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University of Texas Medical School, Houston
INTRODUCTION
One of the objectives of the American Society for Clinical Nutrition (ASCN) and the Committee on Professional Nutrition Education has been to promote nutrition education for medical students, residents, and practicing physicians. This priority was revitalized by Dale Schoeller in 2003 during his term as president of the ASCN. Dr Schoeller was an invited guest at the spring Nutrition Academic Award (NAA) meeting in Chicago, IL, on 25 April 2003. Our discussions during this meeting made it clear that the NAA program should form a partnership with the ASCN in an effort to not only disseminate the outcomes of the NAA to other medical schools but also perpetuate the accomplishments and legacy of the NAA. After this meeting, members of the NAA Executive Committee, consisting of Patrick McBride (University of Wisconsin), Brian Tobin (Mercer University), Marilyn Edwards (University of Texas, Houston), Linda Van Horn (Northwestern University), and Charlotte Pratt (National Heart, Lung, and Blood Institute), submitted a proposal for a symposium titled "Evidence-Based Medical Nutrition Education—The NAA Medical Schools Working Together" to the ASCN Committee on Professional Nutrition Education for the 2005 annual meeting. Once the symposium was approved and scheduled, letters were sent to the education deans at all 126 US medical schools inviting them to attend. The symposium, which was held on 2 April 2005 in conjunction with Experimental Biology 2005 and the annual meeting of the ASCN in San Diego, CA, was attended by 135 persons, each of whom had a strong interest in medical nutrition education. The articles included in this supplement represent the presentations at the symposium and present different strategies for integrating nutrition into the undergraduate medical curriculum and residency training programs and provide an update on current nutrition Continuing Medical Education (CME) for physicians. An additional article is included from a recent national survey on nutrition education in US medical schools.
EVIDENCE-BASED MEDICAL EDUCATION
Nutrition is recognized by medical schools as an essential component of medical education, residency training programs, and clinical practice. Medical educators agree that successful integration of nutrition into the curriculum requires that the information be clinically relevant and evidence-based. The practice of evidence-based medicine refers to the integration of individual clinical expertise with the best available external clinical evidence from systematic research. The best available external clinical evidence is based on clinically relevant research, often from the basic sciences of medicine, but particularly from patient-centered clinical research into the accuracy and precision of diagnostic tests, including the clinical examination, the power of prognostic markers, and the efficacy and safety of therapeutic, rehabilitative, and preventive regimens. This evidence-based approach to patient care extends well into the realm of nutritional sciences. Certainly, at a time when we have data from well-designed clinical trials investigating the effects of diet on the prevention and treatment of chronic disease, we would be amiss if we did not include recent clinical nutrition guidelines in the education and training of medical students and residents. The title of the symposium was thus chosen primarily to emphasize the need to teach nutrition in an evidence-based format.
The title of the symposium can also be interpreted to refer to evidence and data that show a successful integration of nutrition into the medical curricula from the NAA program. The NAA consists of 21 US medical schools that were funded by the National Institutes of Health, mostly the National Heart, Lung, and Blood Institute and also the National Institute for Diabetes and Digestive and Kidney Diseases, for a period of 5 y between 1998 and 2005. The symposium consisted of 12 presentations and included speakers from 10 NAA medical schools: Northwestern University Feinberg School of Medicine, University of Colorado School of Medicine, University of Wisconsin Medical School, University of Nevada School of Medicine, University of Pennsylvania School of Medicine, Tufts University School of Medicine, University of Texas Medical School at Houston, Albert Einstein College of Medicine, University of Arkansas for Medical Sciences, and Mercer University School of Medicine. In addition, the Nutrition in Medicine Program, a computer-assisted nutrition and prevention curriculum developed over the past 10 y at the University of North Carolina, was included in the symposium. Many of the NAA schools use the Nutrition in Medicine CD-ROM series in their curriculum and it was felt that an update on Nutrition in Medicine would make a significant contribution to the symposium. Also considered an essential component of the symposium was the training and certification of Physician Nutrition Specialists and the recent developments of The American Board of Physician Nutrition Specialists (ABPNS); this presentation was given by Douglas Heimburger from the University of Alabama, which is also an NAA medical school.
DEVELOPMENT OF A MEDICAL NUTRITION CURRICULUM
Medical nutrition educators work within a unique environment and an established curriculum in their medical schools and are often called on to be creative in their approach to teaching nutrition in a clinically relevant format. The NAA, which is described in detail by Van Horn (1) from the Northwestern University Feinberg School of Medicine, has provided a wealth of opportunities for physicians, basic scientists, nutritionists, and medical educators to work together to develop and enhance the medical curricula with an emphasis on nutrition and the prevention and treatment of cardiovascular disease, diabetes, obesity, and other chronic diseases. Although some NAA schools have focused primarily on the development of a preclinical nutrition curriculum, other schools have included clinical nutrition skills in primary care clerkships as well as residency training in their overall efforts to enhance the curriculum. In their article, Krebs and Primak (2) describe the process of integrating a comprehensive nutrition curriculum at the University of Colorado School of Medicine. They identify several key elements that are necessary for the successful integration of nutrition, which first and foremost include the identification of a core group of faculty to be advocates for nutrition and to serve as role models for the medical students. The importance of having an advocate within the medical school for nutrition education and training is also highlighted in the articles by Hark (3) and Woods (4) and therefore seems to be one of the most critical first steps for schools that are just beginning the process of adding nutrition to their curricula. In addition to having a faculty advocate or champion for nutrition, both Hark and Woods emphasized that it takes time to develop relations with course directors, medical education directors, deans, and curriculum committees, but that this is imperative to a successful integration of nutrition. Likewise, St Jeor et al (5) describe the process of preparing for a school-wide curriculum review and innovative strategies for integrating nutrition, particularly a nutrition theme, through Objective Structured Clinical Examination and Web-based or other computer-assisted instruction. The article by Underbakke et al (6) provides a complete overview of some of the new Web-based tools that have been developed at the University of Wisconsin School of Medicine. In addition, Table 1 in that article lists all the Web-based NAA resources and includes websites for 11 of the NAA schools. Again, for schools that are developing or enhancing their nutrition curriculum, these resources are available at no cost. Another excellent NAA resource for medical schools is the Nutrition Curriculum Guide for Training Physicians completed in 2003 (7).
EVALUATION OF NUTRITION KNOWLEDGE AMONG MEDICAL STUDENTS
An essential component of developing a nutrition curriculum is the ongoing evaluation of students and courses. Hark (3) lists this as one of the lessons learned at the University of Pennsylvania and explains that program evaluation is necessary in maintaining the support of the school administration. Evaluation can be in the form of pre- and posttesting of nutrition knowledge and clinical skills in required nutrition courses, in basic science courses where nutrition is integrated, throughout problem-based learning, and in clinical clerkships. For schools that incorporate the Nutrition in Medicine CD-ROM series, these case-based modules contain quizzes and board-type exams that can be used to assess student knowledge [see the article by Lindell et al (8)]. Data from the American Association of Medical Colleges (AAMC) annual graduation questionnaire that measure the adequacy of nutrition instruction time in the curriculum should also be collected by all schools and compared with national averages. Most recently, however, is the National Board of Medical Examiners' subscore for nutrition on Steps I and II of the US Medical Licensing Examination, which began in 2002. Medical schools should closely monitor these scores and then use these data to improve their nutrition curriculum. The AAMC data for the NAA schools in comparison with all US medical schools from 2000 to 2004 are shown in Figures 2 and 3 in the article by Van Horn (1).
GRADUATE MEDICAL EDUCATION, CONTINUING MEDICAL EDUCATION, AND BOARD CERTIFICATION OF PHYSICIANS IN NUTRITION
Articles in this supplement by Deen (9) at Albert Einstein College of Medicine and Kahn (10) of the University of Arkansas provide an overview of developments in nutrition with regard to Graduate Medical Education (GME) and CME, respectively. Although these are not new, GME and CME are certainly areas that need continued support and strengthening. The Accreditation Council for GME has developed competencies for residency training that can be combined with the learning objectives of the NAA Nutrition Curriculum Guide for Training Physicians. Kahn describes the current CME courses available for physicians; although only a few courses are offered each year, physicians must take advantage of these courses to update their nutrition knowledge. More CME opportunities are needed, however, and this is an area that requires the attention of medical nutrition educators.
One of the areas that is critical to the future of medical nutrition education is the preparation and certification of Physician Nutrition Specialists who will continue to serve as role models in the academic setting. Heimburger (11), representing the ABPNS Board of Directors, provides an excellent update and overview of the activity of the ABPNS. This is certainly one of the ways in which the NAA can make a difference in the future of medical nutrition education by encouraging residents and students to become certified as Physician Nutrition Specialists. The possibility of creating a board exam review course for physicians has been discussed by the NAA executive committee and should be explored further.
THE FUTURE OF MEDICAL NUTRITION EDUCATION: SUMMARY AND CONCLUSIONS
In the schools that have had the privilege of participating in the NAA program over the past several years, medical nutrition education has been strengthened through the development and incorporation of numerous resources and the evaluation of students' nutrition knowledge and clinical skills. When nutritional science is taught in an evidence-based and clinically relevant format, nutrition is recognized by medical school administrators and curriculum committees as an important topic in the education and clinical training of physicians. The articles in the present supplement provide an overview of nutrition education in US medical schools and how the NAA medical schools have integrated nutrition into their curricula and residency programs through evidence-based approaches. Although much has been achieved, more effort is needed to make nutrition an integrated component at all levels of medical education, including residency programs and CME for clinicians. Nutrition role models such as Physician Nutrition Specialists are needed to be part of multidisciplinary teams to combat various diseases (eg, cardiovascular disease, cancer, and diabetes) and risk factors such as obesity, which continues unabated. Continued partnerships of medical schools with organizations such as the ASCN and the ABPNS are needed for effective medical nutrition education.
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