Developments and Challenges in Family Practice Nutrition Education for Residents and Practicing Physicians: an Overview of the North American Experience
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European Journal of Clinical Nutrition (1999) 53, Suppl 2, S89±S96 ß 1999 Stockton Press. All rights reserved 0954±3007/99 $12.00 http://www.stockton-press.co.uk/ejcn Developments and challenges in family practice nutrition education for residents and practicing physicians: An overview of the North American experience KM Kolasa1* 1Department of Family Medicine, East Carolina University School of Medicine, Greenville, North Carolina 27858, USA The history of nutrition education in family medicine residency training and continuing medical education (CME) in North America is brie¯y reviewed. Past efforts have been successful in improving knowledge and attitudes toward nutrition. Some of the barriers to physicians providing nutrition services to their patients, such as poor reimbursement for those services, are largely outside the domain of medical educators. However, the education and training of family practice residents and practicing physicians in nutrition has not yet fully matured. Strategies are needed that impact physician counseling behaviors. Strengthening the content of certi®cation examinations, providing evidence that brief counseling strategies impact patient outcomes, and role modeling counseling through multimedia delivery are three educational strategies with potential. Descriptors: nutrition education; family medicine residency training Introduction 1998) could reduce physicians' frustrations in providing nutrition care. The acceptance of these evidence-based The US Preventive Services Task Force recommends that guidelines could lead to improved reimbursement for nutrition care and education should be an integral part of nutrition services (or penalty for not providing them). each routine medical examination. The estimates vary, but The meteoric growth of the dietary supplement industry it appears that there is a nutrition related reason for at least and consumer interest and spending in alternative therapies 25% of all of®ce visits to primary care providers. Virtually are viewed with frustration and also welcomed as oppor- every published study on the subject shows family physi- tunities by primary care physicians. The National Institutes cians supportive of nutrition counseling for their patients, of Health Center on Alternative and Complementary Med- but few deliver those services (Soltesz et al, 1995; Kushner, icine includes `Diet, Nutrition and Lifestyle Changes' 1995). Physicians report that they have not had adequate among its ®elds of practice, describing it as `the knowledge preparation for their role as promoters of good nutrition in of how to prevent illness, maintain health, and reverse the patients (Cimino, 1996). And, sadly, Sotesz et al (1995) effects of chronic disease through dietary or nutritional reported only 21% of family physicians surveyed found intervention.' professional grati®cation in counseling patients about diet- ary issues. It has been this way for some time. In 1982, Gjerde & Sinnott studied the perceived importance and self reported performance by family physicians and concluded Successes in family medicine education that a stronger emphasis was needed on nutrition education There are many papers that describe the factors associated in training. Those attitudes and behaviors seem to have with successful nutrition education in family medicine persisted. In 1995, Kushner again noted that physician lack residency programs. There are perhaps even more papers of con®dence in counseling skills was an important barrier that describe the obstacles to integrating nutrition education to providing dietary counseling. Some of the barriers to into residencies, in the US and Canada. Most of the papers providing nutrition care to patients can be addressed were published in the late 1980s to early 1990s (Gjerde & through changes in education and training. Sinnott, 1982; Lasswell, 1983; Moore & Larsen, 1983; There are reasons to believe that this situation could Creager et al, 1984; Rubenstein & Berfoff, 1984; Kupper change in the near future. Several trends may positively & Steiner, 1985; Dappen et al, 1986; Gray et al, 1988; impact the family physician's practice of nutrition. The Lopez et al, 1988; Sobal et al, 1988; Nuhlicek et al, 1989; current restructuring of medical practice in the United Murphy, 1989; Jack et al, 1990; Figueroa et al, 1991; States may accentuate the importance of nutrition to patient Feldman, 1991; Kolasa et al, 1992; Lasswell, 1992; Bruer care (Halsted, 1998). The emergence of evidence based et al, 1992; Lazarus et al, 1993.) Each of these efforts was clinical guidelines that support the use of nutrition inter- successful in producing a change in physician knowledge ventions and also de®ne possible outcomes (NIH, 1997, and attitude toward nutrition. Unfortunately, there has not been universal adoption of even these successful curricular *Correspondence: KM Kolasa, Department of Family Medicine, East elements. But even improved knowledge is insuf®cient to Carolina University School of Medicine, Greenville, North Carolina improve clinical nutrition practice (Murphy, 1989). Role 27858, USA. modeling has long been considered important to convey Developments in family practice nutrition education KM Kolasa S90 value of physician competence in nutrition to medical conferences, physician conference meals, and ®eld trips. students and residents. Some researchers have described Published evaluations of these efforts have been limited effective role modeling by the physician nutrition specialist and scattered throughout the medical literature. A fairly (Lazarus et al, 1993; Kirby et al, 1995). There remain too complete compilation of these references is found in Kolasa few of these faculty in North America to be considered a & Lasswell (1995). Most of the described strategies con- realistic solution to the current problem. The call for multi- tinue to be successfully used today. However, some educa- faceted approaches to change physician counseling beha- tional strategies that were focused on improving counseling viors made by Kushner in 1995 remains appropriate today. skills and con®dence, like co-counseling (Gray et al, 1988) have been abandoned because of increased pressure to generate clinical outcome. Perhaps more than before, Nutrition in family practice residencies, a brief education that teaches the practical aspects of nutrition historical review assessment and education of the patient are needed. The The Residency Review Committee for the American Acad- importance of a faculty member being assigned responsi- emy of Family Practice (AAFP) has required education in bility for nutrition is underscored in the STFM manual nutrition since 1982, but with limited agreement about the (1994). core competencies needed by practicing physicians. The Many residency programs use the data from alumni AAFP outlined and periodically reviews the Recommended surveys to update and revise their curriculum but there is Core Educational Guidelines on Nutrition for Family Prac- no standard questionnaire. One program surveyed all its tice Residents (AAFP 1989, 1995). The Society for Tea- graduates from 1971 ± 1991 (Cable & Delaney, 1995). cher's of Family Medicine Working Group on Nutrition Generally these physicians supported an emphasis on pre- Education (STFM, 1987) published the Curriculum in vention and they ranked nutrition counseling as an essential Nutrition. From 1988 ± 1991, the National Dairy Board (51%) or important (38%) curricular area. Interestingly (NDC) supported regional conferences to promote teaching these authors noted a close correlation between faculty in family medicine. The `Physician's Guide to Outpatient interest and curricular topics. They interpreted this to mean Nutrition' was published as a result (Moore & Nagle, that the faculty not only provided relevant training but also 1990). In 1989, Nuhlicek et al described the funding and affected graduate's perceptions of what is important. staf®ng needed for residency nutrition education. In 1990, the STFM with support from the NDC sponsored a con- Nutrition in family medicine continuing medical ference describing nutrition in family medicine. Just as education (CME), a brief overview each residency program is individually designed, the amount and type of nutrition education implemented Surveys of physicians in practice continue to report that varied dramatically from program to program. Some pro- physicians feel that nutrition is important in the care of grams have an identi®ed medical nutrition educator, phy- their patients but also feel that they are inadequately sician or graduate-trained dietitian. Most programs have as prepared to meet those needs (Glanz, 1997). Much of a a minimum, access to a graduate-trained dietitian or nutri- physician's continuing medical education (CME) is infor- tionist through the hospital. Funding for a nutrition specia- mal and comes with professional interactions surrounding list faculty position continues to be problematic, in part the delivery of patient care. In settings where dietitians and because reimbursement for nutrition services is limited. nutritionists are eager to enhance the nutrition care of Regardless which faculty is responsible for nutrition educa- patients they may assume responsibility for educating the tion, most continue to agree with Walsh et al's (1987) physician about nutrition. The American Dietetic Associa- observation that nutrition education needs to be a sched- tion (1994), with the support of several organizations, has uled, required activity of residents