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1 From the Department of Family and Preventive Medicine, University of Arkansas for Medical Sciences, Little Rock, AR
2 Presented at the symposium "An Evidence-Based Approach to Medical Nutrition Education," held at Experimental Biology 2005 in San Diego, CA, 2 April 2005. 3 Supported by the Nutrition Academic Award (R07-HL03955). 4 Reprints not available. Address correspondence to RF Kahn, 4301 West Markham, Slot 530, Little Rock, AR 72205. E-mail: kahnronaldf{at}uams.edu.
ABSTRACT
Surveys show that practicing physicians believe that nutrition is important in the care of their patients but feel inadequately trained to provide optimal nutrition counseling. Even if they receive good training in the preclinical years, the interest and enthusiasm of medical students for nutrition assessment and counseling rapidly diminishes if they do not receive reinforcement from their clinical house officers and faculty mentors. Continuing Medical Education (CME) in the area of nutrition is therefore essential for both practicing physicians and faculty teaching in medical schools or residency programs. This article provides examples of the types and formats of current CME offerings in nutrition and obesity care, describes the strengths and weaknesses of various CME programs available, and offers recommendations for the development of future CME curricula in the areas of nutrition and obesity.
Key Words: Continuing medical education • nutrition • obesity • graduate medical education
INTRODUCTION
Continuing Medical Education (CME) in the area of nutrition is essential for faculty teaching in medical schools or residency programs and for practicing physicians. A lesson from the recently completed Nutrition Academic Award (NAA), a 7-y project sponsored by the National Heart, Lung, and Blood Institute to implement curricular change in nutrition in medical schools, is that teaching medical students about nutrition is necessary but not sufficient for bringing about change in their behaviors related to nutrition assessment and counseling. Educators from the various NAA sites recognized early on that the interest and enthusiasm of medical students for these behaviors rapidly diminishes if they do not receive reinforcement from their clinical house officers and faculty mentors, who themselves often lack the training and tools for engaging in these behaviors. Therefore, to accomplish student behavioral change in the area of nutrition assessment and counseling, it will be necessary to train the house officers and faculty who will be working with these medical students.
A 1991 survey of residency programs concluded that an inadequate number of nutrition-oriented physician role models appeared to be the major constraint in teaching nutrition to residents, regardless of specialty (1, 2). A recent survey of 100 randomly selected US family practice residencies showed that the presence of at least a part-time faculty member dedicated to nutrition was correlated with perceived effectiveness of nutrition education efforts (3). Yet only 10% of programs had a full-time nutrition educator and almost 20% had no nutrition educator. Therefore, continuing education of faculty in residency training programs will be required to develop the critical faculty needed to educate both house officers and medical students.
Similarly, house officers will be less likely to be enthusiastic about learning nutrition skills if they believe that they will not have occasion to use these skills in their future practice. Recent studies suggest that practicing physicians may not be providing optimal nutrition counseling for a variety of reasons. Surveys show that practicing physicians believe that nutrition is important in the care of their patients but feel inadequately trained to meet those needs (4). In one recent study, pediatric residents and faculty documented obesity in their assessments in only 53% of the reviewed visits with obese children (5). In another study, one-fourth of surveyed practicing pediatricians and family practitioners reported that they are not at all or only slightly competent to address pediatric obesity in practice, which suggests that physicians would benefit from additional training in this area (6).
As with medical students, education is necessary but not sufficient for bringing about change in physician behavior in nutrition counseling. Practicing physicians must become familiar with realistic systems for integrating nutrition into patient care. Tools and systems for successful nutrition counseling have been developed (7), and evidence exists that physician nutrition counseling can produce beneficial changes in diet, weight, and blood lipids (8).
CURRENT CME OFFERINGS IN NUTRITION
Current offerings in the area of nutrition CME fall within 2 different categories: 1) general nutrition and 2) obesity. As the prevalence of obesity has dramatically increased over the past decade, programs that previously emphasized general nutrition now seem to be moving toward an emphasis on obesity alone. CME is offered in several formats, including live presentations, Web-based programs, CDs, audio tapes, and journal-based CME.
General nutrition CME examples
Some of the ongoing programs in live presentations of nutrition CME include the Harvard Annual Postgraduate Nutrition Symposium, the Nutrition in Health Symposium sponsored by the University of Arizona and Columbia University, the Food as Medicine series sponsored by the Center for Mind-Body Medicine, and the Mayo Clinic Nutrition in Health and Disease Course. A recent Google (Google Inc, Mountain View, CA) search found only 2 additional ongoing CMEs in nutrition.
The title of the Harvard Seventh Annual Postgraduate Nutrition Symposium held in March 2005 was "The Childhood Obesity Epidemic: Predictors and Strategies for Prevention." Both the 2004 and the 2005 symposia were on obesity. This is an example of how programs that previously taught general nutrition are focusing on obesity. This postgraduate nutrition seminar has been held annually since 1999. The overall goal of the symposium is to educate medical students, physicians, health care professionals (nurses, pharmacists), and dietitians about nutrition and how to implement strategies into practice. The number of participants and physicians attending the symposium increased from 2004 to 2005; however, physicians represented a minority of the total participants.
The Nutrition in Health series sponsored by the University of Arizona and Columbia University began in 2004. The overall goal is to provide practitioners with an understanding of the central role of nutrition in health and healing. The audience for this series is similar to the audience for the Harvard series but also includes naturopaths, chiropractors, and others.
The Food as Medicine series is sponsored annually by the Center for Mind-Body Medicine in Washington, DC. The overall goal is to facilitate the introduction of nutritional information into clinical practice and medical education. The audience is very similar to that of the previously mentioned programs.
The Mayo Clinic Nutrition in Health and Disease course is described as a comprehensive review of ambulatory and hospital nutrition topics by a multidisciplinary group (physicians of many specialties, dietitians, nurses, and pharmacists). This course is designed for physicians in the specialties of critical care, endocrinology, family medicine, gastroenterology, general internal medicine, and preventive medicine as well as dietitians, nurses, and pharmacists.
Web-based CME is available through the Medscape website (9), which has CME offerings in formats such as clinical updates, news, and conference coverage. Medscape's program is accredited by the Accreditation Council for Continuing Medical Education and awards category one credits toward the American Medical Association (AMA) Physicians Recognition Award.
The Nutrition Screening Initiative is an ongoing Web-based series sponsored by the American Academy of Family Physicians and the American Dietetic Association. The overall goal is to promote the integration of nutrition screening and intervention into health care for older adults. The primary audience for this program is family medicine physicians.
Audio Digest Foundation has 9 nutrition-specific CME programs, available for purchase only, as either audio cassettes or CDs that provide up to 2 h of category one credit per program. Some good examples of print-based nutrition CME are Nutrition and the MD and Tufts' Nutrition in Clinical Care journals (10, 11). In September 2005 the American Journal of Clinical Nutrition began offering monthly CME programs, each of which qualifies for 1 h of category one credit toward the AMA Physicians Recognition Award (12).
Obesity CME examples
In September 2003 the Robert Wood Johnson Foundation (RWJF) sponsored an expert panel to evaluate CME and continuing education curricula available for health care providers. The area of interest was obesity treatment and prevention in primary care settings. The RWJF website provides a summary of the findings of this expert panel titled "Continuing Provider Education on Obesity: A Panel Review of Existing Programs," which was published in June 2004 (13). The panel conducted a nationwide poll of leading US researchers and clinicians who identified 13 ongoing CME and continuing education programs, of which 12 submitted materials for review. The nationwide poll also identified 14 expert panelists who rated the 12 programs. Contributors were assured that reviews of programs would not be revealed outside of RWJF except as aggregated summaries.
The programs were rated on clarity and completeness of information about nutrition, physical activity, and behavior change. In addition, each program was examined for educational value, practicality of use in provider settings, evidence of efficacy, and overall value. The expert panel indicated that 8 of the 12 programs provided insufficient evidence to evaluate quality and value or to support a conclusion or recommendation. Four of the programs were found to have evidence supporting the quality of one or more of the rated aspects. Most of the programs were judged by panelists to lack sufficient data on evaluation to judge efficacy of programs in modifying either provider or patient behavior. The panel issued a series of recommendations for future CME curriculum development (Table 1).
View this table:
TABLE 1. Recommendations for future Continuing Medical Education curriculum development
Among current offerings of obesity CME given as live presentations, Harvard Medical School has an ongoing symposium series entitled "Practical Approaches to the Treatment of Obesity." The 2005 19th Annual Symposium, "Implementing the Key Strategies for Successful Long-Term Weight Management," was available live and in Web-cast format.
The Centers for Obesity Research and Education (C.O.R.E.) have conducted a series of workshops around the country. The topics of these workshops include the following: review of the National Institutes of Health and National Heart, Lung, and Blood Institute obesity treatment guidelines; the physician or health care provider as an agent of change; providing an empathetic environment; skills-building and effective counseling and communication techniques; patient assessment; state-of-the-art approaches to nutrition therapy and exercise; and long-term approaches to weight loss and weight maintenance, including medication and surgery. C.O.R.E. scheduled 2 live symposia in 2005, one in San Francisco and one in Boston.
There are several Web-based CME programs on obesity. "The Assessment and Management of Overweight and Obese Patients" is sponsored by the Department of Health and Human Services, the National Institutes of Health, the National Heart, Lung, and Blood Institute, and the North American Association for the Study of Obesity (NAASO) (14). NAASO has 2 additional online CME programs on obesity: "Understanding and Treating Obesity" and "Office Management of Obesity."
For those who prefer their Web-based CME in a format similar to a television talk show, Discovery Health has a program on "Adult Obesity: Reversing the Trend" and another on "Childhood Obesity" (15). Each of these provides free AMA category one credit along with access to reference material and patient information handouts and permits participants to submit questions to the faculty online.
The University of Massachusetts Medical School has a Web-based program on evaluation and management of severe obesity, and the American Academy of Family Practice have Web-based programs covering obesity, metabolic syndromes, and Americans in Motion (AIM).
IF YOU BUILD IT, WILL THEY COME?
Will faculty and practicing physicians access some of these CME offerings in nutrition and obesity? If they do, will the CME influence their behavior with regard to nutrition assessment and counseling? The answers to these questions have yet to be determined.
At a minimum, however, the success of any given CME program depends on at least 3 factors: 1) demand, 2) value as perceived by the target audience, and 3) the ease of obtaining CME. The NAA implementation of undergraduate curricula for nutrition has hopefully created increased demand among faculty and house officers for CME in this area. Similarly, the high prevalence of obesity within the US population offers an opportunity for patients to demand that their primary care providers be able to help them with weight maintenance and weight loss.
Recent experience in Arkansas with an obesity CME program provides an example of the difficulty of persuading practicing physicians to access CME. In 2003 the Arkansas Legislature passed a bill requiring that the parents of every public school child receive a letter informing them of their child's BMI and any associated health risks.
About 400 000 "child health reports" were sent to parents after the completion of the 2004 school year. For children in the "at risk of overweight" and "overweight" categories, the report included the suggestion that the child see his or her family physician or pediatrician to determine whether he or she has risks related to weight. The bottom of each health letter contained a note to physicians to access a free online CME on management of pediatric overweight (16). Additionally, every Arkansas primary care provider who cares for children were sent 3 mailings with information about accessing the CME online and a 2-page "Clinician's Guide to Management of Pediatric Overweight." This guide and the website for the CME program were also published in several statewide journals, including the Journal of the Arkansas Academy of Family Physicians and the Journal of the Arkansas Medical Society. Most of the recommendations from the RWJF expert panel on obesity CME were incorporated into the online CME. Every attempt was made to make the CME valuable by making it free and providing both 1.75 category one credits toward the Physicians Recognition Award and 1.5 prescribed credits by the American Academy of Family Physicians. These prescribed credits are particularly valuable for family medicine recertification. The CME included practical information on office implementation, including a discussion of changes important in office systems, the office environment, coding and billing, and diagnosis codes that may be reimbursable.
Preliminary results of a 2005 survey of the 1300 family physicians and pediatricians in Arkansas indicate that most of these physicians were aware of the 2-page guide and the CME program and had at least one parent bring in bring in a child's BMI letter for consultation (17). After the first 6 mo online, however, only 4 physicians had completed the CME, whereas another 5 were "in progress." In contrast, a total of 49 nurses, either RNs or LPNs, had completed the program. The program was highly rated by nurses and physicians alike as to the extent to which it achieved the objectives. In the 2005 survey, the vast majority of physicians responded that they felt confident in their ability to recommend diet and activity for children and adolescents. This confidence may in part explain why so few physicians have accessed the online CME.
CONCLUSIONS
On the basis of currently available evidence, it is not clear what will be required to accomplish adequate behavior change in the area of nutrition assessment and counseling among medical school faculty and primary care providers. Accordingly, those who are developing nutrition CME programs should consider a preimplementation evaluation of the needs of their intended audience and should attempt to incorporate as many of the recommendations and conclusions as possible from the RWJF expert panel on obesity CME, especially the recommendation to emphasize the incorporation of counseling into office practice. It is highly likely that providers will be more motivated to learn about management of nutrition-related illness if they can be convinced that nutrition assessment and counseling can be reasonably incorporated into their office systems and that their services will be reimbursed.
Although physicians and other health care providers play an important role in helping patients with diet and weight control, it is also clear that the obesity epidemic will not be reversed by changes in health care provider's behavior by itself. Therefore, CME programs in the area of nutrition and weight control should also emphasize the role of health care providers outside the office, specifically, in advocating for improvements in school nutrition and physical activity and for policies and programs that can improve nutrition and physical activity in the community.
ACKNOWLEDGMENTS
The author had no conflicts of interest to report.
REFERENCES