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Study explores how students' attitudes evolve

Ask any medical student "How's it going?" and you're likely to get an earful about what an intense experience medical school is. Much of that intensity relates to the volume of hard science students must learn. But what effect does it have on the softer side of medicine—the development of students' attitudes toward patient care? Surely they are significantly shaped during the four years of medical school.

Impact: Documenting if that's the case would seem simple enough. You design a questionnaire, administer it, then crunch the results, and there's your answer. The problem has been that such surveys have come up with different answers. Some have suggested that students tend to become less empathetic and more cynical during medical school. Others have concluded that medical school has a neutral or positive impact on attitudes related to patient care. What accounts for the variation? Maybe the studies measured slightly different attitudes or used different assessment methods. Or perhaps the problem lay in the fact that "attitude" was usually assessed as a single element.

In a study for the spring issue of the Annals of Behavioral Science and Medical Education, researchers at Dartmouth's Center for Educational Outcomes aimed to overcome these problems. Virginia Reed, Ph.D., the center's associate director, and her colleagues looked at changes in medical students' attitudes from more than one perspective. They asked students their perception of various issues in relation to them personally ("self ") and their assessment of the value placed on the same issues by the entire medical system ("system"). Six issues were examined: communication, empathy, shared decision- making, whole-patient care, prevention, and teamwork.

The study is part of an ongoing Dartmouth initiative called the Medical Education Assessment Project (MEAP). It uses a tool called a "core survey"—a detailed questionnaire that assesses student personalities, attitudes, beliefs, values, and activities. It has been administered to several hundred students at a number of medical schools. The attitudinal study was based on the results from the University of Washington Class of 1999, a group that had an unusually high participation rate. They took the core survey three times—during orientation, midway through year two, and during year four.

Researchers are usually happy to explain the import of their work, but Reed would rather not be quoted about this study. She says it is up to each school to assign values to the findings.

Findings: What were the findings? From a system perspective, students' perception of the importance of communication, shared decision-making, and teamwork increased over four years; empathy and prevention were unchanged, and whole-patient care declined. And from the self perspective, communication, shared decision-making, whole-patient care, and prevention all declined in importance; teamwork was unchanged, and only empathy increased in importance. Thus there was an almost complete disconnect between the system perspective and the self perspective in the students' assessment of the importance of these six areas.

Paper: Reed is determined to be nonjudgmental about the results, though the paper notes that the self perspective may represent more subjective, emotional judgments, and the system perspective more objective, belief- or value-related judgments. If that's so, the paper says, maybe "different factors influence the direction of attitude change for each component."

Perhaps, the paper suggested, "students are exposed to two very different sets of value structures in medical school. . . . Behaviors that students see modeled, either intentionally or unintentionally, in clinical situations are likely to be quite salient in shaping how they act, what they see as important, and what they value personally as physicians, regardless of what they hear in the classroom environment. Thus, a potential conflict exists between what has been described as the medical community's 'stated values' and its 'lived values.'"

In other words, in medical schools as elsewhere, "Do as I say, not as I do" doesn't work.

The next step for MEAP is to measure the development of students' attitudes across medical schools as well as over time.

Roger P. Smith, Ph.D.

If you would like to offer any feedback about this article, we would welcome getting your comments at DartMed@Dartmouth.edu.

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