Effect Measure

I don’t like to be a curmudgeon and I’m pretty tolerant when students write research papers that don’t quite make professional grade. Writing papers may look easy — you just have to report your results, right? — but it isn’t. Nor is designing a study or collecting the data. It takes time and practice to learn this and you make a lot of mistakes. I know from personal experience. It’s the job of mentors, advisors and journal editors to educate students, bring them along, show them how to do it.

Apparently none of these guardians of the literature were awake when the paper, “Medical students and pandemic influenza,” was submitted to CDC’s journal Emerging Infectious Diseases. Here’s the abstract:.

To assess knowledge of pandemic influenza, we administered a questionnaire to all medical students at the University of Alberta; 354 (69%) of 510 students responded. Data from questionnaires such as this could help determine the role of medical students during a public health emergency. (Herman et al., Emerging Infectious Diseases)

It’s an interesting question and there is essentially no data on it. The authors offered a Web-based questionnaire to Canadian medical students in one medical school in September – October 2006, inquiring about demographic information and “risk perception of pandemic influenza (likelihood of developing and dying from the illness), general knowledge about pandemic influenza, willingness to volunteer, and suggested consequences of not volunteering during a pandemic.” So what do we learn?

All 510 medical students at the University of Alberta were invited by email to complete the questionnaire; 354 (69%) responded. Most (62%) respondents were women . . . .

Presumably not all 510 medical students are in the same class but there is no indication how the 354 respondents were distributed by level of medical education. A response rate of 69% isn’t out of this world but it isn’t at all bad for a questionnaire of this type so it’s a shame more complete information wasn’t presented. If 62% of the respondents were women (most?) is this more or less or not at all representative of the sex make-up of the 510 students? This is the kind of mistake a student is likely to make but which should have been caught by faculty advisors or sponsors. How about the Editors? Peer reviewers? If demographic information was collected, why don’t we see some of it?

The text says that over 40% of respondents thought it likely they would be infected but only 4.5% (16 students) thought they were likely to die from such an infection. Interesting. But I consulted the tabulation of results in Table 1 and I find this:

Treatment number(percent)

Nothing can treat pandemic influenza 16 (4.5)
Antibiotics 28 (7.9)
Antibacterial drugs 208 (58.8)
Vaccination 43 (12.1)
Bed rest 275 (77.7)
Fluids 280 (79.1)
Complementary medicine 19 (5.4)
Chicken soup 66 (18.6)

The “likely to die” response is entered here as “Nothing can treat pandemic influenza.” Since these aren’t synonymous we are left wondering what the original question was. Antibiotics and antibacterial drugs? Was this supposed to be antivirals? Is “vaccination” presented as a treatment?

Slightly over 20% think sexual contact is a major route of transmission. Since 80% (correctly) saw close contact with an infected person as a major route of transmission, we may be seeing the world through the hormones of this age cohort for whom close contact has a specific meaning.

Then there’s this:

Given the time lag between identification of the pandemic strain and the time needed to produce a vaccine, any known treatment strategy would not be effective unless it could be applied to the strain that is causing the pandemic.

The conflation of a preventive vaccine and treatment modalities reappears here and suggests a lack of clarity on the part of the designers of the questionnaire. I’m not surprised. The general public thinks doctors and medical students know a lot about disease but in fact doctors are carry around with them the same conventional wisdom as the general public.

You can’t learn everything in medical school. As the authors point out, though, in an emergency it is likely medical students and their graduated counterparts in the profession who know as little about influenza (or less) than they do will be called upon to fill the gaps in a stressed health care system. One solution is to prepare in advance one page fact sheets on the salient points to give to students and other volunteers at the appropriate time. That’s when they’ll need it and when they’ll use it. And if done ahead of time we can make it more likely it isn’t full of out of date material or outright misinformation.

So I commend the students who showed initiative and took this on. I’m not so forgiving of the faculty, mentors, reviewers and editors who missed a chance to educate those students and provide a more useful paper for readers


  1. #1 douchebag
    November 5, 2007

    haha, that shitty, shitty paper is probably the “thesis” for an MD/PhD student.

  2. #2 M. Randolph Kruger
    November 5, 2007

    Point well taken Revere. I run my mail list of the news of the world regarding flu to all of my doctors. The only ones that really knew anything about it? My favorite nurse and GP. My ortho doc was stunned three years ago when I asked her if she knew anything about BF. Not much she said. Then I handed her the graphs from the WHO WPRO that you post from time to time. There was a wide eyed look and a gasp, an inhalation of air. She then said, “Is this right?”

    My neuro guy was in the same boat. He said that he got flyers from the CDC and State health but didnt read that stuff much. I handed the same graphs a month later that were updated and he sat down and then looked up at me and asked where I had gotten it.

    A discussion ensued about masks and protective gear and the like and he said, “Well its likely going to be near impossible to work.” With that I took nearly no issue.

    Your issue with the educators is dead on.

  3. #3 Ben
    November 5, 2007

    If you read Table 1 more closely, you will find this:

    Likelihood (likely or very likely) of the following outcomes if you have pandemic influenza

    Won’t miss school or work 42 (11.9)
    Will miss some school or work 251 (70.9)
    Hospitalization but will recover 79 (22.3)
    Death 16 (4.5)

  4. #4 anon
    November 5, 2007

    the concept of probabilities was invented to formalize
    and make more precise and uniform the language to
    deal with such things.
    Yet questionnaires are often not using
    this superior language, so the results are subject
    to difficult interpretation (sigh)

  5. #5 anon
    November 5, 2007

    1% (1) very likely
    10% (2)
    50% (3)
    90% (4)
    99% (5) very unlikely

    or what do you think ?

  6. #6 anon
    November 5, 2007

    BTW., M. Randolph Kruger , please post in the
    old thread
    when you have a link to the Webster talk/video

  7. #7 Jody Lanard
    November 5, 2007

    It was interesting to see that 21% of the medical students said influenza could be sexually-transmitted.

    Even more interesting:

    In the same survey question (question 24), 51% of the students believe that PANDEMIC influenza could be spread by “contact with infected wild birds and chickens.”

    You can’t tell that by reading Table 1 of the article. The heading over Table 1 just refers to “Knowledge of medical students about influenza spread, prevention,” etc.

    But in the actual survey, available via footnote 4 (University of Alberta. Questionnaire on knowledge and attitudes towards pandemic influenza issues)
    Question 24 reads: “How do you think pandemic influenza is spread?”

    So the students are imagining an influenza PANZOONOTIC (a widespread global disease spread from birds and chickens to humans or other species), occurring simultaneously with a flu pandemic. Which is what many average people imagine, when they think about a “bird flu (sic) pandemic.”

    It was great to see the survey questions on potential volunteer behavior. Since 95% of the students imagined that they would recover from pandemic flu, I wish there had been a question about “willingness to volunteer after survival” — i.e. when there is a good chance that the surviving students would be immune for at least the remainder of “their” wave of pandemic flu. (This is one of my pandemic preparedness hobby horses.)

  8. #8 Tom DVM
    November 5, 2007

    This is not like volunteering for a world war.

    When you volunteer for this war not only are you putting your life at risk but also, in the subclinical infectious phase, your family as well.

    No thinking person would do this to their family even if they would do it to themselves.

    Families of volunteers will need life insurance policies, disability policies, iron clad insurance for the future care of their families if they die in service of the greater good…

    …and food, medical water supplies etc. such that their families will not lack for anything during the pandemic.

    If we get a 1918 type pandemic or worse from H5N1, then anyone who believes we will have a functioning healthcare system or ‘volunteers’ on any level is misinformed.

  9. #9 Patch
    November 5, 2007


    The 1918 pandemic saw many volunteers and health care workers risking their lives for the greater good. Certainly they realized the dangers involved and cared for their families as deeply as we do today, don’t you think? It was THE greatest generation, but are we so far behind?

    I believe that the reaction of the population, as well as a sustainable health care system will depend entirely on the severity of the pandemic. Unlike you, I’m not 100% convinced we are headed for a severe one. While that possibility exists, it is far more possible to be on a scale “less than worse case scenerio”. Furthermore, I don’t believe it is inevitable that the worst in people will come out.

    Maybe there some “idealists” left in this world and maybe just a few of those are studying medicine! I sure hope so!

  10. #10 abc
    November 5, 2007

    So over 2% of Canadian medical students surveyed believe eating sauerkraut will prevent pandemic influenza, eh? And 4% believe antibiotics can prevent it–I’m not sure which frightens me more.

  11. #11 M. Randolph Kruger
    November 5, 2007

    In two words ABC…. No Shit!

    Revere, why did they offer this to the US CDC as a study if it was Canuck medical students? Strange or is that the way things are normally done?

  12. #12 anon
    November 5, 2007

    question 24 reads :
    “how do you think pandemic influenza is spread? (check any that apply)”

    so one single virus which choses this route
    makes it a “yes” !

    1e9 people infected , 1e15 viruses per infected person ,
    1e24 viruses to be spread …

  13. #13 Tom DVM
    November 6, 2007


    Everyone is entitled to their opinion…that is a fundamental scientific principle…

    …however, what some scientist-regulators seem to have forgotten is that we have an ethical obligation to tell the truth…or at least the truth as we see it.

    It’s not about being alarmist or idealistic for that matter.

    I was keenly observant of the SARS outbreak in Ontario Canada and was shocked the way nurses were treated by regulators and governments.

    If you had a daughter under thirty years old with young children under five years old, working as a nurse in a currently short-staffed hospital…to volunteer in a pandemic with moderate severity?

    Maybe it is time for someone with a voice, like our friends Revere, to find out the age distribution of front line healthcare workers in North America…so that we the public can relieve the young ones of their idealism…

    …while planning to provide a service to humanity by giving parents home treatment packages.

    Antivirals don’t work, pandemic vaccines won’t work…and a functioning healthcare system in a pandemic is a pipe-dream because they barely function now.

  14. #14 Patch
    November 6, 2007


    I don’t disagree that your scenario is one possibility.

    But you seem to see things in Black or white. There is no gray. For example, antivirals DO work to some degree at the moment. Pandemic vaccines may work, to some degree. And to write off the health care system, believing that it will be completely destroyed is not very responsible either, in my view.

    Perhaps it doesn’t happen as often as it used to..but I see people risking their lives everyday for the common good. Some find themselves in that role without thinking twice about it. Not everyone will be up to the task just like black isn’t white, but there may be just enough gray to help ease the pain.

  15. #15 Tom DVM
    November 6, 2007

    “…believing that it will be completely destroyed is not very responsible either, in my view.”

    See that’s the thing…

    …it isn’t about being “very responsible”…it is about offering a considered scientifc opinion, based on an individual experience…without fear of retribution.

    I respectfully disagree with your conclusions…but that is a good thing, particularly in science.

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