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1 From the Nutrition Education and Prevention Program, University of Pennsylvania School of Medicine, and the Office of the Vice Dean for Education, University of Pennsylvania School of Medicine.
2 Presented at a symposium held at Experimental Biology '99, in Washington, DC, April 17, 1999. 3 Supported by the National Heart, Lung, and Blood Institute's Nutrition Academic Award. 4 Address reprint requests to LA Hark, University of Pennsylvania School of Medicine, Stemmler Hall, Suite 100, 3450 Hamilton Walk, Philadelphia, PA 19104-6987. E-mail: lhark{at}mail.med.upenn.edu.
ABSTRACT
The Nutrition Education and Prevention Program at the University of Pennsylvania School of Medicine is a successful program that can be used as a model for the development and implementation of a case-based nutrition curriculum across the 4-y medical school experience. This article gives a broad overview of the development, implementation, evaluation, and dissemination processes used by the Nutrition Education and Prevention Program administration and core faculty group at the University of Pennsylvania School of Medicine. Beginning in 1990, the nutrition curriculum was initiated with the assistance of several funding sources. The program was structured using a multidisciplinary faculty group of physicians and registered dietitians from multiple departments, centers, and institutes. The outcome of this process is a textbook, Medical Nutrition and Disease, currently required by numerous medical schools, residency programs, and other health professional programs across the nation. With the use of data from the Association of American Medical Colleges All Schools Survey of Graduating Medical Students, perceptions of the adequacy of nutrition education were tracked over time. In 1991, 80% of University of Pennsylvania medical students felt that nutrition coverage was inadequate compared with 10% of medical students in 1998, a significant change resulting from the nutrition program's effect. The University of Pennsylvania School of Medicine has developed and implemented a successful nutrition curriculum, despite national trends. The case-based integrated curricular model presented in Medical Nutrition and Disease and on our Web site, www.med.upenn.edu/nutrimed, can be used by medical institutions and other health professionals.
Key Words: Case-based curriculum • curriculum reform • medical nutrition • medical students • integrated nutrition curriculum • nutrition education
INTRODUCTION
Nutrition education can be defined as the introduction of scientific principles of nutrition into the clinical practice of medicine (1). Medical nutrition education is directed toward preparing physicians to incorporate nutrition into both the prevention and treatment of chronic illness and to meet the needs of patients and the public (1).
Research on medical nutrition education has focused on the current status of nutrition in the medical school curriculum; knowledge, skills, and attitudes that medical students, residents, and physicians should attain in nutrition; and the suggested content of nutrition curricula for medical schools and residency training. According to Healthy People 2010 (3) and the Guide to Clinical Preventive Services (4), basic clinical preventive services are required by all Americans, yet physicians often do not deliver these essential services at the appropriate intervals. It is estimated that nearly one million deaths annually and 70% of health care costs can be attributed to preventable diseases (5). Healthy People 2010 goals state that "nutrition education and counseling should be included in all routine health contacts with health professionals" (3). Physicians and other health professionals should be prepared to provide nutritional counseling to help their patients prevent and manage disease (6, 7).
The American public has become increasingly aware of the importance of nutrition in health maintenance, disease prevention, and treatment. Physicians are frequently expected to provide their patients with accurate and current nutritional information, but lack adequate training to interview, assess, educate, and motivate patients in the area of nutrition and disease prevention (8–12). In addition, controversies and confusion exist in the current scientific literature about the role of nutrition in health, such as alcohol and antioxidants and the prevention of heart disease (13, 14). The lack of training that medical students and residents receive in the area of prevention, the emphasis during training on acute rather than preventive care, the inadequacy of educational resources committed to disease prevention, and the lack of reimbursement for nutrition counseling by registered dietitians may partially explain the low level of preventive nutrition counseling seen in the clinical practice setting (15–17).
UNDERGRADUATE MEDICAL EDUCATION
In 1962 and 1972 the American Medical Association Council on Foods and Nutrition criticized US medical schools for "not keeping abreast of the tremendous advances in nutrition knowledge," stating that "nutrition received inadequate recognition, support, and attention in medical education" (18). The 1985 National Academy of Sciences report Nutrition Education in US Medical Schools noted that "scientific conferences and congressional hearings convened during the past two decades have reinforced the need to improve the status of nutrition education in U.S. medical schools" (15). Much of the research regarding nutrition education emphasizes the nutrition topics that should be taught and where in the undergraduate medical school curriculum and residency training programs these topics should be integrated (19–24). The literature also outlines specific content guidelines, which could be used as a guide for developing or improving the nutrition items on medical licensure exams.
Additional reports published by the American Medical Student Association state, "Next to smoking, diet and nutrition-related factors are among the greatest contributors to preventable, premature illness and death in the industrialized world as well as in less-developed countries." (24). The American Medical Student Association Nutrition and Preventive Medicine Task Force established the Nutrition Curriculum Project to ensure that adequate nutrition be taught to medical students, to provide a framework for integration of nutrition at all levels of medical education, and to establish and disseminate topics deemed essential for developing physicians' competencies in nutrition (24).
According to the 1996–1997 American Medical Association Liaison Committee on Medical Education survey, 32 medical schools (26%) currently require a nutrition course (25). Of the 93 remaining schools without a required nutrition course, 91 integrate nutrition education into other courses. The specific coverage of nutrition principles and clinical practice skills emphasizing the prevention of diseases is not known at this time. However, in March 1997, the American Medical Association Council on Medical Education resolved to collect data from US medical schools on the current teaching of all aspects of nutrition and dietetics and to compare this with the content related to nutrition in Steps 1 and 2 of the US medical licensing examinations (25).
The American Medical Association Council on Medical Education also resolved to reaffirm the policy, Medical Education in Nutrition, supporting the instruction of nutrition in US medical schools, to widely disseminate to medical educators the suggested objectives and examples of model medical school curricula in nutrition developed by the American Society for Clinical Nutrition and the University of Pennsylvania, to continue to monitor the effectiveness of nutrition training, and to develop new measurement criteria (25).
INCLUSION OF NUTRITION ON THE US MEDICAL LICENSING EXAMINATION
Since the National Academy of Sciences report indicated that as few as 4% of Step 1 and 2 US medical licensing examination items covered nutrition, much attention has been given to these exams as one major explanation for the inadequate inclusion of nutrition in medical school curriculum (15). The first study to review the nutrition content in US Medical licensing examinations since 1984 was conducted by Hark et al (26), who identified the number of nutrition-related items, the nature of nutrition-related items, and how coverage of nutrition changed from 1986 to 1993.
Nutrition coverage on the Part I exam represented 9% of the scored items, increasing to 11% in 1993 on the Step 1 exam. Nutrition coverage on the Part II exam also increased from 6% in 1986 to 12% of the scored items on the 1993 Step 2 exam. Of note, changes on the Step 2 exam occurred within the cardiovascular system section, representing 6% of the nutrition items in 1986 and 14% of the nutrition items in 1993 (26). However, little coverage was given to nutrition-related screening and preventive counseling, with the majority of the overall increase in nutrition most likely related to the increase in items covering vitamin deficiencies (26).
HISTORY OF THE UNDERGRADUATE MEDICAL SCHOOL NUTRITION EDUCATION AND PREVENTION PROGRAM
The University of Pennsylvania School of Medicine, the nation's first medical training institution founded in 1765, graduates 150 new physicians/y. The standing faculty includes >1088 full-time physicians. In 1991 the School of Medicine was awarded a 5-y grant from the Howard Heinz Endowment to initiate the development of a nutrition education program for medical students. This funding supported the establishment of the Nutrition Education and Prevention Program and the development of course materials for a self-instructional, case-based curriculum required for first-, second-, and third-year medical students. The approach to teaching nutrition was unique in that it was integrated across several courses and spanned many departments, centers, and institutes, including medicine, family practice, geriatrics, surgery, obstetrics and gynecology, pediatrics, biostatistics and clinical epidemiology, the Institute on Aging, and the Center for Weight and Eating Disorders. Each content area is coauthored by a physician and dietitian and focuses on the integration of nutrition into the patient medical history and physical examination for the prevention and management of disease.
The basis for the nutrition curriculum included recommendations from the American Medical Association Council on Medical Education, the National Academy of Sciences, the American Society for Clinical Nutrition, the American Medical Students Association, and Healthy People 2000. We have paid particular attention to the Report of the Project Panel on the General Professional Education of the Physician (27) which recommends that 30–50% of the time devoted to lectures be used instead in active learning experiences administered by interdisciplinary and interdepartmental committees and that health promotion and disease prevention information be integrated throughout the curriculum rather than presented as a separate course. Once nutrition education was defined, the core faculty team developed nutrition-related knowledge, skills, and attitude objectives that have been the foundation of the program (Figure 1).
FIGURE 1. . Knowledge, skills, and attitude objectives for the Nutrition Education and Prevention Program. Copyright 2000, University of Pennsylvania School of Medicine, Philadelphia. Reproduced with permission.
In 1994 the Nutrition Education and Prevention Program was awarded a 3-y grant from the National Cancer Institute to expand the introductory nutrition curriculum and to develop, implement, and evaluate a similar educational model to integrate nutrition and cancer prevention throughout the 4-y medical school curriculum. The program goals included emphasizing nutrition's role in cancer prevention and treatment, providing positive role models for medical students, and identifying core faculty members within the University of Pennsylvania Health System who could support the nutrition curriculum's activities.
Through this support, we were able to focus our efforts on disseminating our case-based nutrition curriculum and were approached by Blackwell Science to publish Medical Nutrition and Disease (1). This textbook consists of 12 chapters that provide a broad overview of nutrition, including nutrition assessment, vitamins and minerals in health and disease, nutrition during the life cycle (eg, pregnancy, pediatrics, and geriatrics), nutritional management and pathophysiology of diseases, and enteral and parenteral nutrition support (1).
Each chapter includes 1–3 clinical cases that have direct application to patient care and emphasize prevention of chronic diseases. All chapters and cases were coauthored by teams of physicians and dietitians. By using a template that we established for consistency, all cases are structured such that they resemble an actual patient work-up. After the history and physical examination data are given, a list of questions is presented. Following this list, each question is answered in sentence format, offering students and other health professionals the opportunity for self-instructional learning. Most case answers are divided according to diagnosis, medical implications, nutrition assessment, treatment, and management issues.
ADMINISTRATIVE STRUCTURE TO IMPLEMENT THE NUTRITION CURRICULUM
The Nutrition Education and Prevention Program uses a vast array of resources to develop, implement, evaluate, and disseminate a curriculum to teach nutrition principles and clinical practice skills. In addition to the core faculty group, an advisory board that meets semiannually was established to offer guidance to the faculty and program director. The advisory board members are consulted individually by the core team on an as-needed basis because they represent many of the key resources available for nutrition education and management within the University of Pennsylvania Health System, as well as play a key role in helping to achieve faculty and staff participation in the educational program (Figure 2). Senior University of Pennsylvania faculty members (ie, department chairpersons and program directors) were specifically chosen for the advisory board from the departments of Clinical Nutrition Support, Medicine, Family Practice and Community Medicine, Disease Management, Weight and Eating Disorders, and Pediatrics.
FIGURE 2. . Medical nutrition curriculum administrative structure. Copyright 2000, University of Pennsylvania School of Medicine, Philadelphia. Reproduced with permission.
CURRICULUM 2000 UNIVERSITY OF PENNSYLVANIA MEDICAL CURRICULUM FOR THE 21st CENTURY
In 1995, in recognition of a changing medical marketplace with a continued shift towards ambulatory care, Kelley (Dean of the School of Medicine) and Morrison began a sweeping curricular reform initiative referred to as Curriculum 2000 (University of Pennsylvania School of Medicine, Philadelphia). More than 300 faculty members, university officials, students, and leaders of external organizations, (eg, the National Board of Medical Examiners and the Association of American Medical Colleges) participated in the planning process, which spanned September 1995 through August 1997. Implemented for students matriculating in September 1997, Curriculum 2000 integrates content across disciplines, thus improving upon the traditional approach of rigorously defining scope and sequence of concepts in terms of courses. The 4-y curriculum consists of 6 interdisciplinary modules (Figure 3).
FIGURE 3. . Curriculum 2000 overview, University of Pennsylvania School of Medicine. Copyright 1999, University of Pennsylvania School of Medicine, Philadelphia.
Module 1: Core Principles
Core principles is presented during the morning sessions from September of year one through December of year one. The primary objective of Module 1 is to ensure that all students, regardless of undergraduate major and extent of science preparation, possess the appropriate background knowledge before receiving instruction in the physiology, pathophysiology, and pathology of each organ system. Module 1 comprises morning sessions during the first semester of medical school and covers fundamental concepts in human body structure (eg, gross anatomy, histology, and embryology), molecular biology and metabolism (eg, biochemistry, physiology, and genetics), and host defenses and pharmacologic intervention (eg, immunology, microbiology, and basic pharmacology). Nutrition topics in a case-based format that are integrated into Module 1 include metabolism of protein, lipids, and carbohydrates; inborn errors of metabolism; one-carbon metabolism; insulin action; and the role of vitamins and minerals in cellular respiration. Nutrition-related questions are incorporated into the overall examination and students do not receive a separate grade for nutrition.
Module 2: Integrative Systems and Disease
Integrative Systems and Disease is presented during the morning sessions from January of year 1 through December of year 2. Concepts are organized by organ systems according to the following standardized paradigm: normal development, normal processes, applied clinical anatomy, abnormal processes, therapeutics and disease management, epidemiology and evidence-based medicine, and prevention and nutrition.
Nutritional management of various diseases that are integrated into Module 2 in a case-based format are as follows: cardiology (eg, heart disease, hypertension, and congestive heart failure), gastroenterology and nutrition (eg, normal physiology of digestion and absorption, gastroenterology diseases, nutrition assessment, vitamin and mineral requirements, pediatric and geriatric nutrition, and enteral and parenteral nutrition support), endocrinology (eg, types 1 and 2 diabetes), reproduction (eg, pregnancy and lactation nutrition), pulmonary medicine (eg, chronic obstructive pulmonary disease, sleep apnea, cystic fibrosis, and lung transplant), renal medicine (eg, chronic renal failure, dialysis, nephrolithiasis, and renal transplant), and hematology and oncology (eg, anemias, nutrition support, and the nutritional effects of chemotherapy and radiation). Case-based lectures, small group sessions, and self-learning assignments are designed for each topic and nutrition-related questions are incorporated into the overall examination.
Module 3: Technology and Practice of Medicine
Technology and Practice of Medicine begins in September of the first year and continues through December of the second year. Given as afternoon sessions 2 d/wk, Module 3 addresses the obtaining of patient medical history and physical examination skills, the doctor-patient relationship, nutrition and prevention, health care delivery, and population-based medicine. Often, cases linked with topics covered in the Module 1 and 2 morning sessions are used as vehicles for exploration in Module 3 core knowledge and skill teachings. Nutrition is integrated into the history taking course by training students to routinely incorporate information on dietary intake, vitamin, mineral and herbal remedies, lifestyle, alcohol, and exercise behavior when obtaining patient histories. Standardized patients (ie, trained actors who simulates symptoms and are used to teach medical students about medical history and physical exam skills) are used to evaluate competency, and nutrition-related questions are a component of the standardized patient checklist used to give students feedback.
The integration of nutrition concepts into the physical examination course includes training students to routinely assess the nutritional status of their patients by using anthropometric data (height, weight, and body mass index); physical findings, such as temporal wasting; and the evaluation of laboratory data. Cases used to emphasize nutrition assessment include malnutrition, refeeding syndrome, familial hypercholesterolemia, congestive heart failure, and bulimia nervosa.
Module 4: Core Clinical Clerkships
Core Clinical Clerkships begins in January of year 2 and continues through December of year 3. The required clinical rotations consist of both inpatient and ambulatory experiences and emphasize management of acute and chronic illness, health maintenance, and prevention. Clinical activities are augmented with periodic basic science seminars, which reinforce mechanisms underlying disease and the utilization and development of clinical pathways and guidelines.
Third year medical students are required to nutritionally assess patients during their medicine, surgery, and pediatrics clerkship rotations. During these clinical clerkships, students have the opportunity to interact with patients and complete a nutrition assessment, and present these data to a physician preceptor who is part of our core faculty team. Individual nutrition syllabi are developed for the medicine, surgery, and pediatric clinical clerkship outlining why nutrition is important for each rotation, and reinforcing how this information can be integrated into patient medical history and physical examination.
Students are given an orientation to the nutrition requirement and syllabi during the first day of each rotation. Examples of the diagnoses and surgical procedures for students to select are suggested as well as specific questions within the past medical history, social history, and family history that pertain to nutrition. Examples of signs and symptoms within the review of systems and physical examination with nutritional implications are also given. This information is summarized in nutrition checklists specific for each rotation to prompt students during the interviewing process. In addition, a sample student write-up is provided along with the syllabi during orientation.
Students are expected to document the patient's height, weight, and body mass index, and to calculate the percentage weight change if weight loss has occurred. Laboratory data with nutritional significance are also described and discussed depending on the patient's medical problems. A comprehensive assessment of the individual's nutritional status as well as diagnostic and educational plans related to the nutritional status of the patients is expected.
Students receive a separate grade for nutrition in the third year which reflects these 3 write-ups and are evaluated on both their written and oral presentations. The criteria for the written section are as follows: nutrition checklist (10%), technical comprehension (10%), integration of nutrition into the assessment and plan (10%), inclusion of a nutrition-related journal article (10%), and clarity, expression, and punctuality (10%). Oral presentations are graded using the following criteria: prepared for the meeting (10%), professional conduct (10%), level of interest (10%), responsiveness to questions (10%), and appropriateness of presentation (10%).
Module 5: Electives, Selectives, And Scholarly Pursuit
Electives, Selectives, and Scholarly Pursuit composes the final 1.5 y of Curriculum 2000 and consists of sixteen 4-wk blocks. The primary curricular objective of Module 5 is to cap off the required components of Curriculum 2000 with structured opportunities that will enable students to gain advanced clinical experience and to explore individual interests. Students must complete a subinternship in medicine or pediatrics, 6 additional electives (4 of which must be clinical), and several Frontiers in Medical Science 12-wk seminars, which cover state-of-the-art topics in translational medicine, gene therapy, infectious disease, and cancer, with emphasis on bridging basic science and clinical medicine (from bench to the bedside). Students are required to complete a minimum 3-mo Scholarly Pursuit, ie, an in-depth experience with a physician mentor, in an area of interest in either basic science research, clinical research, or in the community. To evaluate this experience, students complete a 20-page thesis paper outlining their research or experience. Module 5 was implemented in January 2000 for the Class of 2001.
Module 6: Professionalism and Humanism
Professionalism and Humanism, initially recognized as a theme integrated across the entire 4-y continuum of Curriculum 2000, was recently formalized as Module 6. The curriculum for this module addresses such issues as the development of professional skills and attitudes, cultural diversity and its implications for the delivery of patient care, death and dying, and bioethics. Full implementation of Module 6 will be achieved in May 2001 with the completion of Curriculum 2000 by the Class of 2001.
VALUE-ADDED: ACADEMIC SUPPORT RESOURCES
Curriculum 2000 is innovative not only because it is one of the first medical schools to integrate basic science, clinical medicine, nutrition, prevention, professionalism, and humanism across the entire 4 y of medical school, but also because of the tremendous, state-of-the-art resources developed and provided in support of formal educational programs. The student laboratory infrastructure was upgraded with the addition of dual-headed video microscopes and new computers. A multidisciplinary resource room has been established containing learning tools such as plastinated anatomical specimens, slide sets, X-rays and other images, and clinical procedure videos coordinated with topics being covered in Modules 1–3.
The most innovative support resource is, however, Virtual Curriculum 2000, an online multimedia adjunct to Curriculum 2000. Virtual Curriculum 2000 consists of digitized lectures complete with audio, video, and synchronized slides; syllabi and other course materials; computer-assisted instructional programs in anatomy, embryology and histology; and 100 000 medical images. Virtual Curriculum 2000 is so successful that its components are currently being used as a foundation for the development of a range of online educational products including continuing medical education courses (Council on Medical Education) for practicing physicians, instructional programs and Web-based libraries for pharmaceutical company representatives, and board review courses for undergraduate medical students and graduate trainees.
IMPLEMENTATION OF AN INTEGRATED CASE-BASED NUTRITION CURRICULUM
The foundation for nutrition education established from 1990 to 1996 was essential for the successful integration of nutrition and prevention into the Curriculum 2000 blueprints. Lectures, cases, small group sessions, workshops, and self-learning modules, which were previously developed, continue to be a key component of the curriculum at each level. Specifically, the introduction to clinical nutrition course, which covered nutrition assessment and the life cycle, has become a major component of the Gastroenterology and Nutrition Block within Module 2. The clinical nutrition course that was given during the second year of medical school, is fully integrated into Module 2 during all the system blocks including cardiology, pulmonary medicine, renal medicine, brain and behavior, hematology and oncology, endocrinology, and reproduction, as previously described elsewhere (28).
In addition, we spent 1998 and 1999 updating Medical Nutrition and Disease, inviting nationally known nutrition experts to participate in the revision process. We have maintained the same number of chapters and cases, focusing on updating content and references. The second edition was published by Blackwell Science in the fall of 1999 (29).
NATIONAL HEART, LUNG, AND BLOOD INSTITUTE NUTRITION ACADEMIC AWARD FUNDING AND FUTURE DIRECTIONS
With recent funding from the National Heart, Lung, and Blood Institute's Nutrition Academic Award from 1998 to 2003, our current focus is on developing a series of interrelated but independent modules, that can be implemented in a variety of settings and used by trainees at different education levels. The curricular modules are organized within the following broad topics: 1) the science of nutrition related to primary and secondary prevention of cardiovascular disease, 2) methods to assess nutritional status and cardiovascular disease risk, 3) behavioral change and treatment strategies, and 4) nutritional issues for special populations defined by age, sex, ethnicity, and socioeconomic status (Figure 4).
FIGURE 4. . Core competencies (knowledge of nutrition principles): a modular cardiovascular disease-prevention medical nutrition curriculum. Copyright 2000, University of Pennsylvania School of Medicine, Philadelphia. Reproduced with permission.
Within each of these core competencies, specific modules are developed by multidisciplinary faculty teams. The programs focus on the discussion and evaluation of epidemiologic evidence and controversies from metabolic studies, intervention trials, and animal, population, and observational research. Core competencies for knowledge of nutrition principles are listed in Figure 4. Core competencies for clinical skills related to nutrition will also be developed. The program focuses on training medical students, residents, and physicians to acquire and implement clinical nutrition skills consistently (Figure 5). A module will be defined as a self-contained educational experience encompassing core knowledge and skills competencies to achieve the desired objectives. Format, structure, and components of the modules are listed in Figure 6.
FIGURE 5. . Core competencies (clinical skills related to nutrition): a modular cardiovascular disease-prevention medical nutrition curriculum. Copyright 2000, University of Pennsylvania School of Medicine, Philadelphia. Reproduced with permission.
FIGURE 6. . Modular components of the cardiovascular-prevention medical nutrition curriculum. Copyright 2000, University of Pennsylvania School of Medicine, Philadelphia. Reproduced with permission.
EVALUATION OF THE NUTRITION EDUCATION AND PREVENTION PROGRAM
The availability of the Association of American Medical Colleges All Schools Survey of Graduating Medical Students makes it possible to examine students' attitudes about the time devoted to nutrition during their medical education (30). As shown in Figure 7, the percentage of medical students graduating from the University of Pennsylvania School of Medicine who reported that the time devoted to nutrition instruction was inadequate declined significantly over the past decade. The 1995 data reflect graduates who would have matriculated in 1991, the first year that the nutrition curriculum was initiated, explaining in part the significant change seen from 1994 to 1995. In 1999 the average response from all the graduating medical students indicated that 63.8% felt the time devoted to nutrition was inadequate, compared with 10% of the students at the University of Pennsylvania.
FIGURE 7. . Percentage of medical students reporting that the time devoted to nutrition instruction was inadequate. Data from reference 30.
In addition to looking at trends, we have used traditional evaluation methods, including examinations, to assess knowledge of core competencies and achievement of objectives; standardized patients to assess skills; and focus groups to assess attitudes. Evaluation components are described throughout this article and are implemented in years 1–3 for both students and faculty. Access to Virtual Curriculum 2000 is also an innovative mechanism to evaluate the interest in nutrition-related lectures and self-learning material. Future evaluation endeavors include identifying compliance with basic standards of care, ie, adequacy of documentation regarding nutrition and prevention. Measures to be assessed include documentation of height, weight, and body mass index, documentation of students' dietary intake, and ability to provide nutrition counseling. Medical students will keep a log of the patients they see during their core clinical clerkships that includes a note of their patient's chief complaints. Standards of adequate performance will be developed by the core project team and the advisory board. We will also conduct brief semistructured interviews with patients at risk of cardiovascular disease and assess if they recall receiving nutritional counseling from their physician or health professional. If patients do recall such counseling, we will then determine the patient's judgment on the effect of such counseling on their behavior, in addition to their satisfaction with the content and style of communication.
COUNSELING AND COMMUNICATION SKILLS
Before completing their first 2 y of medical school and at the conclusion of medical school, students will be required to complete a multistation summative examination to assess clinical skills. Many of the cases will include standardized patients with a variety of chief complaints and medical histories. We plan to create 7–10 stations that require, as either a major or minor component of optimal performance, consideration of issues related to nutrition and counseling regarding cardiovascular disease prevention and management. The blueprint for the cases will be specified by the core project team, who will work closely with pertinent groups within the Nutrition Education and Prevention Program Office to ensure that the nutrition cases are integrated into the overall summative examination. Cases that include a nutrition component can also be given as a standalone examination to targeted groups of residents and practicing physicians (eg, subgroups who have and have not been exposed to the modules). We expect to target the skills outlined in the core competencies.
DISSEMINATION OF THE INTEGRATED CASE-BASED NUTRITION CURRICULUM
Disseminating the experiences and educational materials developed by the University of Pennsylvania School of Medicine to the broader academic medicine community is and will continue to be a priority. Medical Nutrition and Disease resulted from the need to develop self-learning nutrition education curriculum for medical students (1, 29). Medical Nutrition and Disease has been purchased and favorably reviewed by nearly 60 US medical schools and 40 family practice residency programs, demonstrating the viability of developing a generalized nutrition curriculum that can be transferred to other academic centers and used by educators of other health professionals including dietitians, nurses, and physician assistants (1, 28). This exposure has put the authors in contact with medical educators at academic medical centers worldwide who have expressed interest in replicating the University of Pennsylvania School of Medicine's model for nutrition education. We have also been asked to serve as advisors for nutrition curricular development and implementation, to share exams and course syllabi, and to develop surveys. In addition, we exhibited the Nutrition Education and Prevention Program at the Association of American Medical Colleges annual meeting in the Innovations in Medical Education (ie, exhibit booth) since 1995 and participated in the Association of American Medical Colleges Group on Educational Affairs Small Group Discussion Workshops as well.
Another key aspect of the dissemination campaign is the use of electronic media and Internet technology. The Nutrition Education and Prevention Program has created an Internet Web site (www.med.upenn.edu/nutrimed) that includes course goals, objectives, schedules, required assignments, examinations, program evolution, and syllabi, all of which can be downloaded and adapted to each institution. The Web site is visited frequently by both University of Pennsylvania medical students and medical and nutrition educators from around the world (1000 hits/mo).
The University of Pennsylvania School of Medicine has developed and implemented a successful nutrition curriculum, despite national trends. The Nutrition Education and Prevention Program administrative structure (Figure 2) and case-based integrated curricular model has been the main reason for our success and we are pleased to be able to share this curriculum with medical educators via Medical Nutrition and Disease and our Web site.
REFERENCES