STD training in Canadian medical schools

OBJECTIVE: The emergence of the acquired immune deficiency syndrome in 1981 and the consequent publicity surrounding seJl.'"Ual behaviour has increased the Ukelihood U1al patients will seek medical advice. Sexually transmillecl disease (STD) leaching and poslgracluale medical programs in Canadian schools of medicine have not been adequately documented . Accordingly. U1e Laborato1y Centre for Disease Control. Deparlmenl of National Health and Welfare, sought lo determine the magnitude and scope of STD training in these schools . DESIGN: A four page questionnaire sought information on preclinical. clinical and residency training in terms of the number of classroom and laboratory hours of instruction , the subspecialty responsible for providing the training. and the clinical 'hands on' experience of the teachers: each respondent was a lso asked lo assess the quality and scope of instruction provided at his/her medical school. SETTING/PARTICIPANTS: The questionna ire was mailed to U1e Dean of each of the 16 schools of medicine in Canada: il was requested thal the questionnaire be forwarded to and completed by the person responsible for STD training al the university . RESULTS: Thirteen schools (81 % ) completed U1e questionnaire. Each school indicated U1al some STD instruction was provided al the undergraduate level: lhe mean number of hours of classroom instruction was 6. 1. Physicians with STD clin ical 'hands on' experience were responsible for leaching in 12 schools . Infectious disease residents spent 4 to 80 h on STDs, while those from other residency programs where STD was not an elective spent 2 to 8 h. Each medical school was asked lo provide an evaluation of ils program. Only three respondents considered their STD training program adequate. The majority of schools responded U1al infectious disease residents received sufficient training but the training offered medical sludenls and residents in other programs was less U1an adequate. The quality of leaching was considered ·excellen l' in three schools , ·good' in nine. and 'poorly co-ordinated' in one. CONCLUSIONS: There is no simple solu tion lo ensure lhal eve1y physician in Can ada receives s ufficient clinical training in STDs. Collaborative and cooperative efforts by federal, provincial and local governments, professional societies. licensing bodies. medical schools. residency programs, STD clinical directors and provincial and lenilorial directors of STD contro l, should be encouraged.

T HE EMERGENCE OF THE ACQUIRED IMMUNE DEFICIENCY syndrome (AIDS) in 1981 and the consequent publicity surrounding sexual behaviour and •safer sex• practices has increased the li kelihood that patients will seek medical advice .
Most physicians have clinical experience in the diagnosis, treatment and management. of the traditional sexually transmitted diseases (STDs) -gonorrhea and syphilis -and most are familiar with the effectiveness of the control measures of early detection.appropriate treatment and contact tracing.Although the total number of cases of these STDs has been declining over the previous two decades.for the first time ever females aged 15 to 19 years recorded tl1e h ighest rate of go n orrhea in 1988 (1).As well.tl1e increasing number of gonococcal strains resistant to penicillin (PPNG) has challenged the clinical complacency of physicians in the treatment of gonorrhea.Many Canadian physicians regard tl1e incidence of PPNG as a minor problem.However, British Columbia experienced an increase in the proportion of PPNG well above the hyperendemic rate of 3.0% during the first six months of 1990 (2) .
Surveillance data on the incidence of gonococcal in fection in adolescents a n d young adu lts serve as a marker for the most common bacte rial genital pathogen in industrialized countries, Chlamydia trachomatis.This pathogen is two to three times more common tl1an gonorrhea and is the major cause of reproductive health problems in women.Chlamydial infection in women is often asymptomatic and , undiagnosed and untreated, it may ascend to th e upper genital tract.contributing to pelvic in fl an1matory disease and its sequelae of infertility, ectopic precrnancy and chronic pelvic pain.In Canada, the incidence of ectopic pregnancy increased from one in 1 75 to one in 77 between 1977 and 1984.and heralds a need for more rigorous clinical and laboratory scrutiny of this potent pathogen (3).Furthermore.the establishment of the royal commission on new reproductive techno logies is testimony to the number of women who are infertile, frequently as a consequence of ch lamyd ia infection.The annual cost to the Canadian health care system of non-AIDS STDs and complications exceeds $200 million (4).
Viruses which are sexually transm itted, such as human immunodeficiency virus (HIV), h uman papillomavirus (HPV), and herpesvirus present a special ch allenge for physicians.Such infections are lifelong and incu rab le, and may have severe and fatal conseq u ences.Physicians must recognize that control m easures for viral STDs differ from tl1ose for bacterial STDs in that a greater emphasis must be placed on chan ging or reducing behaviours wh ich place persons at ris k of acquiring an STD.STDs in children a re important indicators of sexual abuse (5).Many physicians do not understand the implications of STDs in prepubertal children, nor do they screen ch ildren who are suspected of having been sexually abused for STDs.
STD diagnostic and treatment services and phys ician training in STDs were considered inadequate even before AIDS became established (6) .In the United States.fewer than 10% of physicians received clinical training in STDs.although one-half of them engaged in su bspecialty practices where more than 5% of their patients had STD related problems (7).
Information on STD teaching and postgraduate medical programs in Canadian medical schools has not been adequately documented .Consequently, the Division of STD Control of the Laboratory Centre for Disease Control sought to determine tl1e magnitude and scope of STD education in these schools.

MATERIALS AND METHODS
A questionnaire sent to the Deans of the 16 Canadian schools of medicine in 1987 required completion by the person(s) responsible for STD training.The questionnaire was adapted from the one developed by Stamm et al (8).Information was sought on p reclinical training (lectures.laboratory experience.classroom and laboratory hours, course affiliation.instructors' clinical experience), and on undergraduate clinical training (number of students instructed, number of hours .clinic setting, mandatory or elective attendance, and the subspecialty responsible).STD training in residency programs was assessed based on the number of residents participating and tl1e hours allocated by each subspecialty.Information on continuing medical education programs involved the number of sessions, the number of hours assigned to each session, the target a udience and the topics covered.In a ddition , each respondent was asked to provide a p ersonal evalu ation of his or her school's program.

RESULTS
Thirteen schools (81 % ) responded.Each indicated that some STD instruction was provided in the preclinical years.The number of teaching hours ranged from one to 15 (mean 6.1).Where instruction hours exceeded six, infectious disease staff participated, alone or in collaboration with persons from medical m icrobiology.Physicians with STD clinical ('hands on') experien ce were responsible for teaching in 12 schools.
Five schools offered laboratory experience for a median duration of 2 .6 h.Two schools provided 1 to 2 h laboratory instruction in the preclinical years; three schools offered it in a third year course on laboratory medicine.
All schools reported that some clinical training was provided or available to undergraduates and residents , through either hospital-or community-based STD clinics or hospital subspecialty clinics .
Eight schools offered undergraduate students clinical experience in a community-based STD clinic (two).a hospital-based STD clinic (four) or both (two); the duration of training ranged from 3 h (in each of two schools) to four weeks.In the five schools not affiliated with a dedicated STD clinic, electives were availa ble through the infectious disease (four) and primary health care divisions (one) .
Two schools required compulsory clinical training at the undergraduate level.The 164 students enrolled in these programs each received an average of 3 to 4 h clinical ins tru ction.In the six schools affiliated with a dedicated STD clinic and where STD clinical training was not mandatory, a pproximately 28% of eligible students (104 of 36 1) undertook the elective.Ten per cent of students chose STD clinical training as an elective in schools wh ich offered training through a subspecialty.
Nine schools provided data on resid ents• STD clinical train ing.In six, residents in certain subspecialties were required to undertake this training.Included were infectious disease residents in four schools.community medicine.family medicine a nd internal m edicine residents in two schools, and m edical microbiology.obstetrics/ gynecology and pediatric residents in one school each.In th e three remaining schools, STD clinical training was available as an elective.Infectious disease residents spent 4 to 80 h on STDs, while those from other subspecialties spent 2 to 8 h.Inform ation on elective STD clinical programs for residents in other specialties was limited , but ranged from 2 to 20 h.
Twelve respondents provided a personal evalu ation of their program.Ten were infectious disease staff members, one was an internist and in one instance the respondent's qualifications were not known.Only three 120 respondents considered their STD training program a dequate.The maj ority felt that infectious disease residents received sufficient train ing, but that training offered to medical students and residents in other subspecialties was less than adequate.The quality of teaching was considered 'excellent' in three, 'good' in nine , and 'poorly co-ordinated' in one.One respondent commented that any expansion or extension of STD experience should not be undertaken at the expense of other infectious disease train ing.
All respondents stated that they offered continuing m edical education sessions on STDs.The number of sessions offered per annum ranged from one to 10.The average number of hours per STD session was 3.8.Infectious disease was the discipline cited most frequently (nine times) as being responsible for the STD portion, followed by medical microbiology (four).internal m edicine (three).obstetrics/ gynecology (two) a nd family medicine (one).The frequency of STD topics was update (six).diagnosis (four).overview (three).treatment (three) and prevention (one).Individual STD topics a ddressed were chlamydia (10).gonorrhea (nine), herpes (seven).pelvic infla mmatory disease (seven).human papillomavirus (three).nonspecific vaginitis (two) and chancroid (one).AIDS was cited 10 times as a course topic, although not exclusively as an STD.The ta rget audiences for the continuing medical education sessions were general practitioners (12).obstetricians / gynecologists (three), dermatologists (two) and infectious disease specialists (one).Pediatricians, surgeons.nurses , pharmacists, social workers and 'any physicians' were each cited once.

DISCUSSION
The objective of this study was to determine the exten t to which Canadian m edical schools prepared undergraduates, residents and other physicians in the provision of diagnostic, treatment and educational services for STD.
Th ere are no established Canadian criteria against which m edical schools• STD programs migh t be measured.In tl1e United States, a commissioned review committee recommended that "by 1990.all medical schools s h all establish clinical staff affiliations with public or private STD treatment facilities so that all m edical students and physicians-in -training will receive a minimum of 20 hours of supervised clinical experience" (9).
These survey results indicate tl1at.a p art from certain residency programs, Can adian medical schools provide considerably less instru ction than the minimum number of hours recommended in the United States.Indeed, respondents felt that more time and better quality STD training was n eeded in 11 of the 13 schools that responded .
The competition for teaching time in m edical schools provides little opportunity to a dd new topics or eA'iend time allocated to old ones.Adler and Wilcox (10) found an actual reduction in STD instruction time in British medical schools, despite the presence of a genitourinary medicine subspecialty and the recognition of increasing STD-associated complications.
In Canada, the provision of additional STD training at the undergradu ate level must be reviewed.Th e n eed for adequately trained primary health care physicians persists, and residency programs require upgrading.These deficiencies have stimulated alternative and supplementary approaches to medical school/residency STD training, but their effectiveness has not been evaluated.Supplementary approaches have included the development of national standards by the Department of National Health and Welfare for the diagnosis, management and treatment of STDs (11,12), and for examination of children suspected to have been sexually abused (5), as well the provision of at least one provincially funded STD training program for physicians and nurses .
The skills required by physicians to adequately diagnose, manage and treat STDs are simple and straightforward.Such skills should focus on history taking, the physical examination.obtaining appropriate specimens and counselling skills.Videos supplemented with written handouts may represent a cost-effective method of teaching these skills.Physicians, the health care system and the community at large should place greater emphasis on preventive behaviours such as abstinence.reduction in number of casual partners and con-dom use , as a major strategy to reduce the inciden ce of STDs in Canada.
There is n o s imp le solution to en s u re that every physician in Canada receives s u fficient clinical training in STD.Coll aborative and cooperative efforts by fede ral, provi n cial and local governments, profession al societies, licen s ing bodies, medical sch ools, residency programs , STD clinical directors and provincial and territorial directors of STD control s h ould be encouraged.Continuing medical education sessions, ad hoc seminars and scientific conferences have a role to play in providing up-to-date information, but they cannot match 'hands on' experience and training.
Professional societies should accept a leadership role in professional STD training.They qualify because of their clinical interest, expertise in diagnosis , treatment and management and, in some instances, becau se of their apparent willingness to accept teaching responsibilities.The extent and duration of STD training for the various levels of clinical practice, and to qu alify physicians as subspecialty fe llows and certificants.should be recommended by peers .
Licensing bodies should shoulder some of the responsibility, as well , to ensure that physicians who are licensed to practice medicine are adequately trained in STDs.The examinations of the Medical Council of Canada, the Royal College of Physicians and Surgeons.and the College of Family Physicians should ensure that questions reflect, in scope and magnitude, current epidemiology and practice standards for STDs.