A Comprehensive Approach to Teaching Smoking-cessation Strategies

Objectives: Medical school graduates should be able to assist patients who smoke to quit smoking. After participating in this module, students will demonstrate that they can (1) intervene with tobacco users using the “5As” for brief intervention from the U.S. Public Health Service clinical practice guideline, (2) use the Fagerstrom Test for Nicotine Dependence, (3) offer interventions in response to the patient's needs and motivations, (4) adjust pharmacotherapy to each patient's circumstances, and (5) provide a motivational message to smokers not ready to try to quit. Description: This required module in a family practice clerkship is a comprehensive approach to smoking cessation that incorporates key intervention strategies from the new clinical practice guideline, Treating Tobacco Use and Dependence. The module consists of assigned readings, a didactic session, relevant practice of skills, and a final performance-based assessment. Students draw on earlier instruction about the causes of smoking and nicotine addiction, build on their patient interviewing and education skills, and learn new information about the effects of smoking on health and health care costs. At each of the clerkship sites, a faculty member introduces the module and discusses the epidemiology of smoking, the physiologic basis for addiction, nicotine dependence, and how to adjust advice to a patient's willingness to quit. Paper cases are discussed. The instructor role-plays how an appropriate response can be adjusted for different smokers. The students review videotapes of quit-smoking interventions and discuss how they can use the skills in clinical settings. The students evaluate the performances demonstrated in the videotapes using the behavioral checklist that will be used later for their own performance-based assessments. After the didactic session, students practice and enhance their skills by advising patients in their preceptors' offices using the practice guideline. A performance-based assessment (PBA) of the student's skills is part of the final clerkship examination. Students offer a brief smoking-cessation intervention to a simulated patient. Each session is videotaped. The simulated patient provides the student with some immediate feedback on his or her performance. Two faculty members review each of the tapes and evaluate the student's performance using the behavioral checklist. The mean score of the two reviewers makes up 10% of the final clerkship grade. The score sheets with comments are available for the student to review. Discussion: In the past, the smoking-cessation module was not implemented systematically across clinical campuses, students reported redundancies in the readings, and they disliked being videotaped. They asked for additional guidance in preparing for the PBA and for more timely feedback on their performances. All of these issues have been addressed with the improved module based on the new national guideline. Evaluation of the new module includes students' scores on the performance assessment, reactions from the community coordinators, feedback from the simulated patient about students' doctor-patient interactions during the interview, and students' feedback about the smoking cessation module as to its implementation, practice relevance, and skills learned.