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1 From the Tufts University School of Medicine, Department of Public Health and Family Medicine, Boston, MA
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 National Institutes of Health grant 1K07HL03073 (Nutrition Academic Award). 4 Address reprint requests to MN Woods, Tufts University School of Medicine, Department of Public Health and Family Medicine, 150 Harrison Avenue, Jaharis 265, Boston, MA 02111. E-mail: margo.woods{at}tufts.edu.
ABSTRACT
The Nutrition Academic Award received by Tufts University School of Medicine strengthened our first-year Nutrition and Medicine course and clearly resulted in more nutrition in third-year clerkships and residency programs. Standardized patient cases in nutrition counseling for cardiovascular disease and weight loss were developed and incorporated into the clerkships and residency programs in internal medicine and family medicine. This was a value-added benefit that provided practice in initiating lifestyle changes and motivational skills, while expanding nutrition education. Eight standardized patient educators were trained in collaboration with physicians in internal and family medicine. Six slide shows on nutrition topics, 1–2 h each, were developed and included clinical cases, dietary analysis, and patient handouts. The Medicine Clerkship included 4 nutrition sessions and the standardized patient experience, whereas the Family Medicine Clerkship included 1 nutrition session and the standardized patient experience. Working with faculty in the Department of Family Medicine, we developed a nutrition mentoring program for the family medicine residents and used 3 nutrition messages that were a modification of the Dietary Approaches to Stop Hypertension (DASH) diet to teach diet evaluation, intervention strategies, feedback from nutrition referrals, and follow-up. Seven sessions on nutrition and chronic disease with cases were offered to the residents in family medicine, which concluded with a nutrition intervention session using standardized patient educators. This expanded nutrition program in internal and family medicine along with the standardized patient experience receives excellent ratings from physicians, residents, and medical students.
Key Words: Graduate medical education • medical nutrition education • standardized patient • Objective Structured Clinical Exam • OSCE
INTRODUCTION
The Nutrition Academic Award offered Tufts University School of Medicine the opportunity to expand the school's nutrition offerings to third-year clerkships, residency training, and attending physicians. Since 1991 the School of Medicine had a required, first-year nutrition course of 27 h, but we had been unable to add significant material into the third or fourth years. Therefore, we used the new funding to develop a standardized patient experience to teach clinical skills regarding the role of nutrition in chronic disease, assessment of current dietary intake, and evaluation and recommendations to be provided to students in the clerkships and to residents in internal and family medicine. In addition to the standardized patient experience, we added 6 h of nutrition education to the 12-wk Internal Medicine Clerkship and 1 h to the 4-wk Family Medicine Clerkship.
DEVELOPING THE STANDARDIZED PATIENT PROGRAM
The standardized patient experience that we developed involved a 15-min interview with a standardized patient educator (SPE) to assess, educate, and negotiate on dietary and exercise intervention, followed by 15 min of feedback. Standardized patients in medical education have gained more in recognition and visibility (1-5) but are still not widely used because of the cost of training plus the ongoing effort needed to recruit and train standardized patients. New requirements in testing of clinical skills in a standardized format before licensing (objective structured clinical exam, or OSCE; 6) may encourage greater use of this method during medical school. The use of standardized patients to teach nutrition counseling skills has been more limited as evidenced by the work of the schools receiving the Nutrition Academic Award. This may change as the result of the development of a subscore in nutrition within the Step 1 and Step 2 exams (6), which are generally taken during medical school and before licensing.
We developed 2 standardized patient scenarios to focus our nutrition education: scenario 1, first visit, cardiovascular disease risk reduction; and scenario 2, second visit, weight loss. These 2 scenarios were sometimes offered within the same session or could be separated into different clerkships.
The learning objectives for each of the 2 scenarios were identified, and a patient profile was developed on family history, social history, personal likes and dislikes, current dietary eating pattern, and general attitudes. A sheet of "doorway information" was developed on serum lipids, triacylglycerols, glucose, blood pressure, etc, to inform the student on the patient. Using the Arizona Master Interview Rating Scale (5) for developing skills in interviewing, we identified 6 of the 20 skills that we were seeking to address: developing rapport, organizing the session effectively, supplying clear information, providing positive reinforcement, getting the patient's perspective, and checking the patient's understanding.
When the case and background information were complete, we interviewed prospective SPEs and selected 8 men to be trained to represent Mr McHale. All 8 SPEs were trained in groups and practiced individually and with trainers and faculty. The SPEs were additionally trained to give effective feedback to the students, including 2 sessions with an experienced and empathic physician on the realities of medical school and physician experiences.
The students were informed of the nature and goals of the interview sessions and the protocol of 15 min of interview (which was monitored by a faculty person in the room) and 15 min of feedback by the SPE, an observing student, and the faculty observer. The goal was to first have the students evaluate their own performances, and then have the SPE and other observers contribute additional information as needed. These sessions were extremely successful as indicated by the evaluation of the medical students in these third- and fourth-year clerkships.
NUTRITION EDUCATION MATERIAL
A set of five 1-h sessions was also developed as a slide show in PowerPoint (Microsoft Corp, Redmond, WA) that addressed the following topics: 1) lifestyle assessment in a clinical setting, 2) nutrition and cardiovascular disease and hypertension, 3) nutrition and weight loss, 4) nutrition and type 2 diabetes, and 5) behavioral skills for the physician and the patient for successful change in dietary patterns. These materials included patient handouts and assessment tools.
MOVING ON TO GRADUATE MEDICAL EDUCATION
The availability of the SPE and the extended sessions on nutrition education, which included clinical cases, allowed us to approach both the internal medicine and the family medicine residency programs to incorporate nutrition education into their training. The internal medicine residency was interested in presenting the 5 sessions to their residents during their training in the outpatient clinic. Most of the residents had not had any nutrition in medical school. A 1.5-h session once a month during the outpatient clinic is scheduled for this residency program. This resulted in each resident in internal medicine getting 5–6 nutrition sessions during the first 2 y of their training.
The residency program in family medicine was being revised at the time and it offered an excellent opportunity to introduce our program in nutrition and clinical skills. Because nutrition education is identified by the American Association of Family Physicians as an area of competency within the residency program, the faculty welcomed our involvement in enhancing their nutrition program.
NUTRITION EDUCATION IN FAMILY MEDICINE RESIDENCY TRAINING
During 3 meetings with the family medicine physicians, a plan was developed to train the faculty to become nutrition mentors to the residents. Four sessions were delivered to the faculty over a 3-mo period. The focus of the education and nutrition interventions were on 4 common, chronic conditions: hypertension, cardiovascular disease, type 2 diabetes, and weight loss and maintenance. The DASH (Dietary Approaches to Stop Hypertension) diet was used as the foundation of the nutrition education approach because it has been shown to be effective in hypertension (7, 8) and, recently, type 2 diabetes (9), and it meets the requirements for reduction of hyperlipidemias by reducing risk factors for cardiovascular disease (10). Its recommendation of a high intake of fruit and vegetables—which are low in calories, high in nutrients, and high in fiber to achieve satiety—also makes it useful in weight loss and maintenance. Additional information on the DASH diet with 7 days of menus can be found on the National Institutes of Health website (11).
A patient handout was developed that featured the 3 main messages of the DASH Diet as "WHAT?" categories that were then divided into "WHY?" for each of the 4 conditions separately. On the reverse side, the "WHAT?" was repeated, followed by "HOW?" to reach the goal of each of the 3 messages (Table 1).
View this table:
TABLE 1. The 3 messages (modification of the DASH diet)1
Four 30-min sessions were scheduled with the family medicine faculty to review the dietary approach for each of the 4 conditions. The process of interviewing a patient for dietary change was featured each time (Table 2). The physicians then experienced the SPE sessions and shared their feedback on the usefulness of the exercise for themselves and for the residents. A pocket-sized, laminated card of the 3 messages, "WHAT?," and "WHY?" was produced and distributed to the physicians for easy reference during clinic visits with patients.
View this table:
TABLE 2. The nutrition counseling process
Seven 1-h sessions were delivered to the residents within a 3-mo period. They were asked to start by collecting dietary information on their own intake and analyzing it on an available website (fitday.com, but now mypyramid.gov could be used). This was followed by dietary assessment of patients that focused on the 4 chronic diseases (obesity, hypertension, cardiovascular disease, and type 2 diabetes) as related to the 3 messages. Behavioral skills needed by the physician to help patients succeed in their dietary changes were also addressed. Clinical cases were presented in the last 15–20 min of each session. The SPE session was then carried out with the residents.
Although the standardized patient experience lasted 15 min, the physicians questioned whether they would have that much time to devote to this interaction; in fact, most of the physicians believed that they might be limited by time constraints to only 1, 3, or 5 min. Therefore, abbreviated formats were developed as practical alternatives for nutritional counseling in those 3 limited time periods. The outline of topics for 1, 3, or 5 min of nutrition counseling during a family medicine clinic visit is shown in Table 2. The family medicine clinic used paper charts at the time, and the patient forms were revised to include nutrition questions and follow-up. To support the integration of nutritional counseling into the process, we also revised the patient Subjective/Objective/Assessment/Plan (SOAP notes) to include questions on nutrition, and streamlined and standardized the nutritionist's note to the physician on the content of his or her session with the patient (as related to the 3 messages).
View this table:
TABLE 3. Materials for patients
We believe that we have addressed the critical factors needed for the education program: 1) a consistent, concise message; 2) a consistent process; 3) consistent patient handout material; 4) appropriate questions to address nutrition in the patient's charts; 5) brief, informative nutritionist's notes to the physician; and 6) interested and involved physician mentors for the residents in family medicine.
Follow-up will include retesting of knowledge, attitudes, and behaviors of the residents each year for 3 y to determine the effectiveness of the program, plus tracking of referrals to the nutritionist and tracking of billing for nutrition consulting by the physicians. A questionnaire on the number of nutrition counseling sessions that a resident or physician does per month and the average length of time will be administered twice yearly for the next 3 y. This should result in data on 40 residents and 10 faculty physicians at 4–6 time points from baseline and over the next 3 y.
WHAT WE LEARNED
This experience in expanding nutrition education at a typical medical school highlighted some common problems and solutions that we expect would be relevant to other institutions. It was clear from our experience and from discussions with other Nutrition Academic Award members that having a well-placed advocate is important, as is developing relations with the curriculum committee, the dean of education, clerkship directors, or resident directors. These relations can take a few years to establish and require opportunity regarding mutuality of interests and timing of reorganization of the curriculum.
Providing a learning experience that allowed these programs to meet their own defined goals was essential. Although the use of objective structured clinical exams has been developing over the past 40 y for assessing all types of clinical experiences (12–14), it is still a relatively infrequent exercise for lifestyle change and is a valuable addition to the learning experience considering new data correlating lifestyle habits and health risks (7, 10, 15, 16). This standardized patient experience was also instrumental in motivating the programs to develop other standardized patient experiences which further enriched their teaching programs.
The development of clear, concise nutrition counseling with the 3 messages was also key. The faculty needed to feel that they could effectively deliver nutrition counseling that had a basis in evidence-based medicine and that they themselves knew and understood. They could then, in turn, serve as enthusiastic mentors to the residents.
The overall goal is to remove the image that nutrition counseling is a black box that goes on in the privacy of the nutrition referral relation and does not relate to what the physician does in the clinic with his patients. It is our experience that it takes a few years (2–3 y) to develop, test, and revise nutrition education material that meets the needs and expectations of all relevant parties in the process. In addition, any change in residency directors can result in reevaluation and revamping of the approach and time allotments in the residency education. This is a constantly evolving and ongoing process.
BARRIERS TO CHANGE
Several difficulties still have not yet been effectively overcome. The most important is that we do not have a medical care delivery system that is preventive oriented. We provide care when things go wrong. The model for an effective lifestyle intervention approach, to be delivered in a typical medical care setting with verification of significant impact on prevention of disease or decreases in progression, has not been identified. What we do have are several effective intervention research trials that have used lifestyle (diet or exercise) interventions and that have shown the efficacy and cost-effectiveness of lifestyle interventions (17–19).
Second, we still do not have a critical mass of physicians educated in nutrition who can provide nutrition and lifestyle change advice, with or without a nutritionist, to their patients in a clear, consistent, and developmental model. Third, although we do have methods for the physician to bill for dietary counseling (20), it may not be efficient for the physician to do this. If a session is <15 min, it may not seem worthwhile to bill, and few physicians may feel comfortable providing dietary counseling for that length of time. The level of physician self-efficacy appears to be important in this regard (21). Referrals to nutritionists are limited by disease and insurance coverage; often even those covered do not result in referrals because of the lack of easy availability of a nutritionist or the lack of continuity of care between the physician and the dietitian. Work on numerous research nutrition interventions has recognized that between 6 and 8 sessions with a nutritionist (in individual or group settings) are needed to effectively deliver the information, behaviors, and practices that a patient needs to achieve the dietary changes that can affect disease biomarkers and risk (7, 22, 23).
These are the challenges before us. The time necessary to develop such a program and the materials to support this program change are seldom available, and we thank the Nutrition Academic Award for providing this opportunity for us. We offer our materials and experience with graduate medical education in faculty and residency training in family medicine and internal medicine as a model for developing a simple, clear, consistent, and coordinated approach to dietary intervention for hypertension, cardiovascular disease, type 2 diabetes, and weight loss in a clinical setting. We are interested in making our materials available to other physicians and specialties to develop their own individualized approach to providing good nutrition advice to their patients in an efficient and consistent manner (Table 3).
NEXT STEPS
We need to continue to provide a variety of venues to bring more nutrition education to the graduate medical education program. At the same time, we should provide support and encouragement for physicians interested in nutrition to take the exam to qualify as a Physician Nutrition Specialist (24). In addition, we will all need to work on research and clinical projects that test different methods of delivering lifestyle interventions in eating patterns and exercise that are efficacious and cost-effective. We will need to provide a successful lifestyle change model that reduces risk of chronic disease in a timely manner to capture the attention of the medical community for a nondrug, sustainable intervention for these chronic diseases that can be used in a standard medical care setting.
ACKNOWLEDGMENTS
I acknowledge the following persons for their work on developing and delivering the nutrition programs to the medical students and residents: Joseph Gravel, Director of Family Medicine Residency, Tufts University School of Medicine, for his support and encouragement in developing the resident program; Paula Gardiner, Andrea Gordon, and Jade Schechter, who were instrumental in crafting the education program to meet the requirements and interest of the residents in family medicine with relevant clinical cases and examples; Erika Schlichting-Damon, who contributed to the revision of the patient clinical notes and the dietitian's feedback provided to the physicians as well as the clinical cases involving nutrition intervention; Wayne Altman, who made significant contributions to the nutrition education of the third-year medical students during the Family Medicine Clerkship and has supported and expanded the use of the nutrition counseling standardized patient education session within the clerkship; and Mary Lee, Dean of Education at Tufts University School of Medicine, who has provided continued support and influence to help expand nutrition within the medical education system.
The author and persons acknowledged herein had no conflicts of financial or personal interest in any company or organization sponsoring this program or education activity.
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