Background and Purpose There is a perception among some physicians that medical students and house officers receive little or no training in the diagnosis and treatment of patients with cerebrovascular disease. However, there is a paucity of data addressing the issue of medical education in this area. This study was performed to determine the quantity and type of undergraduate and postgraduate medical education on cerebrovascular disease that is presented to medical students and house officers.
Methods This was a prospective questionnaire study sent to 40 mainly academic medical centers in the United States and Canada. Data were collected on the percentage of programs offering stroke education, percentage of medical students and house officers taking such courses, and the duration of teaching programs.
Results Sixty-one percent of the programs had dedicated stroke teaching efforts during clinical rotations, averaging a total of 13.1 hours of didactic and clinical teaching. Medical students received approximately 5 hours of preclinical stroke instruction. Only 35% of the programs offered stroke training for house officers in their internal medicine program. Most programs (81%) offered stroke conferences and computer-based instruction.
Conclusions At some institutions, medical students received a modest amount of stroke education during their clinical rotations. However, almost 40% of programs did not have required stroke education programs for medical students. Most internal medicine programs that we surveyed did not have specific stroke education efforts for house officers. Increased educational efforts in this area may be indicated.
Stroke remains the third leading cause of death among adults in the United States despite some progress in its treatment and prevention.1 In addition, several recent studies have shown that many patients who have a stroke do not seek or receive medical care in a timely fashion.2 3 Even patients who have a stroke while hospitalized may not receive timely medical care. In some cases, a diagnosis other than stroke is made, further delaying proper medical therapy.4 Many experts in the field of cerebrovascular disease feel that a lack of proper medical education combined with a nihilistic attitude among healthcare professionals may contribute to inadequate and delayed care of stroke patients.4 5 6
To the best of our knowledge, there have not been any published studies focusing on undergraduate and postgraduate education on cerebrovascular disease. This study was undertaken to better understand and define various aspects of undergraduate and postgraduate medical education on cerebrovascular disease. We tested two hypotheses: (1) that medical students receive limited formal education on cerebrovascular disease and (2) that house officers in internal medicine programs receive very little formal education on cerebrovascular disease.
Questionnaires dealing with stroke education were sent to 40 vascular neurologists at major medical centers in the United States and Canada. These neurologists and programs were chosen on the basis of their experience and expertise in cerebrovascular disease. In many cases, they were the directors of the cerebrovascular program, stroke service, or neurology service at their respective institutions.
Each questionnaire had a preamble instructing the responder to identify specific and dedicated teaching efforts that focused on stroke. Questions were asked about the percentage of medical students taking a neurology rotation, as well as the dedicated teaching experiences focusing on stroke. Additional questions focused on stroke training received by house officers in the internal medicine program, stroke conferences, and teaching methods at each institution. Responses for teaching experiences differentiated between didactic and clinical sessions. A sample questionnaire is available on request.
Questionnaires were returned from 31 of the 40 (78%) programs canvased. Two of the responding institutions were from Canada, the remainder from the United States. At these institutions, neurology is a required rotation for medical students at 25 of 31 (81%) programs. At those institutions where neurology is not a required rotation, neurology is taken by an average of 37% (range, 2% to 95%) of medical students.
Sixty-one percent of the programs (19 of 31) had dedicated teaching experiences on stroke for medical students (Table 1⇓). During a typical clinical rotation, medical students receive an average of 3.3 hours of didactic teaching and 9.8 hours of clinical teaching on stroke (Table 2⇓). Eighty-nine percent (26 of 31) of the responders indicated that medical students receive specific preclinical instruction about cerebrovascular disease. At the institutions offering preclinical stroke instruction, students received an average of 3.3 didactic hours of instruction and 2 hours of case presentations.
Only 9 of 26 (35%) institutions have specific training focusing on cerebrovascular disease for house officers in the internal medicine program (Table 1⇑). At the institutions providing such training, house officers receive an average of 2 hours of didactic instruction and 12.3 hours of clinical instruction (Table 2⇑). The latter number is somewhat skewed because one institution indicated that house officers received 80 hours of clinical stroke instruction. If this one response is removed, the average clinical instruction is 1 hour (median, 0 hour).
The vast majority of the institutions (81%, 25 of 31) have conferences dedicated to cerebrovascular disease. In most cases, the conferences have either a clinical or a combined clinical/laboratory focus. We found that 81% of the institutions (21 of 26) offer computer-based instruction for medical students and house staff.
This study was performed to quantify the amount of undergraduate and postgraduate education that medical students and house officers receive on cerebrovascular disease. Contrary to common perceptions, the majority of the programs surveyed have dedicated undergraduate teaching efforts focusing on cerebrovascular disease. These programs provided an average of 13.1 hours of didactic and clinical instruction on cerebrovascular disease during clinical rotations. Yet, almost 40% of the programs surveyed did not have dedicated teaching efforts in stroke for medical students.
The vast majority of medical students receive preclinical instruction on stroke, although this averages approximately 5 hours in the preclinical years. In contrast to the undergraduate figures cited above, the vast majority of internal medicine programs do not offer any specific training in cerebrovascular disease. Those that do have such training offer very limited formal or supervised instruction. This amount of instruction may be suboptimal, especially compared with the amount of preclinical instruction that students may receive on other common and important diseases such as heart disease, cancer, diabetes, and AIDS. However, published quantitative data on medical student and house officer training in these areas are quite sparse, so exact quantitative comparisons are difficult.7 8 9
The data presented in the study probably represent a “best case scenario,” since we tended to choose centers with active stroke programs. This might account for the unexpectedly high amount of stroke teaching received by medical students at these institutions. As such, these results may not be indicative of the instruction being performed at other facilities. It is worrisome, however, that house officers at many institutions received little or no formal training in cerebrovascular disease. These results should be interpreted with caution, since data on postgraduate training were available from a small number of programs. Future studies should canvas a larger number of institutions, obtain data from administrators involved in the medical school curriculum, and include data on test results and outcomes related to stroke care.
The case could be made that medical students become house officers and that knowledge accrued during medical student training carries over to the postgraduate years. However, our experience in the field of cerebrovascular disease has shown that repeated training is needed, especially considering the heterogeneity of cerebrovascular disease and the dynamic nature of therapeutic options in this area.5 10 11 12
It might be argued that surveys such as ours tend to underestimate teaching of a particular topic by focusing on specific lectures or rounds that highlight a given disease while discounting teaching in related areas (ie, atherosclerosis, thrombosis). However, when stroke is mentioned in the context of these more general disease processes, it is typically in passing and without any in-depth focus. It is not known if nonneurologists are involved in stroke teaching and to what degree. However, we feel that intense teaching efforts on stroke may be needed to enhance knowledge in this area.
Data from a review of Medicare claims show that in the United States only 9.8% of stroke patients have a neurologist as their attending physician (G. Sampson, unpublished data, 1995). Therefore, the vast majority of stroke patients are cared for primarily by nonneurologists (internists or general practitioners) who may receive limited input from a neurologist on a consultative basis. Improved training of internists and general practitioners in stroke, combined with more timely recognition and treatment of stroke patients, may help to alleviate much of the nihilistic attitude toward stroke that currently exists in the medical community. This statement is supported by several recent studies showing that physicians with expertise in caring for stroke patients provided more cost-effective care with fewer complications and a reduced mortality compared with physicians without such training.13 14 Other studies have shown that improved education can significantly reduce time delays between stroke onset and patient arrivals at a hospital.15 16 The widespread use of computers for medical education provides one mechanism for enhancing training in this area.
In conclusion, we found that at selected institutions medical students receive a modest amount of stroke training. However, medical students at almost 40% of the institutions do not receive any formal training in stroke, while house officers receive a paucity of training in this area. If these results are confirmed by more extensive studies, they may lead to changes in medical education in this area. Considering the growing importance of acute stroke therapies, some institutions might consider increasing stroke training for their medical students and adding such training for house officers in specific programs.
The author acknowledges the efforts of the following physicians in providing information for this study: Vladimir Hachinski (University Hospital), James Robertson (University of Tennessee), Linda Hershey (SUNY Buffalo), Robert Adams (Medical College of Georgia), Mark Dyken (Indiana University), Ashfaq Shuaib (University of Saskatchwan), John Harbison (Medical College of Virginia), Mark Goldberg (Washington University), Tom Brott and John Quinlan (University of Cincinnati), L. Creed Pettigrew (University of Kentucky), James Toole (Bowman Gray), Cathy Helgason (University of Illinois), Ralph Greenlee (University of Texas Southwestern Medical Center), Mark J. Alberts (Duke University), Harold Adams (University of Iowa), J.P. Mohr (Columbia University), David Wiebers (Mayo Clinic), Mark Kritchevsky (University of California, San Diego), Thomas R. Price (University of Maryland), Howard Kirshner (Vanderbilt Medical Center), Edward Feldman (Brown University), Marc Fisher (University of Massachusetts), Camilo R. Gomez and Marc Malkoff (St Louis University), Michael S. Pessin (Tufts University), Steve Levine (University of Michigan), and Patrick Griffith (Morehouse School of Medicine).
- Received May 8, 1995.
- Revision received June 12, 1995.
- Accepted June 30, 1995.
- Copyright © 1995 by American Heart Association
American Heart Association. 1991 Heart and Stroke Facts. Dallas, Tex: American Heart Association; 1991.
Foulkes MA, Wolf PA, Price TR, Mohr JP, Hier DB. The Stroke Data Bank. Stroke. 1988;19:547-552.
Alberts MJ, Brass LM, Perry A, Webb D, Dawson DV. Evaluation times for patients with in-hospital stroke. Stroke. 1993;24:1817-1822.
Millikan C. Animal stroke models. Stroke. 1992;23:795-797.
Wechsler L, Koroshetz W. Therapy for acute ischemic stroke. In: Ropper A, ed. Neurological and Neurosurgical Intensive Care. New York, NY: Raven Press Publishers; 1993:265-278.
Alberts M, Rutledge V, Bennett C. An analysis of hospital charges in acute stroke patients. Stroke. 1995;26:170.
Indredavik B, Bakke F, Solberg R, Rokseth R, Haaheim LL, Holme I. Benefit of a stroke unit: a randomized controlled trial. Stroke. 1991;22:1026-1031.
Barsan W, Brott T, Broderick J, Haley EC, Levy DE, Marler JR. Urgent therapy for acute stroke: effects of a stroke trial on untreated patients. Stroke. 1994;25:2132-2137.
Alberts MJ, Perry A, Dawson DV, Bertels C. Effects of public and professional education on reducing the delay in presentation and referral of stroke patients. Stroke. 1992;23:352-356.