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Original Contribution  |   January 2018
Medical Student Decision-Making: Standard Surgical Excision or Mohs Micrographic Surgery to Manage Basal Cell Carcinoma
Author Notes
  • From the Nova Southeastern University College of Osteopathic Medicine in Fort Lauderdale, Florida. 
  • Financial Disclosures: None reported. 
  • Support: None reported. 
  •  *Address correspondence to Christopher Mancuso, MHS, OMS III, 844 Broken Sound Pkwy NW, Apt 414, Boca Raton, FL 33487-3667. Email: cjmancuso@gmail.com
     
Article Information
Medical Education
Original Contribution   |   January 2018
Medical Student Decision-Making: Standard Surgical Excision or Mohs Micrographic Surgery to Manage Basal Cell Carcinoma
The Journal of the American Osteopathic Association, January 2018, Vol. 118, 19-25. doi:https://doi.org/10.7556/jaoa.2018.004
The Journal of the American Osteopathic Association, January 2018, Vol. 118, 19-25. doi:https://doi.org/10.7556/jaoa.2018.004
Abstract

Context: As future physicians, osteopathic medical students will play a critical role in helping patients make informed decisions regarding treatment options.

Objective: To examine the influence that the time, cost, and cosmetic effects associated with treatment options for basal cell carcinoma (BCC), along with students’ demographic characteristics, have on treatment decision-making. The influence that different sources of information have on students was also studied.

Methods: Medical students were recruited from the Nova Southeastern University College of Osteopathic Medicine for this cross-sectional study. Students were presented with a case scenario in which they were a patient with primary nodular BCC in a low-risk zone, and they were asked to select standard surgical excision (SSE) or Mohs micrographic surgery (MMS) as a treatment option. They also completed an anonymous survey that assessed the way that factors associated with the treatment options (time, cost, and cosmetic effects) influenced their treatment choice, along with the influence that different sources of information have. Measures of central tendency, frequencies, and other descriptive analyses were used to define the characteristics of the sample. χ2 analysis, correlational analysis, and t tests were used to examine the associations between the treatment decision, treatment-related factors (time, cost, cosmetics), and year in medical school. Statistical significance was set at P≤.05.

Results: A total of 450 students completed the survey and were included in the bivariate analysis. Three hundred forty-five students (76.7%) selected MMS as a treatment option and 105 (23.3%) selected SSE. Significant differences were found in the influence of time, cost, and cosmetic effects associated with treatment between students who selected MMS and those who selected SSE (P<.001). Cost played a more influential role in treatment decision-making for students who selected SSE than for those who selected MMS. Time and cosmetic effects played a more influential role in treatment choice for those who selected MMS. The most influential sources of information were health care professionals and medical literature, with 398 (88.4%) and 313 (69.6%) students, respectively, indicating that these sources were highly influential when making medical treatment decisions. The internet had a low influence over students’ treatment decision-making (238 [52.9%]).

Conclusions: This study represents an initial step toward understanding factors that influence patients’ treatment decision-making in a situation in which there is no medically preferred treatment option. The findings point to the importance of time, cost, and cosmetics as influential factors for patients choosing between different treatment options.

Physicians play a critical role in helping patients make informed decisions. This responsibility is even more germane in cases in which there is more than 1 treatment option and the medical literature does not provide clear evidence that one treatment is superior to the other, such as the surgical treatment for primary nodular basal cell carcinoma (BCC) in a low-risk zone. Studies have examined the sources that patients and physicians use to get information about treatment options1-3 and the factors associated with treatment decision-making, such as time, cost, and cosmetic effects associated with the treatment.4-10 
Studies that have examined medical students often focus on training related to clinical decision-making because, as future physicians, they will soon be responsible for helping patients make treatment decisions.11,12 Although these studies support the importance of developing effective interventions to improve students’ clinical decision-making skills, examining the process through which students make clinical decisions and the factors that can influence these decisions is also necessary to understand the factors that may affect patient care recommendations. Treatment characteristics (eg, time, cost, cosmetic effects) and patient characteristics (eg, age, sex, health insurance status) can play a role in treatment decision-making.4-10 Yet, the literature on factors associated with medical students’ clinical decision-making is limited. To the authors’ knowledge, no studies have examined osteopathic medical students’ treatment decision-making when presented with cases in which there are no preferred treatment options. 
Studies that looked at practicing physicians and residents have successfully used case scenarios to examine treatment decision-making in situations in which there is no medically preferred treatment option.3,13 In the present study, a hypothetical case scenario was used to examine the influence of time, cost, and cosmetic effects associated with treatment options and the students’ demographic characteristics on choosing between standard surgical excision (SSE) and Mohs micrographic surgery (MMS) for management of primary nodular BCC in a low-risk zone. Because previous studies14,15 have suggested a greater preference for MMS over SSE, owing to the same-day pathologic reporting and the better cosmetic results of MMS, we hypothesized that students would be more likely to select MMS than SSE as their preferred treatment option. 
Methods
The present study used a cross-sectional design. The protocol was determined to be exempt by the institutional review board at Nova Southeastern University in October 2016. From October 2016 to February 2017, osteopathic medical students at Nova Southeastern University College of Osteopathic Medicine who were aged 18 years or older were recruited to complete a 15-minute, anonymous survey. During 4 osteopathic principles and practice laboratory classes, a brief presentation on the study was given, during which students were invited to participate. Because these classes consisted primarily of first- and second-year medical students, a message and a link to the survey were posted on the Facebook group page for each class (ie, first-, second-, third-, and fourth-year students) to recruit third- and fourth-year students. 
Students who agreed to participate were given a packet consisting of a participation letter, hypothetical case scenario, and survey. The participation letter explained that completing the survey was strictly voluntary and that students were free to withdraw from the study at any time. It also explained that by completing the survey, they were providing consent to participate. After completing the survey, students placed their completed packet in a box at the back of the classroom. Those who completed the survey online were presented with an electronic version of the participation letter, followed by the hypothetical case scenario and the brief survey. Face-to-face and online procedures were comparable. 
Case Scenario
Students were put in the place of a patient with moderately aggressive, nonterminal BCC with a nodular subtype located on the cheek and without metastasis in the hypothetical case scenario presented to them. After the case description, the surgical treatment options (MMS and SSE) were described, including the steps in each procedure, the effects of each procedure, and costs of each procedure. After reading the scenario, students were asked to select their preferred treatment option. To control for order effects, 2 versions of the case scenario were randomly distributed. In version A, SSE was presented first, and in version B, MMS was presented first. The order of the description of the treatment options mirrored the order in which the treatment options were presented (eg, when the description of MMS was presented first, MMS was the first treatment option listed). 
Survey
The survey was designed to measure the influence that time, cost, and cosmetic effects associated with the treatment option had on the student's choice of treatment, as well as the amount of influence that various sources of information had on their treatment decision-making. The survey also gathered demographic information of the students. To develop the survey, items were created or modified using items found in the literature that were applicable to assessing BCC.16,17 The survey was pilot tested to ensure that students understood the items. Eighteen items were used to collect basic demographic information, including age, sex, ethnicity, race, state of residence, annual household income, highest-earned educational degree, legal marital status, current employment status, health insurance status, current health care, and previous experience with skin cancer. 
The portion of the survey that assessed the influence that different treatment factors had on treatment decision-making included 9 questions rated on a 5-point Likert scale ranging from 1 (“did not influence my decision at all”) to 5 (“influenced my decision very much”). Items that addressed how time associated with the treatment options affected decision-making focused on factors related to the amount of time the student would have to spend at medical appointments, the amount of time the student would have to wait to find out the outcome of the procedure, and the number of medical appointments required (eg, “How much did the time you would have spent at the doctor's office influence your treatment decision?”). Items regarding the influence of the cost of treatment addressed total cost of the procedure, whether the procedure would be covered by insurance, and out-of-pocket cost (eg, “How much did the cost of the treatment influence your treatment decision?”). Items that measured the influence of cosmetic effects of the treatment assessed how the amount of scarring, the amount of healthy tissue removed, and the chance of needing a second excision affected the student's treatment choice (eg, “How much did the amount of scarring influence your treatment decision?”). 
Another portion of the survey included 6 items that assessed how information from health care professionals, the internet, medical literature, family and friends, conferences, and advocacy groups affected treatment decision-making (eg, “How does information from doctors or other healthcare professionals influence how you make treatment decisions?”). These items were rated on a 5-point Likert scale ranging from 1 (“would not influence my decision at all”) to 5 (“would influence my decision very much”). To facilitate interpretation, the data from this section were divided into 3 categories: responses of 1 and 2 indicated a low influence, 3 indicated a moderate influence, and 4 and 5 indicated a high influence. 
Statistical Analysis
Data were analyzed using SPSS version 23 (IBM). Measures of central tendency and frequency and other descriptive analyses were used to define the characteristics of the sample. The number of students who selected each treatment option was tabulated. χ2 analysis, correlational analysis, and t tests were used to examine the bivariate associations between the treatment decision, treatment factors (ie, time, cost, cosmetics), and year in medical school. The association between demographic factors and treatment decisions was examined using parallel procedures. Statistical significance was set at a P≤.05. 
Results
Of the 450 students, 252 were men (56.0%), 197 were women (43.8%), and 1 did not specify (0.2%). The mean age of the students was 25.1 years (range, 18-48 years). Four-hundred twenty-three students (94.0%) were single, 429 (95.4%) had health insurance, and 442 (98.2%) were first- or second-year students. The participation rate was 88% among first- and second-year students and 1.5% among third- and fourth-year students. Three hundred forty-five students (76.7%) selected MMS, and 105 (23.3%) selected SSE as their preferred treatment option. The demographic characteristics of the students are presented in Table 1. No statistically significant demographic differences were found between students who chose MMS and those who chose SSE. 
Table 1.
Students’ Demographic Characteristics by Treatment Choice for Basil Cell Carcinomaa
Characteristic SSE (n=105) MMS (n=345) Total (N=450)
Age, mean (SD), y 24.9 (2.9) 25.2 (2.8) 25.1 (2.8)
Sex
 Female 37 (35.2) 160 (46.4) 197 (43.8)
 Male 68 (64.8) 184 (53.3) 252 (56.0)
 Not specified 0 1 (0.3) 1 (0.2)
Marital Status
 Single 98 (93.3) 325 (94.2) 423 (94.0)
 Married 6 (5.7) 16 (4.6) 22 (4.9)
 Divorced 1 (1.0) 3 (0.9) 4 (0.9)
 Separated 0 1 (0.3) 1 (0.2)
Year in Medical School
 First year 46 (43.8) 185 (53.6) 231 (51.3)
 Second year 59 (56.2) 152 (44.1) 211 (46.9)
 Third year 0 6 (1.7) 6 (1.3)
 Fourth year 0 1 (0.3) 1 (0.2)
Health Insurance Status
 Has insuranceb 96 (91.4) 333 (96.5) 429 (95.4)
 Medicaid 5 (4.8) 10 (2.9) 15 (3.3)
 No insurance 4 (3.8) 2 (0.6) 6 (1.3)

a Data are given as No. (%) unless otherwise indicated.

b Employer-based, self-paid.

Abbreviations: SSE, standard surgical excision; MMS, Mohs micrographic surgery.

Table 1.
Students’ Demographic Characteristics by Treatment Choice for Basil Cell Carcinomaa
Characteristic SSE (n=105) MMS (n=345) Total (N=450)
Age, mean (SD), y 24.9 (2.9) 25.2 (2.8) 25.1 (2.8)
Sex
 Female 37 (35.2) 160 (46.4) 197 (43.8)
 Male 68 (64.8) 184 (53.3) 252 (56.0)
 Not specified 0 1 (0.3) 1 (0.2)
Marital Status
 Single 98 (93.3) 325 (94.2) 423 (94.0)
 Married 6 (5.7) 16 (4.6) 22 (4.9)
 Divorced 1 (1.0) 3 (0.9) 4 (0.9)
 Separated 0 1 (0.3) 1 (0.2)
Year in Medical School
 First year 46 (43.8) 185 (53.6) 231 (51.3)
 Second year 59 (56.2) 152 (44.1) 211 (46.9)
 Third year 0 6 (1.7) 6 (1.3)
 Fourth year 0 1 (0.3) 1 (0.2)
Health Insurance Status
 Has insuranceb 96 (91.4) 333 (96.5) 429 (95.4)
 Medicaid 5 (4.8) 10 (2.9) 15 (3.3)
 No insurance 4 (3.8) 2 (0.6) 6 (1.3)

a Data are given as No. (%) unless otherwise indicated.

b Employer-based, self-paid.

Abbreviations: SSE, standard surgical excision; MMS, Mohs micrographic surgery.

×
As shown in Table 2, there were significant differences in the influence that time, cost, and cosmetic effects associated with the treatment option had on students who selected MMS and those who selected SSE (P<.001). Cost played a more influential role in decision-making for students who selected SSE than for those who selected MMS, while time and cosmetic effects played a more influential role in treatment decision-making for students who selected MMS than for those who selected SSE. 
Table 2.
Influence of Cost, Time, and Cosmetic Results by Students’ Treatment Choice for Basil Cell Carcinoma
Survey Score, Mean (SD)
Factor Associated With Treatment SSE MMS t448 P Value
Cost 9.01 (2.8) 5.31 (3.0) 11.15 <.001
Time 5.64 (2.9) 6.96 (3.2) 3.80 <.001
Cosmetic result 6.51 (2.4) 8.11 (2.6) 5.53 <.001

a Mean scores ranging from 1 to 15, with 1 indicating the lowest influence and 15 indicating the highest influence.

Abbreviations: SSE, standard surgical excision; MMS, Mohs micrographic surgery.

Table 2.
Influence of Cost, Time, and Cosmetic Results by Students’ Treatment Choice for Basil Cell Carcinoma
Survey Score, Mean (SD)
Factor Associated With Treatment SSE MMS t448 P Value
Cost 9.01 (2.8) 5.31 (3.0) 11.15 <.001
Time 5.64 (2.9) 6.96 (3.2) 3.80 <.001
Cosmetic result 6.51 (2.4) 8.11 (2.6) 5.53 <.001

a Mean scores ranging from 1 to 15, with 1 indicating the lowest influence and 15 indicating the highest influence.

Abbreviations: SSE, standard surgical excision; MMS, Mohs micrographic surgery.

×
Table 3 summarizes the degree of influence that different sources of information had on the students’ treatment decision-making. Health care professionals and medical literature were the most influential sources of information, with 398 (88.4%) and 313 (69.6%) students, respectively, indicating that these sources of information were highly influential. The internet was the source in which the largest number of students indicated that it had a low influence over their treatment decision-making (238 [52.9%]). 
Table 3.
Influence of Different Sources of Information on Students’ Treatment Decision-Making for Basil Cell Carcinomaa
Source of Information Low Influence Moderate Influence High Influence
Health care professionals 12 (2.7) 40 (8.9) 398 (88.4)
Internet 238 (52.9) 143 (31.8) 69 (15.3)
Medical literature 33 (7.3) 104 (23.1) 313 (69.6)
Family and friends 202 (44.9) 154 (34.2) 94 (20.9)
Conferences 128 (28.4) 181 (40.2) 141 (31.3)
Advocacy groups 160 (35.6) 160 (35.6) 130 (28.9)

a Data are given as No. (%).

Table 3.
Influence of Different Sources of Information on Students’ Treatment Decision-Making for Basil Cell Carcinomaa
Source of Information Low Influence Moderate Influence High Influence
Health care professionals 12 (2.7) 40 (8.9) 398 (88.4)
Internet 238 (52.9) 143 (31.8) 69 (15.3)
Medical literature 33 (7.3) 104 (23.1) 313 (69.6)
Family and friends 202 (44.9) 154 (34.2) 94 (20.9)
Conferences 128 (28.4) 181 (40.2) 141 (31.3)
Advocacy groups 160 (35.6) 160 (35.6) 130 (28.9)

a Data are given as No. (%).

×
Discussion
As hypothesized, the majority of students selected MMS as the treatment option for the given case scenario. This finding is not surprising because medical students would likely understand that MMS uses a more thorough histologic examination of the tissue sample than SSE and that MMS has a slightly higher rate of success than SSE.18 Also, MMS allows for same-day analysis, which significantly reduces the waiting time for final results and potentially reduces the stress in patients waiting for these results.7 Yet, almost a quarter of the students selected SSE. For these students, the cost of the procedure significantly influenced their treatment decision, and they considered time spent at medical appointments and cosmetic effects of the treatment option less influential. It could be that students who selected SSE considered other factors, such as the relatively low severity of the cancer and the high probability of recovery from the less costly procedure in making their decision. They may have weighed these factors differently if the science had favored MMS over SSE as a treatment option. 
The findings regarding the influence of different sources of information on treatment decision-making warrant discussion. Although the internet was the source in which the largest number of students indicated that it had a low influence over their treatment decision-making, it was surprising that 47.1% said that the internet had a moderate or high influence on their decision-making. The mean age of the students was 25.11 years; therefore, it is possible that because students aged 18 to 41 years can be reliant on technology, they would rate the internet as a reliable source of information. Also, internet sources were not defined, and there is great variability in the reliability of different internet sources. It was somewhat concerning that only 29% of students reported that advocacy groups highly influenced their medical decision-making, as advocacy groups are generally intended as a source of support for patients. Because advocacy groups were not defined, the meaning was open to interpretation. Students who reported being influenced by this option could have been referencing physician- or professional-based advocacy groups who disseminate credible and science-based information, whereas students who did not endorse this option may have been thinking about other types of advocacy groups, such as antivaccine or anticircumcision groups. 
Similar to the results of a randomized study7 in which the influence of cost on the general public's preferences for a surgical option to remove BCC was examined, the current study showed that time and cost influenced medical students’ treatment decision regarding surgical treatment for low-risk zone primary nodular BCC. The current study also confirmed the findings of Essers et al14 and Mosterd et al15 regarding the influence of cost and cosmetics on treatment decision-making. Essers et al14 found that participants preferred lower-cost treatment options when faced with a decision of MMS or SSE. Mosterd et al15 showed that MMS was favored over SSE for recurrent BCC on the face and suggested that cost and cosmetics should be considered in treatment decision-making because of the increasing number of young patients with BCC. The consistency of findings across these studies suggests that time, cost, and cosmetic effects play a role in treatment decision-making for this type of skin cancer by practicing physicians, residents, and medical students. 
It is interesting to note that demographic factors did not significantly influence treatment decision-making. Patients’ demographic characteristics, specifically sex and race, have been shown to influence medical trainee's treatment decisions regarding chronic pain management.19 Future studies should focus on patient characteristics and whether they play a role in BCC treatment decision-making among osteopathic medical students. The way a physician presents information to a patient can greatly influence how a patient chooses a treatment option.20-23 One study showed that modifying a single word in a physician's question to his or her patient could change a patient's treatment decision.21 Medical educators should interpret trial outcomes in ways that promote the well-being of patients and be cognizant of potential disparities in the value that physicians, trainees, and patients place on different treatment outcomes.24 
The current study was limited in that it only surveyed osteopathic medical students at 1 institution, so the results may not be generalizable to students in other areas. Furthermore, because the third- and fourth-year students were rotating through off-campus hospitals and clinics, the sample consisted primarily of first- and second-year medical students, which may have affected the results. Although no statistically significant association was found between year in medical school and treatment decision, a slight preference was found for MMS by first-year students. This preference may be explained by the difference in curriculum between the students. Dermatology is a second-year course, so first-year students may not have been as well educated on the topic. Because the study was cross-sectional and the survey was short, causality could not be examined. 
Conclusion
This study represents an initial step toward understanding factors that influence medical students’ treatment decision-making from a patient's point of view in a situation in which there is no medically preferred treatment option. The findings point to the importance of time, cost, and cosmetics as influential factors in choosing a treatment option for low-risk zone primary nodular BCC. Future studies should investigate more than 1 medical school, include more third- and fourth-year students in the sample, and evaluate the curriculum differences between the different years in medical school. 
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Table 1.
Students’ Demographic Characteristics by Treatment Choice for Basil Cell Carcinomaa
Characteristic SSE (n=105) MMS (n=345) Total (N=450)
Age, mean (SD), y 24.9 (2.9) 25.2 (2.8) 25.1 (2.8)
Sex
 Female 37 (35.2) 160 (46.4) 197 (43.8)
 Male 68 (64.8) 184 (53.3) 252 (56.0)
 Not specified 0 1 (0.3) 1 (0.2)
Marital Status
 Single 98 (93.3) 325 (94.2) 423 (94.0)
 Married 6 (5.7) 16 (4.6) 22 (4.9)
 Divorced 1 (1.0) 3 (0.9) 4 (0.9)
 Separated 0 1 (0.3) 1 (0.2)
Year in Medical School
 First year 46 (43.8) 185 (53.6) 231 (51.3)
 Second year 59 (56.2) 152 (44.1) 211 (46.9)
 Third year 0 6 (1.7) 6 (1.3)
 Fourth year 0 1 (0.3) 1 (0.2)
Health Insurance Status
 Has insuranceb 96 (91.4) 333 (96.5) 429 (95.4)
 Medicaid 5 (4.8) 10 (2.9) 15 (3.3)
 No insurance 4 (3.8) 2 (0.6) 6 (1.3)

a Data are given as No. (%) unless otherwise indicated.

b Employer-based, self-paid.

Abbreviations: SSE, standard surgical excision; MMS, Mohs micrographic surgery.

Table 1.
Students’ Demographic Characteristics by Treatment Choice for Basil Cell Carcinomaa
Characteristic SSE (n=105) MMS (n=345) Total (N=450)
Age, mean (SD), y 24.9 (2.9) 25.2 (2.8) 25.1 (2.8)
Sex
 Female 37 (35.2) 160 (46.4) 197 (43.8)
 Male 68 (64.8) 184 (53.3) 252 (56.0)
 Not specified 0 1 (0.3) 1 (0.2)
Marital Status
 Single 98 (93.3) 325 (94.2) 423 (94.0)
 Married 6 (5.7) 16 (4.6) 22 (4.9)
 Divorced 1 (1.0) 3 (0.9) 4 (0.9)
 Separated 0 1 (0.3) 1 (0.2)
Year in Medical School
 First year 46 (43.8) 185 (53.6) 231 (51.3)
 Second year 59 (56.2) 152 (44.1) 211 (46.9)
 Third year 0 6 (1.7) 6 (1.3)
 Fourth year 0 1 (0.3) 1 (0.2)
Health Insurance Status
 Has insuranceb 96 (91.4) 333 (96.5) 429 (95.4)
 Medicaid 5 (4.8) 10 (2.9) 15 (3.3)
 No insurance 4 (3.8) 2 (0.6) 6 (1.3)

a Data are given as No. (%) unless otherwise indicated.

b Employer-based, self-paid.

Abbreviations: SSE, standard surgical excision; MMS, Mohs micrographic surgery.

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Table 2.
Influence of Cost, Time, and Cosmetic Results by Students’ Treatment Choice for Basil Cell Carcinoma
Survey Score, Mean (SD)
Factor Associated With Treatment SSE MMS t448 P Value
Cost 9.01 (2.8) 5.31 (3.0) 11.15 <.001
Time 5.64 (2.9) 6.96 (3.2) 3.80 <.001
Cosmetic result 6.51 (2.4) 8.11 (2.6) 5.53 <.001

a Mean scores ranging from 1 to 15, with 1 indicating the lowest influence and 15 indicating the highest influence.

Abbreviations: SSE, standard surgical excision; MMS, Mohs micrographic surgery.

Table 2.
Influence of Cost, Time, and Cosmetic Results by Students’ Treatment Choice for Basil Cell Carcinoma
Survey Score, Mean (SD)
Factor Associated With Treatment SSE MMS t448 P Value
Cost 9.01 (2.8) 5.31 (3.0) 11.15 <.001
Time 5.64 (2.9) 6.96 (3.2) 3.80 <.001
Cosmetic result 6.51 (2.4) 8.11 (2.6) 5.53 <.001

a Mean scores ranging from 1 to 15, with 1 indicating the lowest influence and 15 indicating the highest influence.

Abbreviations: SSE, standard surgical excision; MMS, Mohs micrographic surgery.

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Table 3.
Influence of Different Sources of Information on Students’ Treatment Decision-Making for Basil Cell Carcinomaa
Source of Information Low Influence Moderate Influence High Influence
Health care professionals 12 (2.7) 40 (8.9) 398 (88.4)
Internet 238 (52.9) 143 (31.8) 69 (15.3)
Medical literature 33 (7.3) 104 (23.1) 313 (69.6)
Family and friends 202 (44.9) 154 (34.2) 94 (20.9)
Conferences 128 (28.4) 181 (40.2) 141 (31.3)
Advocacy groups 160 (35.6) 160 (35.6) 130 (28.9)

a Data are given as No. (%).

Table 3.
Influence of Different Sources of Information on Students’ Treatment Decision-Making for Basil Cell Carcinomaa
Source of Information Low Influence Moderate Influence High Influence
Health care professionals 12 (2.7) 40 (8.9) 398 (88.4)
Internet 238 (52.9) 143 (31.8) 69 (15.3)
Medical literature 33 (7.3) 104 (23.1) 313 (69.6)
Family and friends 202 (44.9) 154 (34.2) 94 (20.9)
Conferences 128 (28.4) 181 (40.2) 141 (31.3)
Advocacy groups 160 (35.6) 160 (35.6) 130 (28.9)

a Data are given as No. (%).

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