Harms associated with the vignette topics illustrated here are well known, and our findings suggest that this common knowledge is reflected in the willingness of entering medical students to educate regarding these behavioral risk factors. Students also showed high levels of respect for patient autonomy, as indicated by willingness to assure patients of continued care whether or not the patient accepted the proffered health recommendations. With respect to recommending risk factor elimination, students were most willing to recommend elimination of diet and exercise risk factors in an overweight and sedentary individual, followed by smoking and continued alcohol use in a patient with indications of alcoholism. The most marked (and statistically significant) finding relates to the adolescent contemplating initiation of sexual intercourse: only 28
% of students were willing “always or nearly always” to recommend avoidance of sexual intercourse, and 15.1
% indicated they would “never” recommend abstinence in this context. Neither respondent gender nor population health knowledge score affected willingness to educate, offer preventive advice, or respect patient autonomy.
Health professionals have historically relied on scientific information to craft educational messages and make recommendations. There are many examples in addition to those illustrated in this study: rather than simply providing facts about seat belts, speeding, fire safety, and other health topics involving behavioral health risk factors, health professionals have taken the additional step of making clear recommendations based on the underlying science. Accordingly, health professionals should be comfortable in providing science-based information and recommendations regarding adolescent sexual activity, as with other behavioral health risk factors.
The most notable adverse consequences of adolescent sexual activity include unintended pregnancy (approximately 650,000 for U.S. women﹤20
years of age in 2006 [12
]) and sexually transmitted diseases (e.g., 420,101 new cases of Chlamydia
infection among U.S. 15–19
year-olds in 2008 [13
]). Although not necessarily causally related, adolescent sexual activity is also associated with emotional ill health [14
]; use of tobacco, alcohol, and illicit drugs [15
]; and low academic achievement [17
] with negative socioeconomic consequences in later life. Because of their developmental, social, and financial state of maturity, adolescents are generally less able than independent adults to deal with the adverse consequences of sexual intercourse should they occur. Contraception, condoms, and other means can mitigate the risks for unintended pregnancy and infection, but there is no disagreement that abstinence is the most efficacious preventive measure [18
]. Thus, reluctance to proceed beyond providing information to recommending against sexual intercourse in this age group appears inconsistent with practice standards for other behavioral health risk factors and with data on associated harms.
A large national survey of U.S. medical students documents unwillingness to limit sexual health education to an abstinence-only message and a preference for comprehensive approaches including alternative strategies for reducing risk, such as cautious selection of partners, contraception, and condom use [23
]. Yet counseling about alternative strategies for risk reduction need not exclude a recommendation of abstinence from sexual intercourse as the most efficacious means of prevention. Medical students and physicians can educate adolescent patients who are considering becoming or already are sexually active about strengths and limitations of available means of prevention and also recommend abstinence, emphasizing that the recommendation is grounded not in moral condemnation, but in concern for protecting their health, and that the physician will continue to care for the patient whatever their decision.
Some may argue that a recommendation for sexual abstinence is unlikely to be heeded and may alienate adolescents. Yet research suggests that adolescents appreciate honest and non-judgmental discussions with health care professionals [24
]. Low acceptance rates for recommendations to stop smoking, refrain from inordinate alcohol consumption, and obtain proper diet and exercise have not deterred health professionals from making artful and respectful science-based recommendations without alienating patients or communities.
Medical school curricula for behavioral health vary widely in form and content, and the topic poses many pedagogical challenges [25
]. In the relatively noncontroversial case of smoking, guidelines are available that include a clear recommendation for smoking cessation or avoidance [26
]. Yet for fraught subjects such as sexuality, there is disagreement in society—reflected here among our entering medical students—about content of such recommendations.
At the University of California, Davis, behavioral health recommendations arise naturally in the clinical setting and are also addressed in the longitudinal Doctoring course spanning the four-year curriculum [27
]. In Doctoring small-group sessions, students discuss cases and interview standardized patients, providing the opportunity to address behavioral health recommendations. Whereas students discuss recommendations for the individual cases, there is at present no overarching discussion addressing underlying principles of determining the content of recommendations. Such a discussion may not lead to full consensus on content, especially for controversial subjects such as sexuality, yet should spur thinking and a mindful, rather than automatic, approach to the patient.
Important strengths for this study include its setting in a highly ranked U.S. medical school, high response rate (100
%), and focus on the substance of counseling offered by medical students as reflected in clinical vignettes for common clinical problems. The study has three important limitations. First, it is set in only one of the more than 150 accredited schools of medicine or osteopathic medicine in the U.S. University of California, Davis School of Medicine students were more likely to be women and Asian or Hispanic than the national population of entering medical students in 2009, yet they had similar mean grade-point average and Medical College Admission Test scores.
It is possible that the different demographic characteristics of the students compared to the national population of U.S. medical students affected our results. For example, a large national study of U.S. medical students showed that women and non-Whites—groups over-represented in our students compared to nationally—were more likely to report counseling among general medicine patients [6
]. However, the magnitude of the differences in counseling frequency scores between groups was small—approximately 5
% between men and women and less than 10
% between the various ethnic groups comprising the respondents. Although we did not collect information from the respondents on ethnicity on our survey, respondent gender had no bearing on likelihood of recommending elimination of risk factors. Thus, it is likely that School of Medicine students and these results reflect a national rather than a regional perspective with respect to willingness to make behavioral health recommendations.
Second, the study focused on entering medical students, and responses represent intention based on their education, values, and experience prior to beginning the medical curriculum. Although the students’ approach to counseling patients regarding behavioral risk factors may change as they progress through medical school and into practice, it is likely that the attitudes they bring at entrance will be influential, and medical school educators should be aware of this as they design relevant curriculum.
Third, the clinical vignette format unavoidably imposes limitations that may affect response. For example, willingness to provide information and recommendations may vary according to the patient’s sex, perceived maturity, presence of other medical conditions, degree to which the patient is known to the caregiver, and circumstances of the clinic visit, none of which were indicated in these vignettes. While these factors may have affected overall willingness to provide information and recommendations, it is unlikely that they explain the marked reluctance to recommend against sexual intercourse in adolescents compared to the behavioral risk factors illustrated in the other three vignettes. This reticence may result from cultural characteristics attendant to the students’ early stage of professional development, a belief that sexual activity among adolescents carries only rare and inconsequential risks, conviction that making recommendations in this area is inappropriate or futile, or to personal discomfort with the topic.