A Description and Qualitative Assessment of a 4-Year Intervention to Improve Patient Counseling by Improving Medical Student Health

Abstract

Background

To test whether promoting medical student health could efficiently improve patient counseling, we developed and implemented a 4-year-long curricular and extracurricular intervention to promote healthy behaviors among students in the Class of 2003 at Emory University School of Medicine, Atlanta, Georgia.

Methods

We asked students: (1) “What did you think about these [listed intervention components]”; (2) “did any of these interventions influence your personal health habits/attitudes toward your personal health”; and (3) “did any of these interventions influence your behavior or attitudes regarding current or future clinical practices, including history taking or counseling? If so, how? If not, why not?” Students evaluated the effectiveness of these formats and proposed changes in our intervention. The focus groups were transcribed and analyzed with QSR N5.

Results

Several major themes emerged from the focus groups:

• Listen to the students early, often, substantively, and noticeably;

• Incorporate many faculty and student leaders;

• Quietly integrate the curricular activities into the regular curriculum;

• Provide a strong, science-based, pragmatic prevention curriculum to complement the personal health promotion;

• Don't just use lectures to teach;

• Offer plentiful, nonrequired, fun extracurriculars;

• Don't nag;

• Have achievable interventions and recommendations;

• Provide collective data, but don't overexpose the students to it, and don't assume that collective data apply to every student, especially if it's unpleasant news;

• Provide personalized data where possible; and

• Uncouple evaluations from the intervention, and keep evaluations brief.

Conclusions

Some students seemed pleased to have their medical school be attentive to their health, and believed that the project positively influenced their personal health practices and clinical practices (which was our goal). The students enjoyed many components of the intervention, especially the extracurricular activities, and recognized that they and their classmates were at risk for unhealthy behaviors that had personal and clinical implications. However, many also felt resentful and that they were nagged. Although we had anticipated these responses, and had therefore taken pains to avoid the things that the students most resented, we were insufficiently sensitive to how strong those responses would be.

Introduction and Background

In 1999, we began a 4-year intervention, a set of curricular and extracurricular activities to improve prevention counseling by improving the personal health practices of Emory University School of Medicine's (Atlanta, Georgia) Class of 2003. We began and carried out this project with a foundation in the relevant literature, with knowledge of the theoretical and practical barriers and aids to our efforts,[1–13] and with strong partners within and outside of our institution. We knew from our[1–3] and others'[14–16] work that physicians' personal habits strongly affect their patient counseling practices, and that prior attempts at improving prevention counseling practices among medical students[17,18] and physicians have been inadequate.[19–21] And we knew that there was room for improvement in student behaviors: Although prior literature typically included small student populations and some student practices are healthy,[22] healthy behaviors seem to be poorly maintained in medical school[23] and residency,[24,25] with (for example) an increase in alcohol consumption and a decrease in socialization and exercise.[26] We also learned that, despite the existence of these poor behaviors, and the personal and clinical consequences of this for students and their patients, the number of medical student health-promotion programs is declining.[27,28] We therefore crafted our hypothesis that we could encourage healthy behaviors among medical students, and that it would be important to do so, as it would make them into better counselors and more avid preventionists.[29] This article describes some important successes and failures of this program, with qualitative information, primarily related by focus groups conducted during the intervention class' senior year. (Subsequent articles will address the quantitative, survey-based findings of our work.)

Foundation of Emory's “Healthy Doc-Healthy Patient” Project

Emory's “Healthy Doc-Healthy Patient” Project (HD) is part of a larger examination of medical student health. For this part of HD, we developed and implemented a 4-year-long intervention to promote healthy behaviors among students in the Class of 2003 at Emory University School of Medicine. This study was a treatment-control group design: Emory's Class of 2003 (with whom we conducted the focus groups in February 2003) was the treatment group, and the Class of 2002 was the control group. Advantages of this design were having similar populations in the treatment and control groups, temporal proximity to avoid secular trends, and relatively good control over students' exposures to the intervention. Disadvantages included having a small sample with limited generalizability and some risks of control-group exposure to the intervention. This article describes the experience of the treatment group: a description of the intervention to which they were exposed and a qualitative assessment of their experiences of that intervention. Subsequent articles will quantitatively compare the counseling and other outcomes of the treatment and control groups.

Objectives

The study's foundation was scientific literature that supports intuition: Healthcare providers preach what they practice. Analyses of physician behavior have shown that physicians who have healthy personal habits are more likely to encourage patients to adopt such habits.[1] However, despite the clear possibility that promoting medical student health should therefore be an efficient and effective way to improve patient counseling, we know of no other coordinated curricular and extracurricular program testing that possibility. Our purpose was to test this new method of promoting prevention among medical students.

The HD Interventions

A major mechanism for developing HD curricular interventions was multiple iterative discussions with course directors in the basic science years and clerkship directors in the clinical years. The principal investigator (PI) approached these individuals first by email and then in private discussions, first explaining the project and giving examples of the kinds of interventions one may consider, and then asking the directors for other ideas that they would be willing to try. Implementation was at the directors'/professors' discretion, with reminders, but without incentives or disincentives. Despite curricular change often being met with resistance at many institutions, there was considerable faculty receptivity both to the concept and its implementation; all contacted faculty agreed to meet, and all incorporated some (and often major) aspects of HD into their work. This can be seen from the multiple curricular interventions listed in Lists 1 and 2 (all of which were confirmed as having actually been implemented). Interventions are organized by year of training, so that medical educators who may be interested in duplicating some of this initiative can see where various components fit into the curriculum. Human Subjects approval was obtained for this work.

List 1. HD Curricular Interventions: Lectures to Whole Class (Only in Preclinical Years)

First year

• Orientation: half-hour PI lecture with questions and answers on scientific basis for HD

Sophomore year

• Behavioral science: physician panel of former substance users (also done in previous years, with a new [minor] emphasis on normativeness of healthful behaviors)

• Behavioral science: 1-hour talk on alcohol and tobacco use habits of physicians, US medical students, and Emory 2003 medical students by PI

• Nutrition course: plant-based diet lecture (given yearly by the PI and her physician-husband) with new emphasis on personal dietary practice

• Pathophysiology: mention made of need for students to have healthful drinking habits themselves in lecture on alcoholic liver disease by regular pathophysiology lecturer

List 2. HD Curricular Interventions: Nonlecture Format

First year

• Anatomy: booklet on strengthening particular muscles, given by anatomists

• Medical decision making: used their own data to learn stats, with homework assignment (from dean/professor) and in-class discussion (from dean/professor and PI)

• Patient-doctor small groups: pairs of students presented papers they chose to write on physician/medical student health (averaging 1 such paper in half the small groups)

• Problem-based-learning small groups: unit on a substance-abusing physician (also done in prior years), with accompanying email from PI on physicians' substance use rates

Sophomore year

• Clinical methods: afternoon on exercise with mixed lectures and demonstrations, moderated by PI with guest lecturers

Junior year

• Dermatology: letter on the importance of skin cancer prevention for themselves and their patients, a review article on skin cancer-prevention strategies, and a container of sunscreen for their own use, all from clerkship director

• Ethics/medicine: completed advanced directives and living wills for themselves

• Ethics/psychiatry: completed a Beck Depression Inventory and an alcohol (CAGE) screening questionnaire on themselves

• Family/internal medicine orientation: Instead of role-playing being patients, students practiced patient counseling with their own personal health practices (with 2 follow-ups in family medicine, all with PI, for a total of 1-3 hours)

• Family/internal medicine orientation: 30 minutes of instruction and practice with health-risk appraisals (HRAs), reviewing results of their HRAs on their own, and with a classmate

• Family medicine: students (and occasional preceptors) kept 1-week logs of daily number of fruits/vegetables and exercise amount/type, and submitted to clerkship director

• Family medicine: wrote description of their ideal lifestyle a decade hence

• Ob/Gyn: articles assigned on women physicians' characteristics during pregnancy, sexual abuse/domestic violence rates, and depression/suicide rates in preparation for lectures by Ob/Gyn faculty on these topics

• Ob/Gyn: students given American Cancer Society breast self-exam shower card

• Ob/Gyn: students given condoms and emergency contraception offered as requested (offered occasionally in prior years, also)

Senior year

• Medicine subinternship: Under the PI's (and, later in the year, other preventionists') supervision, students practiced doing histories, physical exams, assessments, and plans on each other, with an emphasis on reviews of their personal health practices for 1-2 hours

• Medicine subinternship: All ward attendings and supervising physical exam faculty were sent a 1-page email message explaining HD prior to their beginning a month supervising the seniors, asking them to reinforce HD concepts

Few curricular components are required at Emory in the first 2 years, but most students usually attend class. Students received no extra credit for participation in the intervention, and exposure to specific course components was untracked for individuals and (such as exposure to the extracurricular interventions) not universal in the first 2 years. Full participation in the curriculum is expected and usual in the last 2 (clinical) years.

In addition to curricular interventions, we also provided many noncompulsory, extracurricular opportunities (see List 3). These ideas were generated by our HD team or derived from conversations with Emory faculty, or were, most gratifyingly, often the products of conversations with and requests from intervention-group students (also noted in List 3).

List 3. HD Extracurricular/Optional Interventions

(includes approximate number of student attendees [typically all students in the Class of 2003 being electronically invited], presented in chronologic order within year; “SI” denotes a student-initiated idea)

First year

• Saturday visit to PI's mountain house (10 students)

• One-hour healthy, quick-cooking class by PI and a nutritionist (10)

• One-hour lunchtime (with free healthy lunch) panel (including PI and her husband) on living a well-balanced life (30, SI)

• Personal health prescriptions provided to students subsequent to lifestyle review with PI (5)

• Afternoon hike and healthy dinner with PI (4)

• Emailed message inviting M1s to submit projects that they would like done for HD intervention (all)

• Emailed note to students encouraging a healthful and pleasant summer vacation (all)

• Students worked full time with PI for summer on new interventions for their class (3, SI)

Sophomore year

• “Health Heads Up” – monthly emailed summary of a half-dozen prevention-related studies, written by classmate (all, SI)

• Lunchtime massage “hands-on” seminar with data on physiological effects of massage (free healthy lunch provided) (30, SI)

• Lunchtime yoga/meditation seminar by visiting MD on the health and psychological effects of yoga and meditation (free healthy lunch provided) (50, SI)

• A piece of fruit and a “have a healthy/happy holiday” note put into students' boxes the day before prewinter holiday exams, and a similar note posted on their emails (all)

• Personal health prescriptions provided to students subsequent to lifestyle review with PI (5)

• Lunchtime talk (free healthy lunch provided) on pathophysiology of stress and what can be done about it by Emory PhD counselor (30)

• Emailed message that HD featured on the back cover (and on page 8) of the Emory Medicine magazine (message read by 104 students)

• Two wine-tasting seminars (attended by about 30 students each time, SI) to teach about using alcohol for purposes other than inebriation at PI's house

• Monthly walks/runs (1-10, SI)

• Weekly yoga classes (1-6, SI)

• Sponsored entrance fees for races (5, SI)

• Healthy breakfasts prior to joint exams (all, SI)

• Healthy Quick Asian Cooking class, proposed by and cosponsored with Asian student group (30, all)

• PI presented HD at plenary for Student National Medical Association meeting in Atlanta (10 Emory students and 200 other medical students, SI)

Junior year

• Validation study for HD food-frequency screener, including 5 in-person, 24-hour recalls; 2 HD food-frequency questionnaires; personal analysis of fat and fruit-vegetable intake; and $100 for participants (20)

Senior year

• Students given toothpaste and a travel toothbrush imprinted with “Well, at least my teeth are healthy” (all)

• PI attended Match Day and graduation activities, and attended senior banquet, giving students champagne and flutes (engraved with “”EUSM Class of 2003 – To your health!”), and toasted/thanked them

We chose interventions for several different reasons. Some suited theoretical models, such as having the PI modeling desired behaviors or having students lead activities to provide the role modeling and opinion leaders described in Bandura's social learning theory.[30] Some, such as lectures on the scientific basis of HD, provided the intellectual foundation so that this sophisticated population would understand and possibly subscribe to the reasons why they were receiving the intervention. And many interventions were chosen to respond to students' desires for self-improving, yet fun extracurriculars.

In addition to these personal health interventions, we believed that students needed to understand the scientific basis of disease prevention in order to be motivated to improve their personal and clinical health habits. Because provision of this basic prevention curriculum was not part of our study question, we gave both treatment and control groups an expanded, more coordinated prevention curriculum than had been provided to prior classes at Emory. In addition to their traditional 12-hour, sophomore nutrition course, we helped coordinate about 10-15 hours of additional lectures and some nondidactic exposures about nutrition, exercise, tobacco, alcohol, heart disease, hypertension, cancer screening, patient counseling, and other topics in prevention, with materials usually presented by locally based national leaders in these fields.

Methods

The focus groups' purpose was to hear fourth-year medical students' (M4s') responses to HD, and to learn whether HD had affected their personal health habits and/or their professional counseling practices. Only M4s who had completed all of the HD senior-year interventions by January 2003 were eligible for participation in these 2 focus groups (75 students out of a class of 112). To minimize response bias, we advertised a generic “discussion about your medical school experience” via email, offering the students dinner and $50 for 2 hours of their time as incentives. Twenty-two students quickly responded to this email invitation, of whom 15 had completed their intervention exposures (and were therefore eligible to participate) and had no scheduling conflicts. Final group demographics were one group of 7 students (3 women, 4 men; 3 Asian, and 4 white) and a second group of 8 students (5 women, 3 men; 7 white students and 1 “other”); this was a similar mix to our study population.

Two departmental staff members who the students were unlikely to associate with HD and who were experienced in qualitative research methodologies facilitated the discussions. We organized the discussions around a presentation of the 3 intervention types that best characterized HD interventions: lectures, nonlecture curricular interventions, and extracurricular interventions. These interventions are outlined in an expanded and modified form to enable reader usage in Lists 1-3 (actual formats presented to students are available from the authors). For each format, we asked students to respond to the following set of questions:

• What did you think about these (listed intervention components)?

• Did any of these interventions influence your personal health habits? Did they influence your attitudes toward your personal health? If so, how? If not, why not?

• Did any of these interventions influence your behavior or attitudes regarding current or future clinical practices, including history taking or counseling? If so, how? If not, why not?

Students were then asked to evaluate the effectiveness of these formats, and to articulate any changes that they would propose to their medical school curriculum to better support healthy habits.

The focus groups were transcribed and then analyzed with QSR N5, a qualitative research software program that facilitates thematic coding. We had originally considered conducting additional focus groups and/or individual interviews. However, on the basis of both the within-group variety and between-group congruency of student responses during the first 2 focus groups, we determined that we had reached saturation regarding students' evaluations of HD. Many of the comments that were made in the focus groups also echoed comments that had been casually made in prior years by the students, and were concerns about which we were aware and had tried (with varying degrees of success) to address during the intervention.

Results and Discussion

Below we give examples of each intervention type, highlighting major topics and themes that emerged from the 2 focus groups (labeled “A” and “B” after each numbered speaker), and especially noteworthy quotes for each theme.

Lectures

Of the 3 formats through which the HD program was delivered (lectures, nonlecture curricular components, and extracurricular components), focus group responses suggested that students found the lectures (List 1) least positive. Senior students had few or no memories of 2 essentially mandatory lectures: a half hour on the basics of HD presented in their first-year orientation and an afternoon of lecture/demonstration about exercise that was their last class of sophomore year. Two other lectures provoked actively dissatisfied responses: a lecture presenting their alcohol/tobacco data from the HD surveys and the lecture on plant-based diets. Students, however, were unanimous in their praise for the panel of medical students and physicians with substance abuse issues, remembering it in great and positive detail several years after the event.

Physician Panel on Substance Abuse

Respondents described the physicians' substance abuse panel as highly effective and useful, both in format and content (List 1, sophomore year, lecture 1). Students reported that physicians who develop substance abuse problems aren't significantly different from themselves (and that therefore they aren't immune), and that many of the behavior patterns that contributed to these physicians' substance abuse problems are directly traceable back to patterns established in medical school. They also realized that with greater access to controlled substances comes greater responsibility, and thus they need to prescribe controlled substances thoughtfully. They recognized, too, that substance-abusing physicians can get help without necessarily sacrificing their careers. Although this panel was sorted into the “lecture” category, the format of having physicians speak from their personal experiences was less didactic than a traditional lecture, and was part of the appeal:

• 3B: “Their stories were so shocking. Like you couldn't help but pay attention.”

• 6B: “I agree … there was a definite impact of just seeing this and seeing this as such a huge problem among physicians. And I think that just knowing that if I ever found myself in that situation, that I know that there are outlets for that, that are out there to protect me … .”

• 5B: “And I think sometimes we think that it will never happen to you. You know, I always thought, it will never happen to me. But from those stories, they didn't think it would happen to them either. You never know if that kind of stuff will happen, it could happen to you.”

• 3B: “And they were all young. They looked like us.”

• 7B: “And it was so easy to trace their behavior from medical school, like you know, through their careers.”

Alcohol-Tobacco Lecture

In the students' sophomore year, the PI presented them with a 1-hour talk on the results of their and our national survey data regarding students' and physicians' alcohol and tobacco use, showing that binge drinking (> 4 drinks at least once in the past month) was more common in their medical school class than at other US medical schools (List 1, sophomore year, lecture 2). Almost 3 years after this presentation, students were still reacting to these data, describing it as an example of HDs' (and its PIs') attempts to badger them into behavior change. Several of the students argued that poor sampling times skewed the results, and others voiced resentment about the survey's focus on their class as a whole and nonindividuation of results from this questionnaire. Their negative responses seem to have been exacerbated by the sensitivity of the question, their mixed and complex attitudes toward the high binge-drinking rates in their class, some students' erroneous perceptions that the PI was presenting the same information multiple times, and that we had ended the medical school's provision of kegs after their exams (although we had asked only that nonalcoholic alternatives also be provided). These data, the PI's presentation of the data, and their perceptions challenged a venerable medical school tradition of coping and bonding with classmates by drinking:

• 4B: “I remember the one where the alcohol and tobacco information was presented. I think we all certainly had an idea about where Emory was, but compared to other schools it probably surprised us a little bit.”

• 2B: “We heard that lecture, though, several times, like 3 or 4 different times, the exact same information throughout the curriculum, so it was a little repetitive.”

• 3B: “I'll be honest with you, sometimes when they would start and they'd say, Healthy Doc, I'd be like, Oh God! We're going through this again, you know, like, I get it, we drink too much. It would get repetitive and kind of redundant. I kinda felt like, I'd had enough.”

• 2B: “I guess we kinda thought that the sample wasn't entirely representative of what our true habits are because they were kind of skewed always around breaks or after tests, or things like that, and so, it maybe wasn't as effective in changing habits and things like that because you could automatically make the assumption that it was just poor sampling time.”

• 3B: “You see it as a group that our class drinks this much, but you can always say, ‘oh that's the outliers, that's so and so.'”

• 5B: “Yeah, that's a bunch of guys getting drunk all the time that skews the rest of the class ha, ha!”

Plant-Based Diets Lecture

The lecture presented on plant-based diets prompted a variety of responses (List 1, sophomore year, lecture 2). Some students believed that the lecture presented this as the only way to eat, and thus felt personally attacked because they eat meat. Others argued that while a plant-based diet probably was the healthiest diet, that it was not something that they could realistically promote to their patients because of their perceptions of the high cost of fresh vegetables. Overall, students noted that they would have liked to have received a wider range of nutrition information than that presented by the lecture (although we had indeed coordinated our curriculum with the rest of their 12-hour nutrition curriculum), and to have had that information be more pragmatic and geared toward the indigent population that they primarily now serve:

• 7A: “I thought that that actually seemed kind of biased, did it not? That was like if you eat meat you're definitely going to hell and you're gonna have a heart attack by the time you're 40.”

• 5A: “Like our patients at Grady have access to like $500 a week for vegetables. You know, it's not realistic, it's not a way to teach to people that are not ‘upper class’ how to actually do that.”

• 3A: “I do remember one thing from that: Nuts reduce heart disease. Now I eat nuts. I started eating nuts.”

• 4A: “If someone explained what the actual research behind any of those was, so when people ask me a billion times a day, I would actually say something besides, ‘That's bad.’ I think offering practical options for everything, whether it be you or your patients – healthy eating or whatever – rather than idealistic would be much more effective. Because we don't have any money either. Nobody has any money, and you know with – to eat tofu and everything, is expensive.”

Nonlecture Curricular Components

Students responded to the nonlecture curricular components in a variety of ways (List 2). Of remembered components, they responded especially well to those that were invisibly integrated into the curriculum, such as those that took place in their Obstetrics/Gynecology (Ob/Gyn) rotation (assigned readings on women physicians, provision of breast self-exam cards, condoms, and emergency contraception). Responses to the components more obviously a part of the HD program were more negative, particularly those that involved self-assessment. Several students saw exercises, such as the practice history/physical and assessment/plan on each other, and their personal and attendings' fruit/vegetable/exercise logs as onerous and/or ineffective, especially when faculty were uninvolved.

The following are comments on assigned readings on women physicians (List 2, junior year, Ob/Gyn activity 1):

• 4A: “I thought that was really good, I actually did those readings and thought they were excellent, they were very good.”

• 7A: “I did do those readings, actually, and I saw that it was helpful. I mean, like nowhere else would we get a reading like this, which I mean you could take it to be good or bad … I think that it might be more relevant to the women physicians in the room, but I thought they were excellent.”

The following are comments on the fruit, vegetable, and exercise logs (List 2, junior year, family medicine activity 1):

• 1B: “I thought it was incredibly redundant because we took that so many times, along with that 10-page questionnaire.”

• 7B: “I didn't think that one was that bad. I thought that was kind of useful for me to see where I was, but it was kind of obnoxious to fill it out and do it.”

• 4A: “And that [the fruit, vegetable, and exercise log] was also required and my preceptor also was like, ‘What are you talking about?’ My preceptor was not about to even spend the time to.”

The following are comments on practice counseling on peers in medicine subinternship (List 2, senior year, medicine activity 1):

• 2B: “It's not anything we're interested in doing at that point when we've done 4 months of medicine in our med school already, and a month of family and whatever.”

• 4B: “Not only was it a waste of time but people didn't take it seriously so … most people were just talking to each other.”

• 2A: “I think in general my suggestion would be to have less of that self-assessment and peer assessment. I think it was supposed to be personal enhancement for us, and I don't think it was effective if it wasn't for data collection … because your peers, I mean, it's just – it's a joke.”

Extracurricular Components

Students were positive overall about the extracurricular components of the HD program, many of which were suggested by the students themselves. (These are noted as “SI” for “student initiated” in List 3.) Whether or not they chose to or were able to participate in these activities, they liked having various healthy options made available, especially wine tasting (to learn how to use alcohol as something other than an inebriant), healthy breakfasts before exams, weekly walks/runs, the weekend visit to Dr. Frank's mountain house, and the yoga classes. As noted immediately above, several students commented that faculty involvement in these activities signaled to them that faculty supported their efforts to lead a balanced, healthy life. Students also clearly liked that these were optional activities, of which they were able to select what interested them, and appreciated our responsiveness to their interests and concerns:

• 6B: “I liked the breakfasts, that was always nice.”

• 7B: “We got bagels. And fruit and stuff. It was the best breakfast.”

• 7A: “I did do the wine tasting seminar. That was fun.”

• 1, 2, and 5A: “That was fun, that was fun.”

• 6B: “I wish I had gone to the yoga classes. I always see things and I just never went.”

• 7B: “I think one good thing about all this stuff is that it makes us – it makes us aware of these things so that we can recommend them, you know, like being aware of yoga classes.”

• 2B: “And she did a few things like, you know, she'd invite people up to her house in North Georgia, which was actually a very nice thing … it was kind of healthy ideas just sort of in a different way than we've ever seen it.”

• 7B: “It was neat to see that somebody did it. Like you see magazine pictures of like solar everything, but never know that somebody actually did it.”

• 6B: “I do remember the stress relief lunchtime talk. I actually remember a lot of people going to it and it was a really good talk. I have a lot of memories of that.”

• 2B: “Yeah, it was also that he seemed to have it paced with like the terms of pathophysiology about how stress really affects your body. I thought that was good.”

• 3B: “Yeah, I'm looking at these [lists of extracurriculars] and thinking, ‘Why didn't I go to more of these?’” [general laughter].

General Evaluation of HD and Medical School Experience

Effect on Clinical Practice

Students seem to have understood the premise of HD, the relationship between their personal health practices and their clinical practices, and to attribute some of their interest in prevention to the intervention. Some students stated that they now believed that discussing prevention with patients was “second nature” to them. Several stated that it was important for all medical students to establish prevention counseling habits while in medical school, although others believed that it was sufficient for primary care physicians to receive such training in residency. Although some believed that the prevention training that accompanied HD was superfluous, others believed that their prevention training was insufficient, especially in providing specifics:

• 1A: “I think that for me the influence it had was to pound in that idea that if you're a healthy physician, your patients will believe what you say, more than if you're a superfat, smoking physician.”

• 6A: “I think that in terms of usefulness, I think it sort of depends on what field you're going to go into. And we pretty much, we all knew what was healthy and what was not at this point in med school.”

• 5A: “I disagree, though. It's like we're all going to be doctors. People are going to see us as doctors. And people are going to come to us with questions.”

• 3B: “To me it kind of seemed obvious. You know if someone was to say, ‘How can I exercise,’ that you would say, ‘well I do this.’ It just seemed kind of obvious, and I don't know if that's because our class has this and it's just ingrained into us, but it didn't seem like new information.”

• 6B: “I certainly did more [counseling] than I would have expected, and I don't know if it had anything to do with this or not, but I do remember that often coming up and talking to patients about it, so maybe I remember more than I expected. And maybe I wouldn't have if it hadn't been so pressed into us.”

• 2B: “We don't get a lot of preventive medicine and sort of recommendation-type instruction … and you may not be able to answer with any specifics or with current research about what that actually means to a patient.”

• 6B: “I think that that type of information would have been good both for us counseling our patients and probably for ourselves.”

• 3B: “In our standardized patient exams, sometimes that's all I do, though, is talk about preventive stuff … I don't know if I would have done that otherwise, because it seems just like second nature to do that, so maybe it's because we had it so integrated into our curriculum.”

• 1B: “It's hard to tell what we'd be like without all this stuff.”

• 5B: “But I think if we hadn't learned this thing, if it wasn't emphasized to us, in the future, like, if I was seeing a patient, it wouldn't even go through my mind to ask them about their exercise habits or eating habits. I think I would do a typical H&P [history and physical] and that's it and leave it there. But I think in the future I may make an effort to address that problem.”

• 5B: “I think also, if you never get in the habit of doing that, later on you're not going to do that. So if you start in the habit right now, when we're in the initial stages, we can mold ourselves to ask those primary questions. Later on, it goes a long way to really ask those questions when we get into practice. Or you know, if we stay with the same population, even if we reach 10 people a year, you still have made a difference. That's 10 people you have reached.”

Influence on Personal Health Habits

Many students stated that multiple aspects of the HD program had a positive influence on their personal health. They particularly liked the practical ways in which HD supported their positive efforts and reinforced the influence of their peers' already generally healthy habits, such as providing healthy options at breakfasts served before exams or supporting exercise through scheduling walks/runs and yoga classes; even if they didn't always take advantage of these options, they appreciated their existence. However, many students were also annoyed by the emphasis on personal health, finding it preachy, insistent, and impractical:

• 4A: “I do think that we're lucky. I can't believe that I'm saying this, but I do think that we're lucky, because I think at a lot of other medical schools there is no push to becoming healthy, and although we were bombarded with it [pause], its nice that we do have options.”

• 3B: “So I think for me, it's kind of natural, so I don't know whether what I tell my patients actually changed, but it gave me ideas for what I do in my own life.”

• 6B: “I think that probably those breakfasts, before the joints [exams], did influence my later breakfast eating habits … it showed me that there was a different way to live!”

• 3B: “She did do, she told me one thing that has revolutionized my ice cream eating – is that Ben & Jerry's frozen yogurt is actually really good, and it really is!”

• 3B: “I think what promotes my health the most is that probably everyone around me is active and that makes me, like I feel bad when I'm lazy when everyone else in the class is like, ‘I'm running a marathon tomorrow!’ you know? So I think that helps, just being in a group of people that are in general active.”

• 6B: “It's so easy to just say, ‘Well, you know, I'm in medical school, I don't have time to exercise. I have too much stress – I should be able to eat whatever I want,’ but when you look at your peers… .”

• 2B: “It's more important in a way for setting the tone for what's going to be important in our life, but we're all going to face those things that are going to make us really reevaluate our lifestyles.”

• 5B: “Right. We're going to get more busy.”

• 6B: “Exactly. It's not going to get easier.”

• 2B: “Just one more thing: About those walk/runs, she also sponsored people's entrance fees into some races and things like that. I thought that was really cool. That was really encouraging for a lot of people that wanted to sign up for some of those races – that was a nice thing associated with HD.”

Negative Aspects

• 3B: “Yeah because he [Dr. Hilton] used to take us all out after the joints [exams] to a bar, and he was like, ‘Well, I'm sorry that I didn't give you a healthy option.’”

• 2B: “It was pretty aggressive to someone who's just trying to do something nice for you to say well ‘why don't you have carrot sticks and celery at the bar for them to munch on, too?’ It's like, oh come on.”

• 3B: “It got to the point that where when there's an HD thing, people would bring Krispy Kreme, or something like that.”

• 2B: “You know, I don't have that many options. I can't afford to buy organic food, so leave me alone.” [ha, has]

• 3B: “You know, again it's just not realistic. I mean, we're going to go out and we're going to have a drink at times. Like to tell us not to do that ever is just not going to work.”

• 7B: “But I mean, I remember like at the beginning of starting school, like feeling guilty for having a car because I don't ride my bike everywhere, you know. And you can't, you know … she was very aggressive about some things and it's nice that she rides her bike, but it's just not safe with our hours.”

• 6B: “I think that all in all, I think one thing that sums up a lot of this is the guilt approach, probably … I think that it seemed that that's a big part of why everyone put this aggressive stigma on it, is that you never like people to harp on you and make you feel guilty about what you do. It's not the best way to change their habits.”

The Questionnaire

Although it was not included in the focus group agenda, students were eager to discuss their dissatisfactions with the HD questionnaire and its administration. Students also attributed many of their negative feelings about HD to their negative reaction to the survey, both their response to taking it and to hearing their results. Students believed that the surveys were too long and repetitive (taking approximately a half hour per administration and given 3 times over their 4 years of medical school), and seemed to resent that it forced them to examine and consider disclosing personal health habits. They were also concerned about data validity, stating that questionnaire timing gave skewed results about their behaviors, depending on whether they had recently taken an exam or been on vacation. They suggested that in the future, the HD program should administer shorter, more targeted surveys, and perhaps make them available online:

• 5B: “Those questionnaires were long! You've got to cut it down; you've got to cut it down!”

• 6B: “They wouldn't give them at a good time – like a lot of times, remember? It was like the worst time when everyone would just want to get out of there.”

• 3A: “And also a lot of it's like, ‘How many drinks have you had this week.’ And you were like, ‘Well. I just took a joint [exam]. None. Unfortunately.’ And, ‘how many drinks are you gonna have next week?’ A lot! You know.”

• 4A: “I think that's when all the hard feelings come from it … it's just because being forced to fill out a questionnaire that is for somebody else's data that is of no benefit to you, is just ridiculous.”

• 1A: “And it's not sensitive to us. It's [HDs] kinda trying to encourage us to be more healthy … and it just gives that to us in the most stressful times – it seems to kind of contradict what it's trying to achieve.”

Participation of Other Faculty and the Medical School Administration (Regarding Both Curricular and Extracurricular Interventions)

Students were especially supportive of interventions when the faculty were varied, actively involved, and upper-level, including representation from the Dean's Office:

• 2B: “I mean the faculty did support this – it's nice to know that your school does support that and that they do want you to have some outside interests and still be able to lead a pretty healthy life … it was nice to be encouraged in that way … . and to have a lot of active people. You know it was just nice because you did have some support for this as something the school promoted, so I think that's always to your benefit if you kind of associate your school with these ideas.”

• 5B: “I think faculty could get more involved. I think there is the support from the faculty and administration, but I think there's more emphasis on grades and applying for residencies and doing well on the boards than exercising. I think what she's doing is a good thing, to emphasize: ‘Look you know, that it doesn't end with studying all day long; you've got to take care of yourself.’ But I think the administration needs to make a bigger push towards all that.”

• 3B: “It would make it fun though, it would make this a lot more fun if you could get just a few of those people who do not live the healthy lifestyle to try to change with us.” [general ha, has]

• 2B: “I mean she had some support from the faculty, like they always seemed pretty eager to say like, ‘OK, you can have one of my lecture hours to come do this or that.’ But I think it's not just like saying, ‘OK today's the HD lecture.’ I think there needs to be some faculty education, too.”

• 1B: “When you have it coming from someone higher up, you know if Dr. Eley [a Dean who participated in some of the curricular and extracurricular HD activities] has time to do this, I could make time to do this. You know, when you get the administration involved, I think it resonates more. You take it more seriously.”

• 2A: “I think they should just bring in more third-party people, to take away that – her face and everyone's attitudes that its going to be so tied with her and her personal beliefs – make it a little bit more broad, and bring in more third-party people.”

Conflicts About Presentation of Questionnaire Data

Students were conflicted about their interest in seeing their data. Although some wanted more information, especially more personalized information, others incorrectly believed that the PI was presenting the same information multiple times:

• 4B: “We had a lecture where she showed us the results – that was only one time where I remember that we got the results from all those surveys.”

• 2B: “We always saw our pool of data but we didn't always get a lot of individual feedback, and maybe it would be more motivating if you knew where you fell … for yourself and your patients.”

• 7A: “There was way too much self-assessment in general. I mean it was just like ‘OK, fine, I'm healthy; OK, fine, I'm a fat slob; whatever, I'm an alcoholic.’ It's like ‘All right, I get it,’ you know. It was just like OK, pretty much everyone either knows if they're healthy or not; they know what they could do better and they either do it or they don't. It's just like, ‘All right, you don't have to keep telling me about it.’”

• 2A: “I did that [HD's food-frequency validation project] and I thought that what made it helpful is that (and the reason I signed up for it is that) I actually got individual results for the first time when I did my food surveys. And it kind of broke it down like what percent calories, what percent fats, and the types of things that you were eating.”

Conclusion

These focus groups taught us many important lessons about students' perceptions of the intervention (see List 4). Some students seemed pleased to have their medical school be attentive to their health (in itself a positive outcome), and believed that the project positively influenced their personal health practices and clinical practices (which was our goal). They enjoyed many components of the intervention, especially the extracurricular activities, and recognized that they and their classmates were at risk for unhealthy behaviors that had personal and clinical implications. However, many were also resentful, and thought that they were nagged. We had anticipated these responses, and had therefore taken pains to avoid the things that the students most resented: None of the data were presented more than once; we tried to minimize the questionnaire length, and the PI stated frequently that the hopes for student healthiness were not because we thought that it would be proper or seemly for them to behave in a certain way, but because we were trying (as we did everywhere else in the curriculum) to produce better physicians. In fact, most of the students' concerns were issues to which we had been attuned since before beginning the intervention, and to which we had tried to be sensitive: providing basic prevention information, not being dogmatic, making the recommendations realistic, giving students some (although not excessive) feedback on their data, responding to student input, incorporating many other faculty into the intervention, and having it be a diverse approach. This suggests that although our intuitions about student reactions were correct, we were insufficiently sensitive to how strong those responses would be; we believe this is a critical take-home point for others interested in such an intervention, and could be addressed with having earlier and more frequent focus groups.

List 4. Major Themes From the Focus Groups

• Listen to the students early and often; respond to them substantively; and make sure that they know that you're listening and responding

• Have this be a multipronged effort, incorporating many faculty, the administration, and peer role modeling

• Integrate the curricular activities thoroughly into the curriculum

• Provide a strong, science-based, pragmatic prevention curriculum, giving them many practical strategies for helping patients

• Don't just use lectures to teach

• Offer plentiful, nonrequired, fun extracurriculars

• Don't nag or induce guilt

• Have interventions and recommendations seem achievable to the students

• Provide collective data, but don't overexpose the students to them, and don't assume that collective data apply to every student, especially if it's unpleasant news

• Provide personalized data when possible

• Uncouple evaluations from the intervention, and keep evaluations brief

The students had many impassioned responses in the focus groups, as well as many useful and sophisticated suggestions for changing approaches that could have helped considerably. Holding more focus groups could have made the students feel more listened to, and undoubtedly would have improved our intervention. It was clear that specifically they would have liked more panel discussions, more faculty involvement, a more comprehensive prevention curriculum that was more fully integrated into their general curriculum, shorter and more targeted surveys, plentiful extracurricular activities, and more institutional support for personal health.

We were interested in reasons why faculty responded so positively to the intervention and students more equivocally. We believe that the faculty's ability to participate only to the extent that HD interested them, and their not being asked to change difficult personal habits, and students' having many required/strongly encouraged components (such as completing the 3 lengthy questionnaires) fostered student resentment; this conclusion was reinforced by the students' enthusiasm for the extracurricular/optional components. Future interventions would do well to be more invisibly integrated into the medical school curriculum (including maximizing the number and variety of faculty role models and more effectively creating cultural compatibility in the medical school) and to clearly separate the intervention from its evaluation (perhaps rewarding or providing incentives for students to complete questionnaires).

Although our quantitative data will tell us more about the effectiveness of various components, several lessons are clear about students' perceptions. Some students overread the message, for example, saying that we wanted them to celebrate by eating carrot sticks or not ever drink (although we had provided 2 wine tastings). Although it is unclear how much this reaction was driven by intervention inappropriateness and how much by student resistance, it is clear that many students resented being told to change some of their habits. It is noteworthy that data and interventions about students' excellent and less-loaded behaviors, such as exercise, prompted few comments.

It would have been extremely helpful to have conducted focus groups earlier, and preferable to have had a purely random sample of students for the focus groups. Certainly, having 3 students from the intervention class working with us during first-year summer was important, as we got an early sense of students' responses and we were able to respond with additional interventions. We found many important lessons from listening to these highly intelligent, goal-oriented, and self-directed individuals.

Funding Information

Funding has been received for this project from the American Cancer Society, the US Centers for Disease Control and Prevention, and Merck Labs.