Objective: Although cigarette smoking is the leading cause of preventable death in the United States, only three medical schools have required courses dedicated to this topic. Thus, many physicians state they have been ill prepared in smoking-cessation counseling. We have addressed this problem at Wake Forest University School of Medicine through an innovative tobacco-dependence curriculum.
Description: Beginning in 1998, Wake Forest University School of Medicine has implemented the new Prescription for Excellence: A Physician's Pathway to Life Long Learning. This curriculum has allowed the integration of tobacco-use principles throughout the school's medical student education program. During the first and second years at our school, students discuss one problem-based learning case in small groups each week. Many of these cases have had tobacco-related content added, focusing on epidemiology, health effects, and nicotine addiction. Additionally, during the first-year course Population Health and Epidemiology, tobacco epidemiology informs many lectures and small-group sessions. Finally, during the first three phases of the curriculum, students are observed taking histories from and performing physical examinations on three standardized patients. One of the skills evaluated in these test situations is obtaining a tobacco-use history. These experiences prepare the students for their third-year experience in smoking-cessation counseling.
During the third year, all 108 medical students spend four weeks in the family medicine clerkship. In the first week of this rotation, faculty lead a small-group tutorial reviewing the basic principles of nicotine addiction and pharmacotherapy and a tobacco-cessation algorithm. Next, students interact with specially trained standardized patient-instructors (SPIs) using mock family practice charts. The SPIs follow scripts delineating teachable moments when physician smoking-cessation counseling would be natural. After a half-hour interview, the SPIs give specific, constructive feedback to the students about their tobacco knowledge and counselling styles, using a validated feedback instrument.1 Later, the students must identify at least one smoking patient during their remaining ambulatory clinics and counsel that patient to quit, incorporating the SPIs' feedback. Students are enthusiastic about this program, with evaluation comments including “excellent,” “very helpful,” “great practice … and great feedback.”
During the fourth year, students complete a scholarly project, one topic for which can be smoking cessation. Also, during Phase V, which will be fully implemented in the spring of 2002, students will revisit basic and clinical science topics using complex clinical cases as a stimulus for learning. These cases will provide an opportunity to further integrate smoking-cessation topics. During Phase V, students will also learn about health care systems, which will provide the opportunity to look at smoking cessation from a global perspective.
Discussion: This stepped curricular approach, introducing principles of tobacco use and cessation, followed by critiqued practice with standardized and real patients, and ending with a broad review of tobacco use, has been very successful and is to our knowledge unique among medical schools. Our approach—which continues with the full support of the school's administration—offers an innovative way to address the national need for curricular models of tobacco dependence.
1. Levenkron JC, Greeland P. Validating the University of Rochester risk factor interview scale. Am J Prev Med. 1987;3:152–6.
Annual, Peer-reviewed Collection of Reports of Innovative Approaches to Medical Education