Type 2 diabetes mellitus (DM2) is one of the most prevalent chronic diseases worldwide and is on the rise (1). According to the International Diabetes Federation (IDF), there are currently 463 million adults living with DM2 around the world. As a result, if no measures are taken to control DM2, it is expected that by 2045, 700 million people will suffer from DM2 (2).
In Peru, according to the last systematic review on the incidence and prevalence of DM2, it was calculated that there were approximately 2 new cases per 100 persons per year (3). Likewise, in the last report on "Burden of Disease in Peru" conducted by the Ministry of Health (MINSA), in the analysis of the burden by disease subcategories, it was found that DM2 represents the fourth cause at the national level of Disability-Adjusted Life-Years (DALYs); while at the regional level of Lima it constituted the first (4.5). In addition, it is known that DM2 and its both acute and chronic complications represent a substantial economic cost (6). In 2019, the global health expenditure related to diabetes was 760 billion USD with a projected growth of 825 billion USD per year by 2030 and 845 billion USD by 2045 (7). Furthermore, in the same year, the IDF reported that the average health expenditure per person with diabetes in Peru was USD 1,135.3 (8).
On the other hand, several studies have shown the importance of education by the health professional towards patients with DM (10–13).
Through this process, information is provided about the disease such as appropriate blood glucose values, the importance of healthy lifestyle behaviors or the consequences of poorly controlled DM2. All this with the aim of improving clinical outcomes, health status and quality of life. (9). Despite this, multiple studies have shown that there are many patients who do not properly apply the self-care tools and behaviors taught by the healthcare professional. (10, 11).
Because of this, it is essential that health workers, especially at the primary care level, have the necessary tools to be able to provide comprehensive care to the patient with DM2. It is important to mention that there are several models used to evaluate medical education. One of the most widely used is Miller's pyramid, which is used to evaluate clinical skills, competence, and performance. This describes a series of levels that move from theoretical knowledge, which serves as the base of the pyramid, to practical knowledge applied in the clinical setting. Thus, we see the importance of theoretical knowledge, since having a solid base ensures that the higher levels can be developed in an appropriate manner (12). It has been seen that proper outpatient care at the primary level (training and knowledge on the part of the health care provider, time spent in the consultation, availability of drugs, etc.) is associated with better results such as a reduction in the risk of hospitalization, better glycemic control, and a lower risk of complications (13–15). Similarly, a systematic review on the barriers that prevented efficient management of DM2 in primary care showed that the quality of care provided to patients with diabetes is related to the knowledge level that the health provider has about the disease. This study found that physicians were not confident when prescribing or intensifying treatment, especially when insulin was involved (16). Likewise, several studies have shown that the knowledge levels of medical students and general practitioners are not the best, especially regarding pharmacological treatment and diet. (17, 18). Likewise, a study in Mexico applied the survey called Diabetes Knowledge Questionnaire (DKQ−24) to medical students, which is usually applied to people with diabetes to measure whether they have adequate knowledge of their disease. This study revealed that the average level of knowledge in first term students was similar to the knowledge of diabetic patients in the same region (13.43 ± 3.04 vs. 13.1 ± 2.4, respectively); and that the knowledge level increased significantly from the years in which clinical subjects were taken (19). Also, a more recent study applied a 21-question open-ended questionnaire on diabetes knowledge and concluded that there were large knowledge gaps between medical residents and nurses emphasizing the importance of providing further education to improve the care of patients with DM2 (20). Another study using the Michigan Diabetes Knowledge Test (MKDT) as an assessment instrument found that senior medical students had less knowledge (score < 50%) in questions related to dietary education (21). Finally, a study was carried out looking at the level of knowledge about diabetic ketoacidosis in medical students and it found that that only 50% of the participants answered most of the questions correctly (22).
Moreover, at the time prior to the current COVID−19 pandemic, students were normally trained in two main ways: through theoretical classes at the university and through clinical practice at the hospital and/or outpatient level. However, once the pandemic arrived, most on-site activities were cancelled. Because of this, 6th-year medical students have not been able to perform clinical practices in hospitals, while most interns were able to have first-hand contact with patients with DM2 and were actively involved in their care, whether at the hospital, outpatient, or emergency level. Thus, the question arises as to whether the fact of having on-site clinical practices influences the knowledge that medical students have about DM2. As we have already mentioned, there are several studies that show that the higher the year of study, the better the knowledge level (23, 24); however, they do not take into account the fact of having performed on-site clinical practices and having had direct contact with patients with DM2. Finally, a study that evaluated knowledge of DM2 in just graduated general practitioners (who frequently treat patients with DM2) and final-year medical students found that medical students had narrowly lower scores than their counterparts (17).
Additionally, it is relevant to mention the context of the medical education of the students in the last 2 years of medical school who were the research subjects of the present study. In the first place, they all received the Medical Clinic II course, which is a theoretical and practical course that takes place in the 5th year of the medical program and consists of clinical practices, internships in a simulation center, discussion of clinical cases, team-based learning and theoretical classes. This course objective is that the student develops the ability to evaluate, diagnose, propose a pertinent and rational work plan, as well as design general therapeutic and preventive measures for patients with digestive, endocrinological, hematological and rheumatological disorders prevalent in the country. Likewise, due to the COVID−19 pandemic, the on-site clinical practices were cancelled. This meant that the 6th-year medical students could not have an on-site externship while the last-year medical students did have one. Finally, as for the internship, it was developed in a normal way from January to March 2020, then it was suspended due to the pandemic and resumed in September 2020 until April 2021. This last part was semi-face-to-face since the schedule was 6 hours per day (7 am to 1 pm) and the practice was predominantly carried out in the hospital setting.
Since medical students, more specifically those in the last years, will be the physicians who will perform the direct care of patients with DM2 soon due to the Rural and Urban Marginal Service, it is important that they have the correct level of basic knowledge about diabetes. This is fundamental since this is one of the diseases with the highest demand at the outpatient level and is within the group of diseases that has experienced the greatest growth between the years 2002 and 2016 (25). Therefore, we consider it important to evaluate whether medical externship and internship are prepared from the point of view of knowledge to be able to address one of the most common diseases in Peru. This study will evaluate the level of knowledge and explore factors associated with it, emphasizing the prevention, diagnosis and treatment of patients with DM2 in medical students of the last two years in order to identify which variables affect the knowledge level and whether there is a need to reformulate the study plan for 5th-year medical students in order to propose strategies to improve the training of students and prioritize the topics in which there is a greater lack of knowledge.