|Chapter 2. REVIEW OF LITERATURE|
There is a large body of literature addressing the topic of nutrition and medical education. This review of the literature will focus specifically on the following areas:
Nutrition Knowledge and Related Behavior of Physicians
1977 survey: physicians score 65% on nutrition test questions. Studies have shown that there is historically a lack of nutrition knowledge and related behaviors among physicians. Krause and Fox (1977) surveyed 1,460 Nebraska physicians on their nutrition knowledge and attitudes. The 292 physicians who responded answered only 65% of the nutrition knowledge questions correctly. Researchers also found a significant negative correlation between years in practice and nutrition knowledge.
1989 survey: physicians score 69% on nutrition test questions. Mlodinow and Barrett-Connor (1989) investigated the nutrition knowledge of physicians and medical students through a questionnaire, which was mailed to 461 internists and given to 24 medical students. The questions covered 13 different topics. Only 184 (40%) of those surveyed responded to the questionnaire. Researchers found that overall the physicians answered only 69% of the questions correctly, with individual scores ranging from 46.8% to 83.9%. On individual topics, the frequency of correct answers ranged from 39.9% to 89.7%. The researchers also found a significant negative correlation between the number of years since graduation from medical school and nutrition knowledge. The mean score of those who graduated since 1980 was 72.2%, compared with 61.0% for those who graduated before 1950.
Nutrition behavior not a part of physician core competencies. To determine the degree to which primary-care physicians indicated that they practice "core competencies" in nutrition, as defined by Young (1983), a nationwide mail survey was sent to 30,000 primary-care physicians. Of the 3,416 who responded, the frequency with which physicians reported practicing appropriate nutrition-related behaviors was well below the acceptable minimal level as also defined in the study by Young (1983). Although the 3,416 physicians who responded to the survey reported favorable attitudes toward using nutrition in their practice, these attitudes were not consistent with their performance. Levine, Wigren, Chapman, Kerner, Bergman, and Rivlin (1993) concluded that the degree to which primary-care physicians practice basic nutritional competencies is "not to a great degree."
1984 survey: physicians rate themselves low to moderate in nutrition knowledge. Lasswell, Jackson, and Culpepper (1984) used a questionnaire covering 21 nutrition topics to assess both perceived knowledge of nutrition and interest in learning more about the topics. Seventy-nine family practice residents from three residency programs were surveyed. This included graduates from 36 medical schools. Overall, most residents perceived themselves as low to moderate in nutrition knowledge. Thirty percent reported little perceived knowledge and 62% reported moderate levels, with only 7% reporting a high level of perceived knowledge. However, 72% reported interest in learning more about nutrition with only 1% reporting little or no interest.
1988 survey: physicians rarely provide nutrition counseling. Kligman, Levin, Senf, and Magill (1988) conducted a study to determine the frequency with which family practice residents screened and counseled their patients for behavioral risk factors that included smoking, alcohol abuse, stress, sedentary life style, nutritional habits, and obesity. Results were gathered through patient questionnaires immediately post visit. Residents provided counseling most often for smoking and stress while poor nutritional habits rarely received any intervention. Residents were also surveyed about their attitudes and likelihood of counseling and stated they needed more training in how to effectively counsel patients in reducing behavioral risks such as poor nutrition.
1988 tests: medical school students rated as unsatisfactory in nutrition knowledge. In a comparison of the nutrition knowledge of freshman and senior medical students, Morgan, Weinsier, Boker, Brooks, and Rombeau (1988) tested entering freshman at eight southeastern medical schools. These scores were then compared with the scores of senior medical students from the same medical schools. The average score for the entering freshman medical students was 53% with a range of 51% to 55%, with all scores indicating a failing grade. While the average score for the senior medical students was higher (69%), that score was still rated unsatisfactory.
1995 survey: physicians correctly answer questions on drug-nutrient interaction 61% of the time. A more recent study of family medicine residents (Lasswell, DeForge, Sobal, and Muncie, 1995) indicated a lack of knowledge on the topic of drug-nutrient interactions. A national sample of 834 family medicine residents in 56 residency programs (Lasswell, Jackson, and Culpepper, 1995) was surveyed on their knowledge of drug-nutrient interactions using a 14-question test. Overall, residents correctly answered only 61% of the 14 questions on drug-nutrient interactions, indicating lack of knowledge in this important area.
Nutrition in Formal Medical Education
Since 1963 the need for nutrition education in medical school has been recognized (Council of Food and Nutrition, 1963). In 1976, responses to a questionnaire distributed to medical schools showed that approximately 10% of the responding medical schools had acceptable instruction in nutrition (Nelson, 1976). Guthrie and Teply (1977) surveyed medical schools and found that 50% of the students responding already considered themselves handicapped during their clinical years due to a lack of a background in nutrition.
According to the Association of American Medical Colleges 1980-81 AAMC Curriculum Directory (AAMC, 1980) only 14 of the 125 medical schools (i.e., approximately 11%) in the United States included a nutrition course in the required curriculum.
1985 study: nutrition education in medical schools is inadequate. A landmark 1985 study by the National Academy of Sciences (NAS), commissioned to evaluate the status of nutrition training and education of physicians, concluded that nutrition education in US medical schools was inadequate (Committee on Nutrition in Medical Education, NAS, 1985). The study recommended required nutrition courses for every medical school in the country, but at the time of the survey only 25% of medical schools had such courses. A study seven years later found a downward trend in the number of medical schools offering a required course in nutrition and a decline in the number of medical schools teaching nutrition (Young, 1992).
The Committee on Nutrition in Medical Education (NAS, 1985) also recommended that a minimum of 25 hours would be necessary to teach the basic nutrition material. However, at that time (1985), only two medical schools taught 25 hours or more of courses specifically labeled nutrition. The committee also recommended that the National Boards [exams required for physician licensing in the U.S.] should include questions covering basic nutrition knowledge, yet less than 3% of questions had anything to do with nutrition. Lastly, the committee recommended that there should be a separate nutrition department in all medical schools. Only one medical school had a nutrition department at that time.
1987-1989: 27% of medical schools required nutrition courses, providing an average of 21 clock hours of instruction. According to the Association of American Medical Colleges, only 34 medical schools, or 27% of those surveyed in 1987-1988, had a required nutrition course. Although the National Research Council Committee on Nutrition in Medical Education found that the average total required number of identified nutrition clock hours was 21, 60% of the schools taught less than 20 hours (National Research Council, 1989). The Southeastern Regional Medical-Nutrition Education Network (SERMEN) is made up of 11 schools with a variety of nutrition education programs. The SERMEN survey indicated that of 236 students interviewed, 54% reported access to a nutrition elective, but only 6% actually took one. Additionally, the survey found that 85% of the medical students were dissatisfied with the quantity of their nutrition training, and 69% were dissatisfied with the quality of their training in medical school (Weinsier, Boker, Feldman, Read, and Brooks, 1986).
1986: less than 50% of family medicine residency programs have nutrition in the curriculum. In October 1986, a survey was developed to assess the status of nutrition education within each of the 384 family medicine residency programs in the United States. Of the 384 programs surveyed, 258 (67%) responded. The results indicated that less than 50% of the programs included a formal nutrition curriculum for their residents (Nuhlicek, Simpson, Lillich, and Borman, 1989). Another study reported that 61% of graduating medical students believe inadequate time is devoted to nutrition in medical school (Physicians for the Twenty-First Century, 1984).
In addition to the knowledge portion of the Lasswell et al. study (1995), the 834 residents were also surveyed about their nutrition education. The majority reported that they had little or no formal nutrition training in medical school (83%) or residency (80%), despite the fact that most (79%) believed it was the physicians responsibility to possess this knowledge and educate their patients.
In a special article on nutrition education in medical schools, Winick (1993) concluded that nutrition is an integral part of primary care residency (family medicine, pediatrics, internal medicine, and obstetrics and gynecology). The article identified family practice residencies as the ideal place and setting to have the greatest impact in educating physicians about nutrition knowledge and skills.
1995: nutrition education can be incorporated into existing medical school curriculum. In a 1995 article, Rasmann-Nuhlicek, Reiter, Midtling, and Holloway explained how at the Medical College of Wisconsin, although there is no free-standing nutrition course, the nutrition section of the Department of Family and Community Medicine worked with the medical college faculty to integrate all of the essential topics into the existing curriculum courses, including life cycle, biochemistry, physiology, behavior, and clinical practice. To accomplish this, the college provided a larger pool of faculty to effectively teach the topics. The faculty included trained physicians, registered dietitians, and basic science faculty. However, the article pointed out the risks of this method--it becomes difficult to track the content of the nutrition program, and merging nutrition topics into the curriculum throughout medical school and during residency courses may obscure the presence of the nutrition topics. Nutrition is a specialized science and therefore, the article concludes, it is imperative that a nutrition curriculum maintains its identity so that the value of nutrition as a specialty science is not lost.
Nutrition Education Intervention Programs
1978 survey: nutrition education in medical school has significant effect on behaviors. Several studies have reported programs that have been implemented to provide nutrition training to residents and physicians. Johnston and Schwartz (1978) studied the nutrition counseling practices of general practitioners, pediatricians, and obstetricians in British Columbia (Canada) through a mail survey. Results showed that physicians who had studied nutrition in their medical school training, attended continuing nutrition education programs, and consulted with a nutritionist/dietitian scored significantly higher in relation to the frequency and quality of their nutrition counseling.
1984: one-year pilot nutrition education program a success. Adams and Jackson (1984) studied a one-year pilot nutrition program for family practice residents, which was considered a success. At the end of the first year there were several noticeable benefits reported, though they were not formally measured. These included an increased quality of nutrition care, increased time allotted to nutrition counseling, the forming of a partnership between the residents and the nutritionist, and an increased development of the concept of the health care team. A dietitian provided nutrition services and was responsible for resident and patient education. Successful components of the program included building rapport with the faculty, residents, and staff, sharing a common conference area with residents and faculty, and nutrition presentations at regularly scheduled noon conferences. Providing individual nutrition consultations to the residents upon request helped develop the relationships even further.
1984: nutrition education at four institutions was not effective. A study of four family practice programs in California found that nutrition education at the four institutions was not highly effective (Walsh, Dappen, and Gessert, 1987). They found that not all educators were qualified in education or experience, which the authors attributed to poor recruitment and high turnover. Program attendance was voluntary which resulted in low attendance by the residents. They recommended that nutrition education taught by talented, experienced educators be part of the regularly scheduled activities of residents.
1983, 1985: nutritionists/dietitians the preferred source for nutrition education. A study by Young (1983) showed that those physicians who obtained their information about clinical nutrition from nutrition-specific resources, such as nutritionists and dietitians, had significantly higher favorable attitude scores than those physicians who obtained their information from non-nutrition-specific resources. These physicians also tended to determine their patients nutritional status, to advise and teach desirable health habits, and to identify patients at risk for malnutrition more frequently than their peers. The study also noted that those physicians who had taken a nutrition course during their medical training held significantly more favorable attitudes about how diet can affect their patients health and had a greater confidence in their ability to provide nutrition counseling than those who had not studied nutrition.
Kupper and Steiner (1985) designed a questionnaire to determine how graduate family practice residents perceived the adequacy of the nutrition training they received during their residency training. During the physicians residency program, a nutritionist provided monthly lectures dealing with nutrition for some commonly encountered nutrition issues (sodium, pediatrics, diabetes, maternity, obesity, lipids, gastrointestinal disorders) and selected less commonly encountered nutrition issues (athletes, fad diets, geriatrics, vegetarianism, TPN, and enteral). Results of the survey showed that of the commonly encountered nutrition-related issues, 73% of the physicians rated their knowledge as adequate to serve their patients needs. Of the less commonly encountered nutrition issues, only 43% thought they were prepared to adequately counsel patients. Overall, the majority of the graduates who received nutrition education during residency reported that their nutrition education was adequate.
1988: co-counseling model worked for specific conditions. A family practice program utilizing a "co-counseling" model for nutrition education at the University of South Alabama Medical Center was evaluated by Gray, Harvison, and Wilson (1988). The residents participated in 12 co-counseling patient sessions with a dietitian. Residents were evaluated through chart reviews and video observations. Reviews were conducted on patients for three conditions: hypertension, pregnancy, and diabetes. Results showed significant increases (after participating in the sessions) in the nutrition counseling scores for hypertension and trends for improvement in nutrition counseling scores for pregnancy and diabetes. Additionally, recommendations were made for family practice residencies to employ dietitians as physician educators.
1989, 1990: nutrition training has no effect on nutrition counseling, but may enhance physician attitudes regarding nutrition. Murphy (1989) investigated the effects of completing a nutrition curriculum on the nutrition counseling practices and behaviors of family physicians. A nutrition counseling survey was sent to 182 family physicians who graduated from the University of Manitoba (Canada) between 1979 and 1983. Seventy of the physicians had received nutrition training during their residency. The remaining 112 were hospital-trained and had not received any nutrition education in their medical training. Results showed no significant differences in nutrition counseling practices and behaviors between the two groups. However, most respondents reported receiving some nutrition education, which had been integrated into other courses during their training. Also, a trend toward higher scores in terms of frequency and duration of nutrition counseling was observed among the physicians who received continuing nutrition education after training.
Murphy (1990) also investigated the effect of a nutrition curriculum on opinions about nutrition among family physicians. Using the same survey from her earlier study (Murphy, 1989), the self-reported measures of physicians opinions toward nutrition were evaluated. For 16 of 24 opinion statements on the importance of nutrition, those physicians who received nutrition education during their residency reported opinions that were significantly more favorable than opinions of those who had no nutrition education during residency. Also noted was that physicians who attended continuing education programs did not differ significantly from those who did not attend continuing education programs, indicating that nutrition education during residency was likely the reason for the differences noted.
1991, 1993: nutrition education programs using registered dietitians and physician nutrition specialists were effective. Leibhart (1991) reported on a program utilizing a clinical setting to educate internal medicine residents in relating nutrition to common medical problems. Residents completed one of 12 individual self-study learning modules each week. A registered dietitian with experience in the topic area reviewed the module. Residents also worked with the registered dietitian during patient consultations. Residents performance was evaluated through pre- and post-testing for each module. Results indicated benefits for both the registered dietitians and the residents. The image of the registered dietitians was enhanced, and they learned how to communicate more effectively with the staff. Residents evaluated the elective positively, consulted the registered dietitians more often, and reported better understanding and improved knowledge of nutrition.
Lazarus, Weinsier, and Boker (1993) studied the effects of a nutrition program provided by a physician nutrition specialist in a family practice residency. The physician nutrition specialist was a family physician with specialized training in nutrition. The nutrition specialist provided recommendations for nutrition patient-care practices to the resident physicians for six months, and was available for consultations. Physicians were evaluated through chart reviews, patient questionnaires, and a 60-question exam. Results showed significant increases in the nutrition knowledge of the physicians, the nutrition knowledge of the patients, the patients belief in the importance of complying with a diet order, and an increase in diet recommendations. The study concluded that residency is an appropriate time for nutrition education programs.
Nutrition courses at Louisiana, Wisconsin medical schools are effective. At the Louisiana State University Medical School, a compulsory clinical nutrition course has been included in the fourth-year medical curriculum. An educational laboratory component is included in the nutrition course in order to give practical experience in the design, instruction, and evaluation of therapeutic diets. The one-hour laboratories were conducted by local dietitians following a physicians lecture on the topic. The dietitian introduced the topic and then allowed the students time to present the case study of a patient needing nutrition therapy. Before and after the program, medical students filled out evaluations consisting of eight true-false questions on the topics. There was a significant positive change in the responses from the pre- to post-evaluations suggesting that the laboratory sessions with the dietitian increased the medical students knowledge in nutrition and dietary assessment (Le Gardeur, Farris, and Lopez-S, 1987). An additional "mutual" benefit was derived from the course. The medical students realized the significant role of the dietitian in the care of patients, and the dietitians became more aware of the increased interest of medical students in the importance of nutrition in the care of patients.
The Medical College of Wisconsin introduced an applied nutrition course into the curriculum of (220) first-year medical students in 1988. The program used registered dietitians as facilitators for problem-based learning in small group discussion sessions. The study concluded that most students agreed that the course was meaningful, motivational, and that registered dietitians were effective as nutrition educators of medical students in this teaching model (Reiter, Rasmann-Nuhlicek, Biernat, and Lawrence, 1994).
A 1989 survey of 384 family practice residency-training programs concluded that the use of a registered dietitians training and experience could ensure the quality of undergraduate and residency training in nutrition (Nuhlicek et al., 1989). Registered dietitians can also generate revenue to help support some of the costs of their salary and the education programs by billing patients for nutrition counseling.
To determine the most effective methods to educate physicians, Weinsier, Boker, Brooks, Kushner, Olson, Mark, St Jeor, Stallings, Winick, Heber, and Visek (1991) studied the teaching practices of nationally recognized nutrition programs in family practice residencies. Of 160 programs identified as having strong nutrition programs, the 23 highest ranked programs were surveyed, and seven of them were visited. Results showed that key elements in creating and implementing a strong nutrition program were:
a clinically active physician-nutritionist role model,
nutrition elective rotations,
practical learning materials and conferences,
a multidisciplinary nutrition support team.
Their study also concluded that the major problem in teaching nutrition to residents is a shortage of nutrition oriented physician role models.
1994: physician-dietician interaction has positive effects. As part of a study to determine how often dietitians recommendations are implemented by physicians, Skipper, Young, Rotman, and Nagel (1994) looked at those factors that improve successful implementation of dietitians recommendations by physicians. As dietitians have more nutrition training then any other health care workers, they are best positioned to assume a leadership role as both providers and educators of nutrition care and information. Forty-four hospitals were surveyed, and responses from 35 were obtained. Of 865 recommendations made, 42% were implemented. Dietary recommendations that were solicited by physicians, or ones that dietitians discussed with physicians, had significantly higher implementation rates. The highest implementation rates were for those recommendations that were discussed with physicians, indicating how powerful the dietitian-physician interaction can be.
In 1994, the American Dietetic Association position paper on nutrition and medical education (White, Young, and Lasswell, 1994) encouraged resident programs to use a registered dietitian with advanced degrees to provide physician education and patient care. They also recommended the development of nutrition curriculum geared to specific medical specialties.
1995: nutrition education program in residency has positive effects. Kirby, Chauncey, and Jones (1995) tested the impact of a nutrition education program in a family practice residency program. The nutrition program included four one-hour teaching sessions with interactive demonstrations and case studies, resident participation in a three-day dietary analysis, and knowledge based pre- and post-tests. This study also utilized a physician-nutritionist, an individual faculty member who was a registered dietitian and held a doctoral degree in nutrition. A control group of family practice residents in a program that had no staff dietitian or faculty nutritionist and did not include nutrition presentations was used for comparison. The intervention group of residents showed a significant test score increase from 50% on pre-tests before the four teaching sessions to 70% on post-tests, indicating evidence of the effectiveness of the nutrition education program. The control group of residents scored a mean of 42% on the pre-test and 44% on the post-test, which was not significantly different. The intervention group of residents also rated their own knowledge of nutrition higher then the control group did.
Summary. This literature review has identified the following areas of concern: the lack of nutrition knowledge among physicians and the need for nutrition education for physicians.It has also shown that:
family practice residency has been identified as an effective time for nutrition education,
noontime lecture conference series are an effective educational tool for family practice residents,
a co-counseling interactive learning approach can be an effective model,
registered dietitians can be effective in educating residents.