|ORIGINAL RESEARCH PAPER
|Year : 2007 | Volume
| Issue : 1 | Page : 13
HIV and Diabetes Treatment Adherence: Premedical Students' Perspectives
NJ Borges1, JM Aultman2
1 Boonshoft School of Medicine, Wright State University, Office of Academic Affairs, Dayton, OH, USA
2 Northeastern Ohio Universities College of Medicine and Pharmacy, OH, USA
|Date of Submission||09-Mar-2007|
|Date of Web Publication||18-Apr-2007|
N J Borges
232 Frederick A. White Center, 3640 Colonel Glenn Highway, Dayton, OH 45435-0001
Source of Support: None, Conflict of Interest: None
Objective: This study explored how future physicians who are early on in their training conceptualize treatment adherence issues for a disease with a high societal stigma (e.g. HIV/AIDS) versus a disease with little to no societal stigma (e.g. diabetes).
Method: We surveyed 121 first and second year students enrolled in a BS/MD program. After observing a videotaped interview of a person with HIV/AIDS, students were asked to identify and resolve ethical dilemmas regarding treatment adherence, which were presented in the interview. This process was repeated for a videotaped interview of a person with diabetes. Students' responses to both interviews were compared.
Results: Analysis of qualitative comments indicated that students had difficulty identifying treatment adherence issues for high and low stigmatized diseases. Regarding the students' abilities to identify psychosocial factors and dilemmas for people with HIV, multiple concerns were identified, whereas most students had difficulty identifying psychosocial concerns for the person with diabetes. Most students had difficulty differentiating psychosocial dilemmas from ethical ones.
Conclusions: Results suggest that premedical students have difficulty identifying and resolving psychosocial and ethical dilemmas for individuals with differently stigmatized diseases. Their ability to understand and resolve treatment adherence issues is limited. Despite the fact that most students knew someone with diabetes, they had more difficulty identifying psychosocial issues associated with diabetes compared to HIV. Findings support the need for education and training in psychosocial/ethical issues related to HIV and diabetes for students to help them better serve patient populations with diseases that bear low and high societal stigma.
Keywords: diabetes, Human Immunodeficiency Virus, medical education, premedical students, treatment adherence
|How to cite this article:|
Borges N J, Aultman J M. HIV and Diabetes Treatment Adherence: Premedical Students' Perspectives. Educ Health 2007;20:13
During the last decade, numerous studies were conducted with medical students and physicians with regard to the provision of medical care to people who have an immunodeficiency virus (HIV). These studies assessed knowledge and attitudes (McDaniel et al., 1995; Ali et al., 1996; Kopacz et al., 1999; Al-Jabri & Al-Abri, 2003), perceptions (Najem & Okuzu, 1998), and willingness to provide care (Radecki et al., 1999). Ethical issues such as the health care provider’s duty to treat patients with HIV have also been studied. Post, Botkin, and Headrick (1995) assert that in addition to assessing cognitive and noncognitive factors of students applying to medical school, admission should also be based on a student’s willingness to accept risks which are inherent in medicine, such as the risks involved in treating people with HIV or AIDS. A lack of awareness however, of HIV/AIDS among individuals entering the profession of medicine has been noted (Anjum et al., 2005).__________________________
Other diseases of a chronic nature carry less of a societal stigma than HIV/AIDS but are still difficult for physicians to manage. Diabetes has been described as an overwhelming disease for health care providers to treat because of the complex and recurring issues that surround it (Beckman, 2004; Crutcher et al., 2004). While negative attitudes among medical students regarding a willingness to care for persons with HIV/AIDS has been documented in the literature (McDaniel et al., 1995; Radecki et al., 1999), this is not the same for diabetes (e.g. Medline database searches from 2000 to present yielded no studies of this nature). A literature review revealed only one study, which surveyed premedical students as part of a cross-sectional study of intent to treat persons with HIV at various stages of medical education (i.e. medical students, residents, and physicians) (Radecki et al., 1999). The literature about diabetes reflects no studies on this topic. Given that HIV/AIDS and diabetes research has mostly focused on medical students and physicians, we chose to expand the literature by surveying premedical students (in a combined BS/MD program). Specifically, the purpose of our study was to explore the process by which BS/MD students (also known as premedical students for purposes of this study) identify, deliberate and resolve treatment adherence issues, including psychosocial and ethical dilemmas, with a highly stigmatized disease (e.g. HIV) versus a disease with essentially little to no societal stigma (e.g. diabetes). We chose diabetes because of the similarity of treatment adherence issues between it and HIV/AIDS. Individuals with either disease share similar concerns about treatment adherence (i.e. unpleasant side effects associated with their medications, medical regimens that must be followed very closely, etc.).
Reviewing the process by which these students resolve an ethical dilemma common to both diseases will assist medical educators in identifying gaps in students’ mental processing and knowledge base, as well as uncovering their biases that may affect how they care for their future patients. We hope to develop educational experiences that reduce the likelihood that these future physicians will provide substandard care to persons with differently stigmatized illnesses when treatment adherence issues arise in the care of their patients. If we can gain a better understanding of premedical students’ abilities to resolve ethical dilemmas surrounding treatment adherence, we can make appropriate recommendations for curriculum changes and develop educational activities that may influence how these future physicians will provide treatment to differently stigmatized patient populations.
Data were collected during 2004 from first and second year BS/MD students at two consortium universities affiliated with the medical school. Students in the BS/MD program spend two years on the consortium campuses before entering medical school. All first and second year students enrolled in the BS/MD program from these two schools were eligible to participate. The institutional review board approved this study and 92% of the BS/MD students consented to participate.
To conduct this study, we first had to videotape interviews of patients and physicians. Standardized patients (SP) were used for the videotaped interviews and were provided with a script (see Appendix A for scripts). One SP played the role of a person with HIV and the other SP played the role of a person with diabetes. Interviews were conducted using the same format in a patient examination room in the medical school’s clinical performance center. A real physician interviewed the SP; both SP and physician were male. We recruited an SP in his twenties to play the role of the college student with HIV and a 60-year-old man to play the role of a patient with diabetes. These age groupings accurately represent the demographics of the population at large for HIV infection (CDC, 2004b, 2004c) and diabetes (CDC, 2004a). The high prevalence of HIV is noted in males aged 20-24 and 65-74 for diabetes. It was important for the students to perceive the actors (i.e. SP) as real patients and our choice of gender and age of the patients coincided with what the students would most likely encounter in clinical practice.
After the interviews were videotaped, the authors arranged to come to classrooms during the regularly scheduled BS/MD lectures. In a classroom setting, a total of 121 BS/MD students viewed a 15-minute videotaped interview conducted by a physician of a person with HIV who presented psychosocial and ethical dilemmas involving treatment adherence. Immediately after viewing the video, students were asked to respond to a questionnaire using open-ended questions (see Appendix B). These questions asked students to identify the dilemmas and to describe how they would resolve them. Students provided a written response to these questions (a 2-inch space was provided after each question) after observing the interview. A similar videotaped interview of a person with diabetes was then viewed and assessed by students in the same manner (i.e. again students were asked to identify dilemmas and to describe how they would resolve them). Videotapes were counterbalanced so that approximately half of the students viewed the HIV case first followed by the diabetes case and visa versa. For example, the second year students at one Consortium University viewed the HIV case first, followed by the diabetes case. At the other consortium university, the second year class viewed the diabetes case first, followed by the HIV case. The same procedures were used when collecting data from the first year students so that no group of students from the same campus viewed the video in the same order. Data were collected using standardized procedures from students in groups based on their year in the program (i.e. first or second year) and their consortium campus (see Table 1).
Table 1 provides a demographic breakdown of participants and the mean age of participants was 18.56 (S.D.=.681). Qualitative responses were reviewed by the authors and grouped by themes (treatment adherence, psychosocial factors/dilemmas, ethical dilemmas, and resolving dilemmas). There were no identifiable differences in responses among the groups who viewed case 1 before case 2. Also, the responses were not characteristically different between first and second year students. Thus, we do not distinguish individual groups in our results; the data reflect all 121 student responses.
Table 1. Demographics of Participants
Analysis of qualitative comments indicated that most students (64%) had difficulty identifying treatment adherence issues for high and low stigmatized diseases. One student recognized how the HIV (PWHIV) infected person’s concern about his appearance and what others might think interfered with his “actively caring for himself.” Thirty-six students (30%) felt that the person with PWHIV’s embarrassment about having HIV contributed to him not taking medications as articulated by one student. Students’ responses included statements such as, “He feels much embarrassment in having HIV and this resulted in him only partially taking his medications.” Some other students believed that the patient’s concerns about how to pay for the medication influenced his non-adherence. Twelve students (10%) identified that the PWHIV was concerned about using insurance to pay for medications either because his parents would find out about his HIV status if he used their plan, or the HIV would inhibit him from receiving his own insurance. Forty-two students (35%) identified that the PWHIV was afraid to take medication because of fear or concern that others would find out.” In describing the patient’s lack of understanding as contributing to non-adherence, a student reported, “He doesn’t understand the seriousness of the disease. He didn’t take his meds how he was supposed to which shows he doesn’t understand what they will do for him.”
Different themes regarding treatment adherence emerged for the person with diabetes. About 33% of all students believed the patient’s lack of knowledge about diabetes and the importance of treatment contributed to non-adherence. Patient’s concerns about side effects and their view that side effects of medication are worse than having diabetes were also recognized. Patients’ distrust of medication and view of medications as “chemicals” were identified as contributing to non-adherence. One student summed it up by saying: “The patient does not understand, and is afraid and skeptical of the medicine, and taking care of the disease seems like more trouble than what it is worth.” Seven students (6%) reported that non-adherence was because the patient was in denial about his diabetes and had minimized the seriousness of diabetes. One student commented: “Patient feels well enough that he cannot justify taking the medication and monitoring his blood sugars.” Another student responded: “Patient does not seem to really understand the seriousness of his illness and seems to be putting it off/not acknowledging it.” A total of 29 students (24%) believed that the patient was “fearful” about taking medication due to the side-effects, but no student considered this as a legitimate fear. One student described the patient as having an “exaggerated fear of the side effects of his diabetes medication.” Another student even suggested that the patient “get counseling to overcome his fear of medication.” Fifteen students (12%) recognized that the patient’s reluctance to change his diet or lifestyle contributed to his difficulty with treatment adherence. One student reported that the patient “Does not want medication to affect life; going out with friends.” Another student even attributed the patient’s non-adherence to laziness.
Regarding the students’ abilities to identify psychosocial factors and dilemmas for PWHIV, 38 students (31%) recognized the PWHIV’s sense of isolation and fear of telling people about his HIV status. In addition, 25 students (21%) recognized the stress and burden that the PWHIV expressed with regard to keeping his HIV status a secret. For example, one student stated: “The stress of his diagnosis is weighing heavily on his choices about disclosing his condition.” Sixty-seven students (55%) also recognized the PWHIV’s feelings of embarrassment and how this contributed to his isolation and/or hesitation to disclose. One student said: “The patient is embarrassed that he has HIV, he sees it as a weakness or something he did. He said people would “blame him”…He wants to tell his girlfriend but he is scared of losing her…”
Most students (73%) had difficulty identifying psychosocial concerns for the person with diabetes, and instead focused on the patient’s lack of understanding and unwillingness to follow their physician’s advice. Eighteen students (15%) recognized the person with diabetes was concerned about having to change his/her lifestyle and was concerned with about how to manage their diet during social outings. One student described the patient as having “…issues with how to control self and respectfully decline certain food items in formal situations,” whereas another student mentioned the impact of diabetes on his home life and recognized the patient’s view that “his wife was pushing the diet.”
About one-third of the students (30%) had difficulty differentiating psychosocial from ethical dilemmas and ethical dilemmas were often listed as psychosocial dilemmas. The primary ethical dilemma identified by students involved the question of whether or not the PWHIV should disclose his/her HIV status. Most students (83%) identified the main moral dilemma of whether or not the PWHIV should contact the person from whom they believed HIV was contracted, as well as their partner, or keep their disease a secret. The role of the physician in disclosing a patient’s HIV status to protect others from infection was also identified. For example, a student stated: “The physician is morally bound to make sure the patient does not spread the virus...” Students gave comments about the physician’s role in adherence with a few students and stated that “it is the doctor’s ethical duty to get the patient to take their medication.” Some students felt that the PWHIV should tell his/her parents about his/her HIV status and one student stated that “The family has a right to know.”
Students had more difficulty identifying ethical dilemmas for the person with diabetes. Twenty-three students (19%) identified the use of herbal or alternative therapies as an ethical dilemma. One student exclaimed: “I would explain to [patients] that herbal medications do not produce results, that they are not validated by the FDA….” Other students identified whether patients can be forced to take medications as an ethical dilemma. One student felt the dilemma for the physician was to “require regular blood monitoring, diet and medication versus letting the diabetes go.” Another student identified the ethical dilemma as the patient’s autonomy versus paternalism, or “what’s best for the patient.” Nineteen students (15%) did not answer this question or reported that there were no ethical dilemmas.
With regard to what students would do if they were the patient’s physician, 83 students (69%) indicated that they would encourage the PWHIV to tell others about his/her status, including their partner. One student was less specific about what he/she might do and stated, “The best way to help a patient with a dilemma (like in this case) is to listen to the patient and help inform them of the possible consequences or possible routes to take.” Another student described the physician’s role in a different light: “it’s hard to maintain a professional standpoint and give good, strong advice without overstepping your bounds but I may have been more upfront with the patient by stating some serious outcomes from his decisions.” One student went as far as to say that the patient “…should tell his family and his girlfriend and the girl who gave it [HIV] to him. If he didn’t, I would find a way to make him because it is also unethical to let people get infected when I could prevent it.” Eight students (6%) mentioned that they would like to help him manage his medications by “giving him a pill box” or “emphasizing the importance of taking medication.”
For the patient with diabetes the common themes that emerged included helping the patient to develop a better lifestyle (i.e. diet, exercise, etc.). There was inconsistency among students regarding their views on herbal medications. One student indicated that he would explain to the patient that “herbal medications do not produce results”, whereas another student mentioned that she would like to “learn what herbal remedies” the patient is taking. Thirty-nine students (32%) conveyed the importance of educating the person with diabetes about his/her disease, long-term consequences of diabetes, treatment options, and side effects of medication. One student reported: “Education is key. Keep in contact. Ask him if he has any concerns. Make sure he’s aware of later consequences.” Only ten students (8%) attempted to look at non-adherence issues from the patient’s point of view, imagining what it must be like to have diabetes and having to face some choices. One student stated, “I would better relate to the patient to make him feel as though we are on the same side.”
Table 2. Themes and Domains associated with Students’ Responses for HIV and for Diabetes
Out of the 121 student participants, only five (4%) indicated knowing someone with HIV and acknowledged the stigma and feelings of embarrassment surrounding that person’s case. One student commented, “[m]any of the issues in the case are very similar to my friend’s situation,” and another student responded, “…my good friend who no longer lives. He was never open about it until he was about to die…” For diabetes, 81 students (67%) indicated knowing someone with diabetes, and in most cases it was a family member who had the disease. The psychosocial issues expressed by the standardized patient with diabetes were similar to participant responses when they described the person(s) who they know who have diabetes.
Results of this study suggest premedical students have difficulty identifying and resolving psychosocial/ethical dilemmas for individuals with differently stigmatized diseases. Their ability to understand and resolve treatment adherence issues is limited. Even though most students knew someone with diabetes, they had more difficulty identifying psychosocial issues associated with diabetes than with HIV.
Reviewing the process by which these premedical students resolve psychosocial/ethical dilemmas common to diseases has assisted us, as medical educators, in identifying gaps in students’ mental processing and knowledge base. It has also helped us to uncover the students’ biases that may affect how they care for their future patients. We hope to help students recognize and become knowledgeable about psychosocial/ethical issues in chronic illnesses so they can provide optimal care to their future patients. Our next step is to use our data to develop educational experiences that can improve training for students to better prepare them to recognize and manage treatment adherence issues. The need for medical schools to address training in HIV/AIDS (Leszczyszyn-Pynka & Holowinski, 2003) and diabetes (Beckman, 2004) has been recognized in the literature. Future studies should work to address improving medical education and training for treating patients with HIV/AIDS and diabetes. The results of this study support the need for education and training in psychosocial/ethical issues related to HIV and diabetes. Future studies may then investigate the impact of early training on subsequent patient care.
Results of this study are limited by its design in that only BS/MD students from one US medical school were included as participants; the results may not be generalizable to all medical students. Although the participants represent a cross-sectional population (e.g. they were in the first two years of a six year accelerated program from two consortium campuses), the commonality between them was that these students’ training thus far was very uniform and standardized. A methodological limitation of this study could be that both the SPs and the physician were male, although the authors address their rationale for this earlier in the paper. The authors recognize that gender bias may have occurred and possibly influenced the results of this study. Future studies should consider balancing the gender of physicians and SPs to address this issue and determine its influence.
The authors acknowledge the students in the BS/MD program at Northeastern Ohio Universities College of Medicine who participated in this study. These students were enrolled in the program at two consortium universities (the University of Akron and Kent State University). We would also like to acknowledge Rajil M. Karnani, MD, for his role in this study.
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