Letters
Table 2. Comparison of Composite Clerkship Performance of Medical Students With and Without Protected Disabilities for Physical and Mental Impairment Students With Protected Disability Status by Type Physical Impairment (n = 23)
Students by Protected Disability Status
Mental Impairment (n = 28)
With (n = 51)b
Without (n = 153)
Composite clerkship assessment scores, median (IQR)a Fund of knowledge
3.3 (2.9-3.5)
3.1 (2.8-3.3)
3.2 (2.9-3.4)
3.4 (3.2-3.6)
Data gathering
3.5 (3.2-3.6)
3.3 (3.1-3.5)
3.4 (3.1-3.6)
3.5 (3.4-3.7)
Communication skills
3.7 (3.5-3.9)
3.6 (3.3-3.7)
3.6 (3.4-3.8)
3.8 (3.6-3.9)
Professionalism
3.6 (3.4-3.9)
3.6 (3.4-3.8)
3.6 (3.4-3.8)
3.8 (3.6-3.9)
Composite clerkship assessment scores, mean (95% CI)a,c Fund of knowledge
3.3 (3.2-3.5)
3.1 (3.1-3.3)
3.2 (3.2-3.4)
3.4 (3.3-3.4)
Data gatheringd
3.5 (3.4-3.6)
3.3 (3.3-3.4)
3.4 (3.4-3.5)
3.5 (3.5-3.6)
Communication skillsd
3.7 (3.6-3.8)
3.6 (3.5-3.7)
3.7 (3.6-3.7)
3.8 (3.7-3.8)
Professionalism
3.7 (3.6-3.8)
3.6 (3.6-3.7)
3.6 (3.6-3.7)
3.7 (3.7-3.8)
students without protected disabilities considering a priori differences in US Medical Licensing Examination step 1 scores and matching variables (students with disabilities were matched to students without disabilities on 3 variables) as a random effect.
Abbreviation: IQR, interquartile range. a
Items were scored on a 4-point scale: 1 = inadequate; 2 = fair; 3 = good (passing); and 4 = outstanding.
b
Total sample of 51 reflects exclusion of 5 students with protected disabilities classified in other category combined with 4 students who were dismissed or withdrew, one of whom was classified in other category.
c
Statistical analyses using multivariable analysis of covariance reflects comparison of performance on clerkship assessments for students with protected disabilities from physical impairment and mental impairment, and
dency programs. However, medical students with protected disabilities performed less well on academic achievement measures and were less likely to graduate than those without protected disabilities. The clinical clerkship performance of students with protected disabilities from mental impairment, but not from physical impairment, was below that of students without protected disabilities. However, the magnitude of the differences was small. Whether these differences portend difficulties in practice is unknown. The difference in graduation rates between students with and without protected disabilities was more notable. The limitations of this study include that of a single institution design, small number of students with disabilities, and the power for a moderate effect. Students with protected disabilities may not have used accommodations. The performance differences and accommodation needs of medical students with protected disabilities need to be better understood to increase the diversity of the physician workforce. Reasons for differences during medical school and subsequent performance during and beyond residency training should be assessed. Arianne Teherani, PhD Maxine A. Papadakis, MD
d
Significant difference is between students with protected disabilities from mental impairment and students without protected disabilities (F = 2.7, P = .04, η2 = 0.06). All tests were 2-sided with P < .05 used as the significance threshold.
Analysis and interpretation of data: Teherani. Drafting of the manuscript: Teherani, Papadakis. Critical revision of the manuscript for important intellectual content: Teherani, Papadakis. Statistical analysis: Teherani. Administrative, technical, or material support: Teherani, Papadakis. Study supervision: Papadakis. Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. Additional Contributions: We thank Eric Koenig, MS, Neera Jain, MS, CRC, Lisa Meeks, PhD, and Barbara Smith (all 4 with the Office of Student Life, University of California, San Francisco) for their help with clarifying rules and procedures for disability services and providing the data on accommodations; and Mark Lovett, MPIA (Office of Medical Education, University of California, San Francisco), for help with acquiring demographic and outcome data and merging with the data on accommodations provided by the Office of Student Life. None of these persons received compensation for their contributions. 1. World Health Organization; World Bank. World report on disability. http://whqlibdoc.who.int/hq/2011/WHO_NMH_VIP_11.01_eng.pdf. Accessibility verified November 7, 2013. 2. Hegazi I, Wilson I. Medical education and moral segmentation in medical students. Med Educ. 2013;47(10):1022-1028. 3. Grimm LG, Yarnold PR. Reading and Understanding Multivariate Statistics. Washington, DC: American Psychological Association Press; 2000.
COMMENT & RESPONSE
Author Affiliations: Department of Medicine, University of California School of Medicine, San Francisco. Corresponding Author: Arianne Teherani, PhD, University of California San Francisco, 1855 Folsom St, San Francisco, CA 94143 ([email protected]). Author Contributions: Dr Teherani had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Teherani, Papadakis. Acquisition of data: Teherani, Papadakis.
Soy Protein and Recurrence of Prostate Cancer To the Editor Dr Bosland and colleagues1 found no effect of a soy protein isolate on biochemical recurrence of prostate cancer. I believe there were problems with the choice of both the intervention and placebo products. The soy isolate was not a true isolate because this would imply a concentrated protein source with minimal additive ingredients. However, the soy isolate also contained sugar (20 g
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per serving) and participants were encouraged to consume this product with water or fruit juice, which could impede any metabolic advantages of the intervention. Information should have been provided on whether the soy isolate reduced body weight, waist circumference, blood glucose, blood pressure, or cholesterol or testosterone compared with the placebo, as might be expected with a beneficial intervention. These cardiovascular and metabolic parameters have been linked either independently or synergistically with a lower risk and progression of prostate cancer.2 The choice of placebo (caseinate-based product) in this trial was perplexing because it contained a high concentration of calcium. Calcium supplementation significantly reduced prostate-specific antigen (PSA) velocity in the placebo group of the Prostate Cancer Prevention Trial.3 In a randomized trial of calcium supplementation to prevent colorectal adenoma, there was some suggestion of a reduction in prostate cancer.4 A meta-analysis of trial-level data found a reduction in prostate cancer with calcium, although there were few events.5 Both the soy isolate and placebo product contained more than 700 mg of calcium per serving, tantamount to supplementation of both groups. The similar amounts in the 2 products increased the probability of similar outcomes between groups. In addition, the protein concentration in the soy and placebo products was more than 19 g per serving. This amount of protein has the potential for appetite satiating effects and weight loss. Because the amount was almost identical between products, metabolic differences would be unlikely to occur, reducing the ability to detect an effect in their study of primarily overweight and obese men. Soy provides isoflavones, but the theory that these compounds will prevent prostate cancer recurrence without any change in cardiovascular or androgen parameters appears optimistic. I appreciate the complexity of any dietary clinical trial in prostate cancer, but it seems unlikely there could be any mechanistic advantage when comparing these 2 interventions. Mark A. Moyad, MD, MPH Author Affiliation: Department of Urology, University of Michigan Medical Center, Ann Arbor. Corresponding Author: Mark A. Moyad, MD, MPH, University of Michigan Medical Center, 1500 E Medical Center Dr, Ann Arbor, MI 48109 (moyad @umich.edu). Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and reported being a consultant for AbbVie Pharmaceuticals, Farr Labs, Max International, and Guthy-Renker Inc; receiving payment for lectures from AbbVie Pharmaceuticals; receiving royalties from Max International for a weight loss system (fiber bar and supplements) and from Guthy-Renker Inc for a male sexual health supplement; and receiving royalties from books for consumers and health care professionals on supplements, male sexual health, and prostate cancer. 1. Bosland MC, Kato I, Zeleniuch-Jacquotte A, et al. Effect of soy protein isolate supplementation on biochemical recurrence of prostate cancer after radical prostatectomy: a randomized trial. JAMA. 2013;310(2):170-178. 2. Moyad MA. Heart health = urologic health and heart unhealthy = urologic unhealthy: rapid review of lifestyle changes and dietary supplements. Urol Clin North Am. 2011;38(3):359-367.
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3. Kristal AR, Chi C, Tangen CM, Goodman PJ, Etzioni R, Thompson IM. Associations of demographic and lifestyle characteristics with prostate-specific antigen (PSA) concentration and rate of PSA increase. Cancer. 2006;106(2):320-328. 4. Baron JA, Beach M, Wallace K, et al. Risk of prostate cancer in a randomized clinical trial of calcium supplementation. Cancer Epidemiol Biomarkers Prev. 2005;14(3):586-589. 5. Bristow SM, Bolland MJ, Maclennan GS, et al. Calcium supplements and cancer risk: a meta-analysis of randomised controlled trials. Br J Nutr. 2013;110(8):1384-1393.
In Reply Dr Moyad questions the choice of the intervention and placebo products in our trial of the effect of soy protein on biochemical recurrence of prostate cancer after radical prostatectomy. The intervention was not purely soy protein isolate, but soy protein was the only component that was different between the intervention and placebo products. Both products were sweetened with sucrose and fructose to ensure acceptable palatability of the soy isolate. Inclusion of sugars did not introduce bias since the products contained the same amounts and there is no evidence that carbohydrate consumption affects PSA or biochemical recurrence. We agree that it is important to assess other effects of soy protein (eg, serum cholesterol levels) and will report these end points in the future. We selected calcium caseinate as the placebo because it is the most commonly used placebo to study the effects of soy on noncancer end points.1,2 The supplemental dose (700 mg) in our products was less than the recommended dietary allowance in men (1000 mg for men ≤70 years and 1200 mg for older men).3 Because we counseled the participants to avoid using milk to mix the protein beverage powders and not take calcium supplements, we believe that intake of calcium was within recommended safe limits (
Table 2. Comparison of Composite Clerkship Performance of Medical Students With and Without Protected Disabilities for Physical and Mental Impairment Students With Protected Disability Status by Type Physical Impairment (n = 23)
Students by Protected Disability Status
Mental Impairment (n = 28)
With (n = 51)b
Without (n = 153)
Composite clerkship assessment scores, median (IQR)a Fund of knowledge
3.3 (2.9-3.5)
3.1 (2.8-3.3)
3.2 (2.9-3.4)
3.4 (3.2-3.6)
Data gathering
3.5 (3.2-3.6)
3.3 (3.1-3.5)
3.4 (3.1-3.6)
3.5 (3.4-3.7)
Communication skills
3.7 (3.5-3.9)
3.6 (3.3-3.7)
3.6 (3.4-3.8)
3.8 (3.6-3.9)
Professionalism
3.6 (3.4-3.9)
3.6 (3.4-3.8)
3.6 (3.4-3.8)
3.8 (3.6-3.9)
Composite clerkship assessment scores, mean (95% CI)a,c Fund of knowledge
3.3 (3.2-3.5)
3.1 (3.1-3.3)
3.2 (3.2-3.4)
3.4 (3.3-3.4)
Data gatheringd
3.5 (3.4-3.6)
3.3 (3.3-3.4)
3.4 (3.4-3.5)
3.5 (3.5-3.6)
Communication skillsd
3.7 (3.6-3.8)
3.6 (3.5-3.7)
3.7 (3.6-3.7)
3.8 (3.7-3.8)
Professionalism
3.7 (3.6-3.8)
3.6 (3.6-3.7)
3.6 (3.6-3.7)
3.7 (3.7-3.8)
students without protected disabilities considering a priori differences in US Medical Licensing Examination step 1 scores and matching variables (students with disabilities were matched to students without disabilities on 3 variables) as a random effect.
Abbreviation: IQR, interquartile range. a
Items were scored on a 4-point scale: 1 = inadequate; 2 = fair; 3 = good (passing); and 4 = outstanding.
b
Total sample of 51 reflects exclusion of 5 students with protected disabilities classified in other category combined with 4 students who were dismissed or withdrew, one of whom was classified in other category.
c
Statistical analyses using multivariable analysis of covariance reflects comparison of performance on clerkship assessments for students with protected disabilities from physical impairment and mental impairment, and
dency programs. However, medical students with protected disabilities performed less well on academic achievement measures and were less likely to graduate than those without protected disabilities. The clinical clerkship performance of students with protected disabilities from mental impairment, but not from physical impairment, was below that of students without protected disabilities. However, the magnitude of the differences was small. Whether these differences portend difficulties in practice is unknown. The difference in graduation rates between students with and without protected disabilities was more notable. The limitations of this study include that of a single institution design, small number of students with disabilities, and the power for a moderate effect. Students with protected disabilities may not have used accommodations. The performance differences and accommodation needs of medical students with protected disabilities need to be better understood to increase the diversity of the physician workforce. Reasons for differences during medical school and subsequent performance during and beyond residency training should be assessed. Arianne Teherani, PhD Maxine A. Papadakis, MD
d
Significant difference is between students with protected disabilities from mental impairment and students without protected disabilities (F = 2.7, P = .04, η2 = 0.06). All tests were 2-sided with P < .05 used as the significance threshold.
Analysis and interpretation of data: Teherani. Drafting of the manuscript: Teherani, Papadakis. Critical revision of the manuscript for important intellectual content: Teherani, Papadakis. Statistical analysis: Teherani. Administrative, technical, or material support: Teherani, Papadakis. Study supervision: Papadakis. Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. Additional Contributions: We thank Eric Koenig, MS, Neera Jain, MS, CRC, Lisa Meeks, PhD, and Barbara Smith (all 4 with the Office of Student Life, University of California, San Francisco) for their help with clarifying rules and procedures for disability services and providing the data on accommodations; and Mark Lovett, MPIA (Office of Medical Education, University of California, San Francisco), for help with acquiring demographic and outcome data and merging with the data on accommodations provided by the Office of Student Life. None of these persons received compensation for their contributions. 1. World Health Organization; World Bank. World report on disability. http://whqlibdoc.who.int/hq/2011/WHO_NMH_VIP_11.01_eng.pdf. Accessibility verified November 7, 2013. 2. Hegazi I, Wilson I. Medical education and moral segmentation in medical students. Med Educ. 2013;47(10):1022-1028. 3. Grimm LG, Yarnold PR. Reading and Understanding Multivariate Statistics. Washington, DC: American Psychological Association Press; 2000.
COMMENT & RESPONSE
Author Affiliations: Department of Medicine, University of California School of Medicine, San Francisco. Corresponding Author: Arianne Teherani, PhD, University of California San Francisco, 1855 Folsom St, San Francisco, CA 94143 ([email protected]). Author Contributions: Dr Teherani had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Teherani, Papadakis. Acquisition of data: Teherani, Papadakis.
Soy Protein and Recurrence of Prostate Cancer To the Editor Dr Bosland and colleagues1 found no effect of a soy protein isolate on biochemical recurrence of prostate cancer. I believe there were problems with the choice of both the intervention and placebo products. The soy isolate was not a true isolate because this would imply a concentrated protein source with minimal additive ingredients. However, the soy isolate also contained sugar (20 g
jama.com
JAMA December 4, 2013 Volume 310, Number 21
Copyright 2013 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Nanyang Technological University User on 06/06/2015
2311
Letters
per serving) and participants were encouraged to consume this product with water or fruit juice, which could impede any metabolic advantages of the intervention. Information should have been provided on whether the soy isolate reduced body weight, waist circumference, blood glucose, blood pressure, or cholesterol or testosterone compared with the placebo, as might be expected with a beneficial intervention. These cardiovascular and metabolic parameters have been linked either independently or synergistically with a lower risk and progression of prostate cancer.2 The choice of placebo (caseinate-based product) in this trial was perplexing because it contained a high concentration of calcium. Calcium supplementation significantly reduced prostate-specific antigen (PSA) velocity in the placebo group of the Prostate Cancer Prevention Trial.3 In a randomized trial of calcium supplementation to prevent colorectal adenoma, there was some suggestion of a reduction in prostate cancer.4 A meta-analysis of trial-level data found a reduction in prostate cancer with calcium, although there were few events.5 Both the soy isolate and placebo product contained more than 700 mg of calcium per serving, tantamount to supplementation of both groups. The similar amounts in the 2 products increased the probability of similar outcomes between groups. In addition, the protein concentration in the soy and placebo products was more than 19 g per serving. This amount of protein has the potential for appetite satiating effects and weight loss. Because the amount was almost identical between products, metabolic differences would be unlikely to occur, reducing the ability to detect an effect in their study of primarily overweight and obese men. Soy provides isoflavones, but the theory that these compounds will prevent prostate cancer recurrence without any change in cardiovascular or androgen parameters appears optimistic. I appreciate the complexity of any dietary clinical trial in prostate cancer, but it seems unlikely there could be any mechanistic advantage when comparing these 2 interventions. Mark A. Moyad, MD, MPH Author Affiliation: Department of Urology, University of Michigan Medical Center, Ann Arbor. Corresponding Author: Mark A. Moyad, MD, MPH, University of Michigan Medical Center, 1500 E Medical Center Dr, Ann Arbor, MI 48109 (moyad @umich.edu). Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and reported being a consultant for AbbVie Pharmaceuticals, Farr Labs, Max International, and Guthy-Renker Inc; receiving payment for lectures from AbbVie Pharmaceuticals; receiving royalties from Max International for a weight loss system (fiber bar and supplements) and from Guthy-Renker Inc for a male sexual health supplement; and receiving royalties from books for consumers and health care professionals on supplements, male sexual health, and prostate cancer. 1. Bosland MC, Kato I, Zeleniuch-Jacquotte A, et al. Effect of soy protein isolate supplementation on biochemical recurrence of prostate cancer after radical prostatectomy: a randomized trial. JAMA. 2013;310(2):170-178. 2. Moyad MA. Heart health = urologic health and heart unhealthy = urologic unhealthy: rapid review of lifestyle changes and dietary supplements. Urol Clin North Am. 2011;38(3):359-367.
2312
3. Kristal AR, Chi C, Tangen CM, Goodman PJ, Etzioni R, Thompson IM. Associations of demographic and lifestyle characteristics with prostate-specific antigen (PSA) concentration and rate of PSA increase. Cancer. 2006;106(2):320-328. 4. Baron JA, Beach M, Wallace K, et al. Risk of prostate cancer in a randomized clinical trial of calcium supplementation. Cancer Epidemiol Biomarkers Prev. 2005;14(3):586-589. 5. Bristow SM, Bolland MJ, Maclennan GS, et al. Calcium supplements and cancer risk: a meta-analysis of randomised controlled trials. Br J Nutr. 2013;110(8):1384-1393.
In Reply Dr Moyad questions the choice of the intervention and placebo products in our trial of the effect of soy protein on biochemical recurrence of prostate cancer after radical prostatectomy. The intervention was not purely soy protein isolate, but soy protein was the only component that was different between the intervention and placebo products. Both products were sweetened with sucrose and fructose to ensure acceptable palatability of the soy isolate. Inclusion of sugars did not introduce bias since the products contained the same amounts and there is no evidence that carbohydrate consumption affects PSA or biochemical recurrence. We agree that it is important to assess other effects of soy protein (eg, serum cholesterol levels) and will report these end points in the future. We selected calcium caseinate as the placebo because it is the most commonly used placebo to study the effects of soy on noncancer end points.1,2 The supplemental dose (700 mg) in our products was less than the recommended dietary allowance in men (1000 mg for men ≤70 years and 1200 mg for older men).3 Because we counseled the participants to avoid using milk to mix the protein beverage powders and not take calcium supplements, we believe that intake of calcium was within recommended safe limits (
