aspects of previous training and accurate reporting of IUD exposure throughout the clerkship. In addition, information bias may have resulted from the repeated administration of the same measures and from the placement of the clinical vignettes following the knowledge questions. Reporting bias based on the desire to mimic the faculty's perceived attitudes toward IUD use may have occurred, though this risk was minimized through the anonymous administration of the survey and the use of faculty who were not involved in assignment of clerkship grades for recruitment.
262
D. Bartz et al. / Contraception 88 (2013) 257–262
This study provides an important snapshot of the improvement that occurs in medical student understanding of the IUD during the obstetrics and gynecology clerkship. Participants’ knowledge and attitudes improved significantly through contact with patients and practicing physicians. However, important knowledge gaps remained, and many medical students were hesitant to recommend IUDs to adolescents or those with a history of ectopic pregnancy even after their clerkship. The level of detail in IUD knowledge and attitudes reported here has not been captured in previous studies and provides insight into current practice patterns being propagated in academic hospitals, suggesting that exposure to IUD placement and didactic activities focused on IUD utilization merit further improvements. However, additional studies are needed to better assess best practices in IUD education and the resulting impact on medical student knowledge and attitudes. A larger study designed to analyze variation in IUD knowledge and attitudes with respect to characteristics of the training environment could assess in greater detail factors associated with improved integration of the IUD into medical student education. Further investigation, used in conjunction with this present study, has the potential to identify targeted areas for curriculum reform that may improve IUD provision among future generations of physicians. Acknowledgments The authors would like to thank the American College of Obstetricians and Gynecologists and Bayer HealthCare Pharmaceuticals for financial support of this study. We would also like to thank Dr. Michael Stelluto, Ms. Paulette Nippet, Dr. Sadia Haider, Dr. Eve Espey, Dr. Sarah Prager, Dr. Frank Schubert, Dr. Jon Hathaway, Dr. Serina Floyd, Dr. Ann Schutt-Aine, Dr. Nancy Stanwood, Ms. Jennifer Fortin and Ms. Jessica Kremen for their contributions to this study. Reprints will not be available. References [1] Jones E, Forrest J, Henshaw S, Silverman J, Torres A. Pregnancy, contraception and family planning services in industrialized countries. New Haven, CT: Yale University Press; 1989. [2] Trussell J, Wynn LL. Reducing unintended pregnancy in the United States. Contraception 2008;77:1–5. [3] Finer LB, Henshaw SK. Disparities in rates of unintended pregnancy in the United States, 1994 and 2001. Perspect Sex Reprod Health 2006;38:90–6. [4] Trussell J. Contraceptive efficacy. In: Hatcher R, Trussell J, Nelson A, Cates W, Stewart F, & Kowal D, editors. Contraceptive technology. New York (NY): Ardent Media; 2007, pp. 747–60.
[5] Mosher WD, Jones J. Use of contraception in the United States: 1982– 2008. Hyattsville (MD): National Center for Health Statistics. Vital Health Stat 23(29); 2010. [6] Hubacher D, Finer LB, Espey E. Renewed interest in intrauterine contraception in the United States: evidence and explanation. Contraception 2011;83:291–4. [7] Committee ACOG. Opinion no. 450: increasing use of contraceptive implants and intrauterine devices to reduce unintended pregnancy. Obstet Gynecol 2009;114:1434–8. [8] Committee ACOG. Opinion no. 392, December 2007. Intrauterine device and adolescents. Obstet Gynecol 2007;110:1493–5. [9] Darney PD. Time to pardon the IUD? N Engl J Med 2001;345:608–10. [10] Allen RH, Goldberg AB, Grimes DA. Expanding access to intrauterine contraception. Am J Obstet Gynecol 2009;201:456e1–5. [11] Speidel JJ, Harper CC, Shields WC. The potential of long-acting reversible contraception to decrease unintended pregnancy. Contraception 2008;78:197–200. [12] Association of Professors of Gynecology and Obstetrics. Women's health care competencies for medical students. Available at: http:// wheocomp.apgo.org/. Retrieved March 6, 2011. [13] Steinauer J, LaRochelle F, Rowh M, Backus L, Sandahl Y, Foster A. First impressions: what are preclinical medical students in the US and Canada learning about sexual and reproductive health? Contraception 2009;80:74–80. [14] Espey E, Ogburn T. Perpetuating negative attitudes about the intrauterine device: textbooks lag behind the evidence. Contraception 2002;65:389–95. [15] Harper CC, Blum M, de Bocanegra HT, et al. Challenges in translating evidence to practice: the provision of intrauterine contraception. Obstet Gynecol 2008;111:1359–69. [16] Schreiber CA, Harwood BJ, Switzer GE, Creinin MD, Reeves MF, Ness RB. Training and attitudes about contraceptive management across primary care specialties: a survey of graduating residents. Contraception 2006;73:618–22. [17] Stanwood NL, Garrett JM, Konrad TR. Obstetrician–gynecologists and the intrauterine device: a survey of attitudes and practice. Obstet Gynecol 2002;99:275–80. [18] Kooiker CH, Scutchfield FD. Barriers to prescribing the Copper T 380A intrauterine device by physicians. Western J Med 1990;153: 279–82. [19] Espey E, Ogburn T, Espey D, Etsitty V. IUD-related knowledge, attitudes and practices among Navajo Area Indian Health Service providers. Perspect Sex Reprod Health 2003;35:169–73. [20] Stanwood NL, Bradley KA. Young pregnant women's knowledge of modern intrauterine devices. Obstet Gynecol 2006;108:1417–22. [21] Vos AA, Veldhuis HM, Lagro-Janssen TL. Intrauterine contraception: the role of general practitioners in four Dutch general practices. Contraception 2004;69:283–7. [22] Bianchi-Demicheli F, Perrin E, Dupanloup A, et al. Contraceptive counselling and social representations: a qualitative study. Swiss Med Wkly 2006;136:127–34. [23] Dehlendorf C, Levy K, Ruskin R, Steinauer J. Health care providers' knowledge about contraceptive evidence: a barrier to quality family planning care? Contraception 2010;81:292–8. [24] Madden T, Allsworth JE, Hladky KJ, Secura GM, Peipert JF. Intrauterine contraception in Saint Louis: a survey of obstetrician and gynecologists' knowledge and attitudes. Contraception 2010;81: 112–6. [25] Westhoff C, Marks F, Rosenfield A. Residency training in contraception, sterilization, and abortion. Obstet Gynecol 1993;81:311–4.
Original research article
Medical student intrauterine device knowledge and attitudes: an assessment of clerkship training☆,☆☆ Deborah Bartz a, b,⁎, Jennifer Tang a, b, 1 , Rie Maurer b, c , Elizabeth Janiak a a
Department of Obstetrics, Gynecology, and Reproductive Biology, Brigham and Women's Hospital, Boston, MA 02115, USA b Harvard Medical School, Boston, MA 02115, USA c Center for Clinical Investigation, Brigham and Women's Hospital, Boston, MA 02115, USA Received 9 July 2012; revised 23 October 2012; accepted 26 October 2012
Abstract Background: Studies demonstrate that many clinician populations have poor knowledge of and harbor negative attitudes towards intrauterine devices (IUDs). We set out to assess the impact of the clinical clerkship in obstetrics and gynecology on medical student IUD knowledge and attitudes. Study Design: In this prospective cohort study, students at seven diverse US medical schools were surveyed at the start and completion of their obstetrics and gynecology clinical clerkships regarding IUD exposure, knowledge and attitudes. Subject responses were compared preand postclerkship. Results: One hundred six students returned completed paired surveys (response rate 82%). The preclerkship mean knowledge percent correct (54%, SD 17%) increased significantly at postclerkship assessment (72%, SD 18%) (pb.0001). The mean attitudes score also increased significantly from pre- (34%, SD 31%) to postclerkship (59%, SD 26%) (pb.0001). Conclusions: US medical student IUD knowledge and attitudes are significantly improved through the obstetrics and gynecology clerkship. However, significant gaps in knowledge persist postclerkship. © 2013 Elsevier Inc. All rights reserved. Keywords: Intrauterine device; Medical students; Educational assessment
1. Introduction The unintended pregnancy rate in the United States is higher than other developed countries [1,2], with 49% of the 6.3 million annual pregnancies being unintended [3]. With a failure rate of less than 1% [4], the intrauterine device (IUD)
☆
Presentation information: These findings were presented as a poster presentation at the Association of Reproductive Health Professionals 2010 Annual Meeting in September 2010. ☆☆ Disclosure: Full financial support for this study was provided through the American College of Obstetricians and Gynecologists/Bayer HealthCare Pharmaceuticals Research Award in Contraceptive Counseling. ⁎ Corresponding author. Department of Obstetrics, Gynecology, and Reproductive Biology, Brigham and Women's Hospital, OBC-3, Boston, MA 02120. Tel.: + 1 617 525 7744; fax: + 1 617 525 7746. E-mail address: [email protected] (D. Bartz). 1 At the time of submission, Jennifer Tang's affiliation has changed to the Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC 27599, USA. 0010-7824/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.contraception.2012.10.028
is highly effective at preventing unintended pregnancies. However, IUD utilization rates in the United States remain low, having reached their nadir in the mid-1990s subsequent to adverse events associated with IUD technology since removed from clinical practice. In 1995, only 0.8% of US women of reproductive age were using an IUD, a proportion which increased to 2.0% in 2002 and to 5.5% in 2006–2008 [5,6]. The IUD's potential to reduce unintended pregnancy has prompted the American College of Obstetricians and Gynecologists and other reproductive health experts to champion expanded use of these methods [2,7–11] and inspired the development of guidelines for medical student learning objectives related to their mechanism of action, risks and benefits [12]. However, there are several reasons to suspect accurate IUD knowledge is not being promulgated to medical students. In a recent survey of 68 US medical school preclinical reproductive health curricula, only 76% covered the topic of IUDs in their contraception lecture [13]. An
258
D. Bartz et al. / Contraception 88 (2013) 257–262
examination of textbooks commonly used by medical students on women's health rotations found the information about the safety of IUDs inaccurate and outdated [14]. Surveys of practicing health care providers, many of whom work in academic medical facilities, frequently endorse exaggerated safety concerns and outdated perceptions about appropriate patient candidates for IUDs [15–23]. These findings suggest that medical students are at risk for learning misinformation about the IUD, which may encourage IUD underutilization in future practice. In this prospective cohort study, we used pre- and postrotation survey measures of IUD knowledge and attitudes as a proxy measure of whether students at seven diverse US medical schools learn scientifically accurate information regarding failure and continuation rates, mechanism of action and contraindications of use of the IUD during their obstetrics and gynecology clerkship.
2. Materials and methods We followed a cohort of third-year medical students starting their clinical clerkship in obstetrics and gynecology at seven US medical schools sampled on geographic and curricular diversity, as follows: (a) Northeast: Harvard Medical School, Boston; (b) South: Duke University Medical School, Durham, and Baylor College of Medicine, Houston; (c) Midwest: Indiana University School of Medicine, Indianapolis, and Loyola University–Stritch School of Medicine, Chicago; (d) West: University of New Mexico School of Medicine, Albuquerque, and University of Washington School of Medicine, Seattle. Schools were also selected for diversity on factors that may impact curricular inclusion of contraception. Among the schools sampled, two had Ryan Residency Training Programs in Abortion and Family Planning at their affiliated hospitals, one is a Catholic institution affiliated with a Catholic hospital, and the remaining four were neither Ryan nor Catholic institutions. Institutional Review Board protocol approval was granted by all seven medical schools prior to recruitment. All students starting their obstetrics and gynecology clinical clerkship for the first time at participating institutions in the spring of 2009 (n= 129) were eligible and asked to participate. Participants completed identical pre- and postclerkship paper surveys, which were paired by an anonymous identifier created by subjects and never linked to identifying information. A single obstetrics and gynecology faculty or staff member from each of the seven institutions assisted in subject recruitment and survey implementation. At all schools except the University of Washington, students were approached as a group during their didactic time during the first week of the clerkship and given the preclerkship survey and accompanying cover letter by the on-site faculty member. Due to the dispersed locations of third-year University of Washington students who rotate through hospitals throughout Alaska and the Pacific Northwest, the
study materials and instructions for that institution were mailed with other clerkship paperwork before the start of the rotation. Study participation was anonymous and voluntary, and consent was implied when students read the cover letter and completed the survey. The postclerkship survey was administered in a similar fashion during the last week of the clerkship. The survey instrument included 39 items representing the following: (a) demographic questions; (b) intended future medical specialization; (c) recall questions about prior IUD training and experience, including an assessment of the medical school basic science lectures; (d) items to capture a self-assessment of knowledge and comfort performing comprehensive IUD counseling; (e) 10 equally weighted questions to assess IUD knowledge, including failure and continuation rates, mechanism of action and contraindications for use; and (f) 14 equally weighted clinical vignettes to assess attitudes toward IUD use in a variety of patient populations. The knowledge and attitude questions were used or modified with author permission from survey questions previously published in the literature to assess IUD knowledge and attitudes in provider populations [17,19]. The clinical vignettes represented management of a wide range of contraceptive counseling scenarios encountered frequently in obstetrics and gynecology and primary care. All patient scenarios presented in the clinical vignettes lacked contraindication to IUD use. Response choices for the vignettes were “recommend routinely,” “recommend only if other methods are unacceptable,” “never recommend” or “not sure.” “Recommend routinely” was considered a correct response to the clinical vignette items. Each survey was designed to take approximately 10–15 min to complete. Analysis was restricted to participants who completed pre- and postclerkship surveys that could be accurately paired. Descriptive analyses were performed on the demographic data and previous IUD exposure data to look for trends in responses. Fisher's Exact Tests and χ 2 were used to compare demographic data between the survey responders and nonresponders. The paired t test was used to assess the difference in the IUD knowledge score and IUD attitudes score as a mean percent correct from before to after the obstetrics and gynecology clerkship. The McNemar test was used to assess marginal homogeneity of the correct responses before and after the clerkship. Student's t test, Wilcoxon rank sum and analysis of variance were performed on items relating to prior and clerkship IUD exposure to assess their impact on IUD knowledge and attitudes over the course of the clerkship. All statistical tests were performed with SAS statistical software, release 9.2 (SAS Institute, Inc., Cary, NC, USA).
3. Results Of the 129 students beginning their obstetrics and gynecology clerkships at the time of the survey, 123
D. Bartz et al. / Contraception 88 (2013) 257–262
completed some of the study procedures for a total response rate of 96%, with high rates of participation (89%–100%) at all schools. One-hundred six subjects returned two completed surveys that could be accurately paired for an 82% final completed response rate. The age and gender distribution of this final cohort was not different from those who submitted incomplete data. Sample demographics and preclerkship IUD training and exposure are detailed in Table 1. Among the 106 subjects included in the analysis, the majority were 22–25 years old (62%), with a small majority (53%) being male. Six subjects (6%) reported an interest in specializing in obstetrics and gynecology, and 49 subjects (46%) reported interest in an adult and/or pediatric primary care specialty that may include contraceptive care as part of the practice. Seventy-four percent of subjects reported that IUD information was taught in the basic sciences portion of their medical school curriculum, most frequently (67%) by obstetrics and gynecology faculty. Forty-two percent of subjects had Table 1 Participant characteristics and IUD exposure prior to the obstetrics and gynecology clerkship (N=106) n (%) Age, years 22–25 26–29 30–34 35–39 Gender Male Female Future specialty plans a Obstetrics and gynecology Adult and/or pediatric primary care specialty Other Undecided Prior IUD exposure a Prior to medical school Medical school My own physician Job/volunteer work Reading/investigation apart from school curriculum Other Gained IUD exposure in preclinical medical school classes Yes No Departments of IUD teaching faculty Obstetrics and gynecology faculty Other faculty Gained IUD exposure in other clinical rotations b Yes No Clinical rotations with prior IUD exposure a Internal medicine Pediatrics Family medicine Radiology a
66 (62) 27 (26) 10 (9) 3 (3) 56 (53) 50 (47) 6 (6) 49 (46) 47 (44) 11 (10) 33 (31) 88 (83) 12 (11) 4 (4) 27 (25) 13 (12) 78 (74) 28 (26) 71 (67) 35 (33) 44 (42) 60 (57) 7 (7) 5 (5) 37 (35) 1 (1)
Respondents could mark more than one answer. b Two respondents did not report on IUD exposure in other clinical rotations.
259
learned about the IUD in prior medical school clerkships, primarily through family medicine (35%). As displayed in Table 2, 21% of subjects reported seeing an IUD placement prior to their obstetrics and gynecology clerkship, and another 44% gained this experience during the rotation. Of those students who had observed any IUD placements, most reported having observed one to four procedures, both before and after the clerkship. Prior to the obstetrics and gynecology rotation, 7% of subjects felt they had sufficient knowledge to counsel patients about the Copper T380A IUD, while 9% felt they could counsel about the levonorgestrel IUD. These proportions increased to 69% and 76%, respectively, following the rotation. Respondents scored 54% (SD ± 17%) mean percent correct on the 10 IUD knowledge items prior to the rotation and 72% (SD ± 17%) at the end of the rotation, a significant improvement in mean knowledge score (18%, SD ± 20%, pb.0001). As displayed in Fig. 1, the greatest proportion of subjects responded correctly both pre- and postclerkship to questions that pertain to IUD mechanism of action and failure rate. Students scored the lowest both pre- and postclerkship on questions about IUD discontinuation rates, IUD use for emergency contraception and return to fertility following IUD discontinuation. The mean percent correct for the 14 IUD attitude clinical vignettes was 34% (SD ± 31%) at the start of the rotation and 59% (SD ± 26%) at the rotation's conclusion, representing a significant improvement in overall IUD attitude scores (25%, SD ± 34%, pb.0001). As displayed in Fig. 2, the greatest proportions of favorable attitudes toward IUD use were reported in scenarios with women with at least two previous deliveries, aged 30–39 and with one sexual partner. The smallest proportions of subjects had favorable attitudes towards IUD use in women b 19 years of age, with more than one sexual partner and with a history of a sexually transmitted infection, pelvic inflammatory disease or ectopic Table 2 IUD experience throughout the obstetrics and gynecology clerkship (N= 106) Before the clerkship
After the clerkship
Number of IUD placements seen 0 IUD 84 (79) 39 (37) 1–2 IUDs 12 (11) 36 (34) 3–4 IUDs 6 (6) 22 (21) ≥ 5 IUDs 4 (4) 9 (8) Do you think you have sufficient knowledge to counsel patients about the Paragard (Copper T380A) IUD? a Yes 7 (7) 73 (69) No 99 (93) 32 (30) Do you think you have sufficient knowledge to counsel patients about the Mirena (levonorgestrel) IUD? a Yes 10 (9) 81 (76) No 96 (91) 24 (23) Data are n (%). a One respondent felt unprepared to counsel patients about Copper T380A IUD or levonorgestrel IUD preclerkship but did not respond to these questions following the rotation.
260
D. Bartz et al. / Contraception 88 (2013) 257–262
Fig. 1. Proportion of correct responses to knowledge questions. The topics covered in the 10 knowledge questions are listed (x-axis) with the proportion of correct responses (y-axis) from all subjects (N= 106) both preclerkship (gray) and postclerkship (black).
pregnancy. Reported attitudes improved the most regarding IUD use by a family member or friend. Univariate analysis was used to assess subject characteristics and aspects of training environment that may influence IUD knowledge and attitudes. Subjects who were taught about IUDs by obstetrician–gynecologists during their preclinical training in medical school had more favorable attitudes (mean attitudes score 39%, SD ± 30%) than those who were taught by instructors outside of obstetrics and gynecology (mean attitudes score 12%, SD ± 22%, p=.009); no difference was noted in IUD knowledge with respect to instructor specialty. Compared to those with no prior IUD placement exposure, subjects who had previously seen one or more IUD placements started their obstetrics and gynecology rotation with significantly higher knowledge (64%, SD ± 17% vs. 51%, SD ± 16%, p=.001) and attitude scores (48%, SD ± 32% vs. 30%, SD ± 29%, p= .013). There was no difference in preclerkship knowledge or attitude scores between students who had learned about IUDs prior to medical school compared to those who first learned about IUDs in medical school, or between subjects who had learned about IUDs in medical school preclinical lectures or in prior clinical rotations and those who had not. There was no difference in postclerkship IUD knowledge or attitude scores when controlling for age, gender or medical specialty interest.
4. Discussion This study assessed whether previously captured provider IUD misinformation and misperception are replicated among medical school students rotating through the obstetrics and gynecology clerkship. Our study subjects consistently had improvement in IUD knowledge and attitudes at the conclusion of the clerkship, although their scores for both were low at the start of the rotation and demonstrated only modest improvement. Our findings suggest that clinical training by obstetrics and gynecology providers on the wards and in clerkship didactics has a favorable effect on US medical students’ knowledge of IUDs. This finding is reassuring and may reflect the renaissance that the IUD appears to be having in the United States. Since the nadir in IUD use in the mid1990s, there has been a consistent, but slow increase in IUD utilization [5,6]. The findings of our study may reflect the contraceptive advances that have contributed to increased IUD utilization in the last decade: the Food and Drug Administration (FDA) approval of the levonorgestrel-containing IUD in 2000, the FDA-approved product label changes to the Copper T380A IUD in 2005 that expanded IUD candidate criteria and new medical research that consistently demonstrates the safety of modern IUDs in many patient populations.
D. Bartz et al. / Contraception 88 (2013) 257–262
261
Fig. 2. Proportion of correct responses to clinical vignettes. The clinical scenarios presented in the 14 clinical vignettes are listed (x-axis) with the proportion of respondents (N=106) who would recommend an IUD routinely (y-axis) both preclerkship (gray) and postclerkship (black).
Previous research provides possible evidence that the effect of these IUD advances may trickle down to training physicians and student physicians. Notably, a greater number of practicing clinicians may currently be trained and feel comfortable performing IUD insertion and removal techniques. At the time that IUD utilization was dismally low in the United States, residents reported minimal exposure to IUD training due to lack of opportunity [25]. Following the devastating effects of the Dalkon Shield IUD — patient and provider fear surrounding the safety of all IUDs, provider fear of IUD litigation and removal of several IUDs from the US market — modern IUD practice has had a difficult time breaking free of the cycle of barriers that may limit its use. It is reassuring that several recent provider surveys consistently demonstrate that younger doctors [15,23,24] and doctors in academic training centers [15,23] report more accurate IUD knowledge and improved IUD provision than older doctors and doctors in private practice. These findings are likely a result of older doctors having personal experience with the devastating effects of the Dalkon Shield in their patients and being less familiar with the newer research of the last two decades that demonstrates improved safety of the modern IUD. In addition, younger doctors have likely had more training opportunities in IUD insertion. Educational activities that directly target IUD insertion, such as increased pelvic model simulation training and the Kenneth J. Ryan Residency Training Program in Abortion and Family
Planning curriculum, may be helping to break the cycle of poor IUD provision due to poor IUD insertion skill. Our study demonstrates that this improved training environment is likely trickling down to medical students. This study had several key strengths and limitations. Through the use of in-person recruitment, we were able to elicit a high response rate from a large sample of students from seven geographically diverse institutions with substantial variation in training environments. As a result, we were able to collect detailed information regarding previous and clerkship-related IUD training. However, our sample is too small to permit analysis with respect to training characteristics that vary by school (e.g., religious affiliation, faculty specialty in family planning) without compromising the anonymity of participating institutions. Another limitation of this study is the potential for recall bias as we relied on subjects’ recollection of detailed aspects of previous training and accurate reporting of IUD exposure throughout the clerkship. In addition, information bias may have resulted from the repeated administration of the same measures and from the placement of the clinical vignettes following the knowledge questions. Reporting bias based on the desire to mimic the faculty's perceived attitudes toward IUD use may have occurred, though this risk was minimized through the anonymous administration of the survey and the use of faculty who were not involved in assignment of clerkship grades for recruitment.
262
D. Bartz et al. / Contraception 88 (2013) 257–262
This study provides an important snapshot of the improvement that occurs in medical student understanding of the IUD during the obstetrics and gynecology clerkship. Participants’ knowledge and attitudes improved significantly through contact with patients and practicing physicians. However, important knowledge gaps remained, and many medical students were hesitant to recommend IUDs to adolescents or those with a history of ectopic pregnancy even after their clerkship. The level of detail in IUD knowledge and attitudes reported here has not been captured in previous studies and provides insight into current practice patterns being propagated in academic hospitals, suggesting that exposure to IUD placement and didactic activities focused on IUD utilization merit further improvements. However, additional studies are needed to better assess best practices in IUD education and the resulting impact on medical student knowledge and attitudes. A larger study designed to analyze variation in IUD knowledge and attitudes with respect to characteristics of the training environment could assess in greater detail factors associated with improved integration of the IUD into medical student education. Further investigation, used in conjunction with this present study, has the potential to identify targeted areas for curriculum reform that may improve IUD provision among future generations of physicians. Acknowledgments The authors would like to thank the American College of Obstetricians and Gynecologists and Bayer HealthCare Pharmaceuticals for financial support of this study. We would also like to thank Dr. Michael Stelluto, Ms. Paulette Nippet, Dr. Sadia Haider, Dr. Eve Espey, Dr. Sarah Prager, Dr. Frank Schubert, Dr. Jon Hathaway, Dr. Serina Floyd, Dr. Ann Schutt-Aine, Dr. Nancy Stanwood, Ms. Jennifer Fortin and Ms. Jessica Kremen for their contributions to this study. Reprints will not be available. References [1] Jones E, Forrest J, Henshaw S, Silverman J, Torres A. Pregnancy, contraception and family planning services in industrialized countries. New Haven, CT: Yale University Press; 1989. [2] Trussell J, Wynn LL. Reducing unintended pregnancy in the United States. Contraception 2008;77:1–5. [3] Finer LB, Henshaw SK. Disparities in rates of unintended pregnancy in the United States, 1994 and 2001. Perspect Sex Reprod Health 2006;38:90–6. [4] Trussell J. Contraceptive efficacy. In: Hatcher R, Trussell J, Nelson A, Cates W, Stewart F, & Kowal D, editors. Contraceptive technology. New York (NY): Ardent Media; 2007, pp. 747–60.
[5] Mosher WD, Jones J. Use of contraception in the United States: 1982– 2008. Hyattsville (MD): National Center for Health Statistics. Vital Health Stat 23(29); 2010. [6] Hubacher D, Finer LB, Espey E. Renewed interest in intrauterine contraception in the United States: evidence and explanation. Contraception 2011;83:291–4. [7] Committee ACOG. Opinion no. 450: increasing use of contraceptive implants and intrauterine devices to reduce unintended pregnancy. Obstet Gynecol 2009;114:1434–8. [8] Committee ACOG. Opinion no. 392, December 2007. Intrauterine device and adolescents. Obstet Gynecol 2007;110:1493–5. [9] Darney PD. Time to pardon the IUD? N Engl J Med 2001;345:608–10. [10] Allen RH, Goldberg AB, Grimes DA. Expanding access to intrauterine contraception. Am J Obstet Gynecol 2009;201:456e1–5. [11] Speidel JJ, Harper CC, Shields WC. The potential of long-acting reversible contraception to decrease unintended pregnancy. Contraception 2008;78:197–200. [12] Association of Professors of Gynecology and Obstetrics. Women's health care competencies for medical students. Available at: http:// wheocomp.apgo.org/. Retrieved March 6, 2011. [13] Steinauer J, LaRochelle F, Rowh M, Backus L, Sandahl Y, Foster A. First impressions: what are preclinical medical students in the US and Canada learning about sexual and reproductive health? Contraception 2009;80:74–80. [14] Espey E, Ogburn T. Perpetuating negative attitudes about the intrauterine device: textbooks lag behind the evidence. Contraception 2002;65:389–95. [15] Harper CC, Blum M, de Bocanegra HT, et al. Challenges in translating evidence to practice: the provision of intrauterine contraception. Obstet Gynecol 2008;111:1359–69. [16] Schreiber CA, Harwood BJ, Switzer GE, Creinin MD, Reeves MF, Ness RB. Training and attitudes about contraceptive management across primary care specialties: a survey of graduating residents. Contraception 2006;73:618–22. [17] Stanwood NL, Garrett JM, Konrad TR. Obstetrician–gynecologists and the intrauterine device: a survey of attitudes and practice. Obstet Gynecol 2002;99:275–80. [18] Kooiker CH, Scutchfield FD. Barriers to prescribing the Copper T 380A intrauterine device by physicians. Western J Med 1990;153: 279–82. [19] Espey E, Ogburn T, Espey D, Etsitty V. IUD-related knowledge, attitudes and practices among Navajo Area Indian Health Service providers. Perspect Sex Reprod Health 2003;35:169–73. [20] Stanwood NL, Bradley KA. Young pregnant women's knowledge of modern intrauterine devices. Obstet Gynecol 2006;108:1417–22. [21] Vos AA, Veldhuis HM, Lagro-Janssen TL. Intrauterine contraception: the role of general practitioners in four Dutch general practices. Contraception 2004;69:283–7. [22] Bianchi-Demicheli F, Perrin E, Dupanloup A, et al. Contraceptive counselling and social representations: a qualitative study. Swiss Med Wkly 2006;136:127–34. [23] Dehlendorf C, Levy K, Ruskin R, Steinauer J. Health care providers' knowledge about contraceptive evidence: a barrier to quality family planning care? Contraception 2010;81:292–8. [24] Madden T, Allsworth JE, Hladky KJ, Secura GM, Peipert JF. Intrauterine contraception in Saint Louis: a survey of obstetrician and gynecologists' knowledge and attitudes. Contraception 2010;81: 112–6. [25] Westhoff C, Marks F, Rosenfield A. Residency training in contraception, sterilization, and abortion. Obstet Gynecol 1993;81:311–4.