European Journal of Clinical (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 : An overview of the North American experience

KM Kolasa1*

1Department of Family , East Carolina University School of Medicine, Greenville, North Carolina 27858, USA

The history of nutrition education in residency training and continuing (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 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 25% of all of®ce visits to 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 . 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 . 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 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 to be effective. provided a Physician Nutrition Education program. This In 1994, as a way to provide guidance to residency program provides training and materials for dietitians to programs without faculty trained in nutrition and to de®ne a work with primary care physicians. However, most educa- core of nutrition education appropriate for family physi- tors focus on the more formal CME offerings. cians, STFM with the support of Ross Products Division, According to the Accreditation Council for Continuing Abbott Laboratories, expanded the document `Physician's Medical Education (ACCME), continuing medical educa- Curriculum in Clinical Nutrition' (STFM, 1994) to include tion (CME) consists of educational activities which serve to outcome based curricular competencies, methods, evalua- maintain, develop or increase the knowledge, skills and tion strategies, references and resources. The methods professional performance and relationships that a physician suggested for implementation of the curriculum are in uses to provide services for patients, the public or the both the patient care and didactic arenas. The in-patient profession. Therefore, CME can be used to obtain nutrition and ambulatory patient care method may include: use of assessment and counseling skills. There are more than 550 nutrition handbooks, nutrition focused rounds, nutrition accredited sponsors of CME activities in North America. screening, co-counseling with a dietetic professional, com- The sponsors of CME activities must complete a needs puter assisted programs, direct observation and precepting, assessment, de®ne objectives for the program, describe the chart review and quality assurance, evaluation of patient activity and an evaluation plan, in order for the program to education materials, teaching patient classes, home be certi®ed. There is no database that describes the number and extended care facility rounds, health fairs and other and kinds of nutrition CME programs offered. However, community and school activities, and preparation of patient the offerings are thought to have been limited. Nutrition newsletters. The didactic experience includes a nutrition seminars are usually offered within other conferences. For rotation or longitudinal conferences=lectures, self assess- example, at the annual AAFP meeting, participants can ments, simulations and role playing, managing standar- enroll in short courses on weight management or nutrition. dized patients and completing clinical practice (CPX) At the 1997 meeting attendees could complete the CD- and objective structured clinical exams (OSCE), case ROM program Images of Cancer Prevention, the Nutrition Developments in family practice nutrition education KM Kolasa S91 Link (Kolasa et al, 1996) for credit. AAFP also offers an A ¯avor for the type of questions can be garnered by annual week long Board Recerti®cation course. An optional skimming resources used by physicians studying for four hour seminar on nutrition is provided. Nutrition pearls Boards: `The Core Content Review of Family Medicine' may be included as various conditions are discussed in the (Connecticut and Ohio Academies of Family Physicians, plenary sessions. But there is no systematic plan to ensure 1968) and `Saunders Review of Family Practice' (Bope et nutrition information is included in relevant CME pro- al, 1997) both include nutrition questions. Annually since grams. For example, unless the role of diet in colon 1968 the Ohio and Connecticut Academies of Family cancer was noted in the needs assessment survey conducted Physicians provided this review so physicians could eval- to plan a day long update on colon cancer, it is unlikely that uate and expand their knowledge of key areas of family the planners would include the topic. Similarly, a CME practice. Those who subscribe are encouraged to increase conference on breast cancer might start with screening and their knowledge by studying the questions, the discussions ignore primary prevention that includes diet. A CME on and other references. Some residency programs use this might include nutrition, but focus on program to evaluate resident's core knowledge and clinical dietary supplementation, botanicals or phytoestrogens, reasoning abilities. `Saunders Review of Family Practice' rather than dietary patterns and counseling skills. (Bope et al, 1997) is viewed as a study guide for the Some CME sponsors produce enduring materials, which American Board of Family Practice Examination. About 30 are de®ned as written, audio, audio-visual, or other electro- questions on nutrition and obesity comprise the chapter on nically produced materials that provide a continuing med- nutrition. A few other questions are interspersed through ical education activity. There have been a limited number sections like , growth and development, caring for of nutrition materials distributed in North America that the elderly, preventive , and general . family physicians could use. Some examples include: an The Family Practice Recerti®cation journal regularly con- AAFP (1990) monograph on `Nutrition'; a University of tains a small number of nutrition related items. Washington School of Medicine (1990) sponsored, two Nutrition advocates need to volunteer as item writers for year, newsletter course `Rx Nutrition: Good Health in these examinations. Perhaps a formal study of the nutrition Practice (1990); a Network for Continuing Medical Educa- items on these examinations is in order. Unfortunately, tion videotape `Current Concepts in Nutrition' (Kolasa, most of these items test knowledge rather than skills. The 1988); the Nutrition Screening Initiative (1994) mono- National Board of Medical Examiners has proposed to add graph. Physicians have been able to subscribe to several performance based assessments to the Step Exam(s) taken nutrition publications and receive credit, such as `Nutrition toward licensing in the year 2002. Nutrition educators must and the MD' and `Nutrition in Clinical Care'. There are few work to ensure nutrition cases are placed on these clinical reports of the effectiveness of these efforts. However, CME practice exam (CPX) and Objective Structured Clinical has long been used to inform physicians and teach speci®c Exams (OSCE) type examinations. More than 70% of the skills, its ef®cacy in many areas is now considered well US and Canadian medical schools use standardized patients established. Carney et al (1995) have completed a rando- in their curriculum (Colliver & Williams, 1993) but there mized controlled trial assessing the effects of differing remain no published nutrition cases suitable for these types educational techniques on the cancer control skills of of exams in the published literature. physicians, including nutrition counseling. They found the educational techniques that rehearsed or portrayed clinical Changing the ease and effectiveness of providing applications increased physician performance. A few nutrition services to patients efforts to deliver nutrition CME through CD-ROM tech- nology and the world wide web are now being attempted As noted earlier, physicians report lack of con®dence in and will be described later in this paper. their skills and ability to impact a patient's dietary beha- viors. Ely et al (1998) found that this was an important factor for physician compliance with counseling and his- Changing the importance of nutrition education to tory-taking recommendations. Zymanski et al (1998) found physicians by testing that physicians in high-, medium-, and low-volume family From kindergarten through post-graduate training, grades practices see patients, respectively for 8.8, 9.8 and based on testing has been an important incentive for student 12.5 min. Stange et al found that visits for preventive learners in the United States' educational systems. Medical services averaged only 3 min longer than acute visits nutrition educators seeking to enhance nutrition training in (1998). Creative experiments are needed to identify ways medical schools have focused on increasing the kind and to increase the physician's perceived effectiveness in chan- quality of nutrition items on board examinations and have ging patient dietary behavior, especially in such short visits. had some success. In 1985 fewer than 3% of the questions The family medicine residency setting could be the setting on the National Boards related to nutrition (Winick, 1993), for this type of research focused on delivering brief but but by 1997, Hark et al found that medical licensing effective services, especially several of the 25 most fre- examinations had about 12% nutrition content. A study of quent reasons for of®ce visit, including hypertension (1st), the number and kind of nutrition questions on the residency general medical exam (3rd), diabetes mellitus (8th), degen- in-training examinations and on the American Board of erative joint disease (10th), heart disease (11th), asthma Family Practice certi®cation examinations has not been (12th), abdominal pain (18th), and pregnancy care (21st). published. Nutrition items are included but no speci®c One approach to increasing the number of physicians number of nutrition questions will appear on any given who provide nutrition assessment and counseling to their In-Training exam for residents or on the Board certi®cation patients is to develop, test and disseminate strategies that examination. Item writers for the Board Exam do classify allow a physician to ef®ciently and successfully change the the questions they write. Nutrition is listed as a topic in the patient's inappropriate dietary behaviors. In other areas of Management=Diagnosis=Knowledge section. clinical practice brief of®ce assessment counseling tools Developments in family practice nutrition education KM Kolasa S92 Table 1 Sample of widely accepted (non nutrition) of®ce based the presence of computers, electronic medical records questionnaires programs and the world wide web is the development and Condition Tool Reference distribution of patient nutrition education materials (Moore & Marlowe 1986; American Dietetic Association, 1994 ± Depression Zung Zung, 1965 1998; Kenner MM et al, in press). Fagerstrom Tolerance Test Fagerstrom 1991 Mini mental status Folstein et al, 1975 Alcohol AUDIT, CAGE, MAST Conigrave et al, 1995 Multimedia and web based medical nutrition education May®eld et al, 1971 for family medicine residents and practicing physicians NIAAA, 1996 Selzer, 1971 It has been well established that learners can improve knowledge using computer assisted instruction but multi- media has potential to do so much more. Kolasa et al 1999 have been widely adopted. Table 1 includes a sample of have demonstrated that use of CD-ROM program could those tools. However, for of®ce based nutrition assessment impact medical students' attitudes about the role of the and counseling no instrument has achieved similar status. physician in nutrition assessment and counseling. However, The Nutrition Screening Initiative (1994) has developed the more interesting question is: can medical students and and successfully piloted the DETERMINE Your Nutri- physicians develop nutrition assessment and counseling tional Health instrument. A monograph for physicians to skills using multimedia programs? The experiments in learn to incorporate nutrition screening and interventions in using CD-ROM and world wide web delivery of nutrition the care of the geriatric patient has been widely dissemi- education to residents and practicing physicians has only nated (Nutrition Screening Initiative, 1994). Continued recently begun. Much of the development and testing of dissemination of these tools and the results clinicians compute-assisted and Web-based nutrition education has achieve using them is critical to their future universal targeted medical students, in part because of availability of acceptance and use. Other tools and strategies have been funding to improve nutrition education in developed and tested but are not in widespread distribution. curricula. Since the barriers to residency and CME nutrition Keyserling et al (1997) demonstrated that the Dietary Risk education are similar to those found in medical education Assessment (DRA) tool and the program `A New Leaf (too few physician role models, a lack of consensus on the Choices for Health Living' could be used by physicians to scope of practice, low visibility of academic clinical nutri- change patient behaviors leading to reduced risk for cardi- tionists, limited time and interest, few accessible educa- ovascular disease. Ockene et al (1996) demonstrated that tional resources with realistic presentations of physicians physicians with a structured program in their of®ce could assessing and counseling patients on nutrition, and limited lead patients to improvement in diet, bodyweight and funding) the experiments in medical nutrition education are lipids. Although not generally thought of as an educational probably applicable to residency training and CME. CD- strategy, this type of experimentation in the residency ROM programs also allow the learner to control pace and setting has the potential to impact not only the practices routing, skip material if already competent, remediate if the of residents but also faculty. So educators need to under- learner thinks they know the material but cannot demon- take more trials designed to increase the ease with which strate it and practice. physicians provide nutrition. Another challenge remains, Both CD-ROM and web based independent learning and that is to ensure that the tools and strategies developed modules have been hypothesized as delivery strategies are packaged, distributed and made easy to learn and use by that address the lack of curriculum time and guaranteed other physicians. clinical exposure, the lack of role models and lack of Physicians appear unaware of reports of successful trained faculty for medical nutrition education. Several nutrition interventions. Just as the literature describing products with good student acceptance have been pub- successful residency nutrition education programs is scat- lished. Kolasa et al (1994, 1997) found that the students tered throughout the literature, so are the reports of suc- liked viewing short video segments of physicians assessing cessful nutrition assessment and counseling tool and counseling patients. Students were observed to pattern development. There is no central depository of successful their assessment and counseling of standardized patients interventions. The world wide web may provide a solu- after the examples incorporated into the CD-ROM pro- tion for part of this dilemma. Tony Helman boasts the gram. Students valued a hypothesis testing segment that largest catalogue of nutrition resources on the Internet at linked dietary behaviors to the natural history of cancer. http:==arborcom.com with the needs of the physician and They indicated that the link convinced them that there was nutritionist speci®cally in mind. This site makes available an adequate scienti®c underpinning for dietary recommen- literature not easily found elsewhere. Kolasa et al (1998) dations (Kolasa et al, 1999). Students also reported the are cataloguing successful of®ce based nutrition interven- presentation was convincing enough to strengthen their tions on a Web site (http:==www.Preventive Nutrition. intent to try and change their own and their patients' dietary com). The Tufts Navigator (http:==navigator.tufts.edu= behaviors. educat_4.html) rates nutrition sites including some direc- Zeisel (1997) reports that the Nutrition in Medicine ted at health professionals. Hardin MD (http:==www.li series is being used in 80% of U.S. medical schools to b.uiowa.edu=hardine=md=nutr=html) lists Nutrition, teach nutrition science. They have reported signi®cant Diet and Food sites. It is important to direct physicians learning ef®cacy with the Cancer and Nutrition modules in-training to these sites to prepare them to provide (Kohlmeier et al, 1998). Chaudhuri et al (1997) noted that effective nutrition interventions as part of an evidence- use of the nutrition CD-ROM program facilitated subject based practice. mastery and fostered an increased sense of independence. Another method that has been used for many years, but There also are few other published medical nutrition CD- may have greater potential for implementation because of ROM programs (Kolasa et al, 1996). Programs designed for Developments in family practice nutrition education KM Kolasa S93 dietary analysis are being used. Nutrition DISCovery per- 1997). But, they do not appear inclined to rely solely on sonalized CD-ROM diet assessment program (Anon, computer assisted programs for learning. Many questions 1996A) is one example. While we are aware of residency remain to be answered about the role of Web delivery of programs using both the Web and CD-ROM programs for medical education. Most of the questions focus on technical nutrition education, there are no published reports. issues such as user interface design, access and availability It is thought that CD-ROM and Web based delivery of and how these factors impact the way learners respond to CME nutrition education has promise. Since CME program the materials. It is known that student can learn in this planners report that too few physicians request nutrition in manner. any one location at any speci®c time, these delivery The Web cannot at this time fully replace CD-ROM strategies offer a way of providing nutrition to interested delivered programs. For example, as we attempted to move residents and practicing physicians. Individuals can send the program Images of Cancer Prevention to the world for CD-ROMs or access world wide web. The question wide web we found the two program segments judged to be remains, however, will they? Mainstream publishers have most effective in changing medical student nutrition assess- yet to offer speci®c nutrition courses. A review of a recent ment and counseling behaviors cannot be ef®ciently deliv- catalogue from CMEA Inc (www.cmea.com) demonstrates ered through the Web at this time. It would take an the point. In that catalogue there are no CD-ROM programs estimated 12 h to download the case studies with the with the word `nutrition' in the title. Nor is nutrition in the physician role modeling video clips. We have an experi- subject index. Programs such as Core Curriculum in ment underway to see if we can utilize the web Primary Care has a module entitled `Preventive Medicine' (http:==PreventiveNutrition.com) and the CD-ROM pro- that might also include nutrition; as might the program gram in a complementary fashion. There are multiple Hypertension in Primary Care. Menopause and Hormone versions of Web browsers with differing capabilities : Effective Patient Care might include also nutri- which is a frustration to developers and users. There are tion in the section `the value of alternative treatments'. still limitations to access the Web. Server problems affect These programs range in price from $150 ± $400. Ziesel et everyone. Some software runs slower on the web than on al (1998) and Medeor Interactive have been offering the personal computers. Nonetheless, the web has potential Nutrition and Cancer module from the Nutrition in Med- since users can learn by doing. We are also experimenting icine series as a self paced CME course. It is advertised as with the use of the web for faculty development by offering offering: continuous self assessment opportunities with virtual seminars (see: http:==www.Preventive immediate feedback, a sustained interaction with a virtual Nutrition.com). patient, lessons on the science needed to deal with the Others are providing interactive conference and Grand patient, a reference shelf with useful clinical tools, calcu- Rounds material on the web for study or CME. These lators for assessing energy and fat intake and optimum efforts are similar to print efforts described earlier but have weight, videos on clinical nutrition techniques, and a hyper- greater accessibility and more immediate feedback. Cyber- linked index that allows the programs use as a reference. ounds (www.cyberounds.com) includes nutrition among The price is $150 which includes the CD-ROM and manual the 15 specialties presented by Tufts University School of and 15 credit hours in Category 1 Physicians Recognition Medicine. Leading researchers describe new research and Award of the AMA. To date, the enrollment has been treatments. A `Second Opinion' section lets visitors post disappointing but the response of those who participate has questions and receive answers from others in the virtual been enthusiastic. Therefore, if an individual physician medical community (Smith, 1998). The conferences are seeks nutrition education, the use of CD-ROM programs, transcriptions of discussions and followed by CME ques- even those designed ®rst for medical students, can meet a tions. While access is currently free, a fee of $125 is need. However, more experience is needed to determine charged for a block of 50 AMA=PRA Category 1 credit. how to best integrate stand-alone computerized learning Levy (personal communication, 1998) reports that about environments like the CD-ROM into residency training and 3 000 participants review each new case, including the CME. nutrition cases, posted. There have been ten nutrition Since the publication and distribution of medical nutri- modules posted to date, with ®ve available for CME. tion education materials has been problematic some med- Current CME Reviews (http:==www.cme-reviews.- ical educators hypothesize that the world wide web may com=cover=main=html) published by MBL Communica- provide a partial solution. Many users believe that the Web tions is currently providing free online continuing medical has potential to build a community of interest. It can education in the area of Eating Disorders. Healthgate provide an environment that allows a virtual community (http:==www.healthgate.com=HealthGate=cme=b.index. to share experiences and materials in medical nutrition html has two CME topics of nutritional relevance. The education. effectiveness of these strategies beyond increasing nutrition Experiments to determine how to maximize the potential knowledge is yet to be assessed. of the web in delivering medical education, including nutrition education are under way. For example, Kipp (1997) reported a positive response by ®rst year medical Integrating multimedia into family medicine training students to computerized modules accessible on the world The East Carolina University Family Medicine Residency wide web. Engel et al (1997) found the web an effective program has created a comprehensive integrated, ambula- method for delivering diabetes nutrition education to third tory centered curriculum to be taught longitudinally over year medical students (http:==medicine.aecom.yu. the resident's three years. This is part of the trend to edu=diabetes=DE.htm). Medical students have found Web longitudinal training seen in residency training in the U.S. based education to be an important additional education Time for additional nutrition education was created in this resource, to enhance studying during non classroom times redesign. Multimedia is used to deliver some of the nutri- and valuable for image intensive classes (Mehta et al, tion education curriculum. Examples are given in Table 2. Developments in family practice nutrition education KM Kolasa S94 Table 2 Incorporating electronic teaching in residency an example

First year resident (R1): (Basic Care and Life Cycle Health Care). Enhance personal nutrition and physical activity. Complete personal dietary assessment using either Nutrition DISCovery CD-ROM or web based valid dietary assessment tool (for example: University of Illinois http://spectre.ag.uiuc.edu/  food-lab/nat/) Role play with attending, 3 ± 5 min consultation. Second year resident (R2) (Diabetes skills). Build on basic nutrition counseling skills Review three cases on Health Sciences Consortium (HSC) diabetes CD-ROM (Kolasa, Lasswell, Lasswell, 1996) Review `Today's Opportunities' videoclips, Images of Cancer Prevention: the nutrition link CD-ROM for role modeling Request preceptor's attention to diabetes nutrition counseling skills Third year resident (R3) (Hyperlipidemia Skills). Build on basic nutrition counseling skills for patients with lipid disorders. Consider antioxidant nutrient concepts. Self study unit includes pretest. Go to http://healthgate/com/HealthGate/cme/bu/index.html Review case Vitamin C, Vitamin E, and lipid lowering Send note to residency director indicating if this information would change their practice and why/why not Complete short Board Review quiz on hyperlipidemia and nutrition. If need additional study, go to http://med/ standard.edu/School/DGIM/Teaching/modules-indexhtml and review lipid disorders

Some additional thoughts on maximizing technology for comes to evaluating multimedia strategies, the evaluation teaching family practice residents design must include an assessment of the appropriateness of content, the user motivation to interact with the content, For the medical educator considering the use of multimedia and clarity of presentation. The evaluation must assess if for their program, a series of questions are posed. First, is the presentation is convincing enough to change behaviors there a tradition of nutrition teaching in the residency and the intent to treat patients with nutrition therapies. New program? If so, can use of multimedia enhance that tradi- strategies for evaluation are in development. tion? If there is a tradition of teaching nutrition but its continuation is in jeopardy (for example faculty with interest have left the program or must generate more patient Conclusion revenue) multimedia may help slow the attack on the The importance of residents' or practising physicians' nutrition tradition. motivation to strengthen their nutrition assessment and If there is no nutrition education tradition, can multi- counseling skills cannot be underestimated when assessing media ®ll a need? If nutrition education is not a required the possible effectiveness of educational strategies. The component of the curriculum are there computer programs STFM (1994) Manual describes many effective strategies or web sites that can stimulate residents and physicians to for teaching and evaluating nutrition. There is need to learn nutrition? explore additional strategies that utilize technology. Only For residency programs that have had limited success in limited trials have been attempted. Once educational stra- implementing nutrition, can the change in organization and tegies are found to be effective, the challenge to create an presentation of the nutrition content which is possible with awareness for and disseminate these tools and strategies multi media, stimulate and help maintain learner interest in remains. the subject? Can the computer program or web site invoke a sense of mystery by presenting unresolved situations that References will retain learner interest. Since learners in graduate programs come with a variety American Academy of Family Physicians (AAFP) (1989, revised 1995): Recommended Core Educational Guidelines on Nutrition for Family of skill in nutrition from none to advanced, can multimedia Practice Residents. Kansas City, MO: American Academy Family be used to build on the existing nutrition skills of some Physicians. learners, while providing remedial work for others without American Dietetic Association (1994 ± 1998): Physician Nutrition Educa- having an negative effect? tion project. Modules available include: `How Does Your Pyramid What is the desired impact on the learner and on patient Stack UP?', `Application of Medical Nutrition Therapy in the Care of Patients with Diabetes', `Dietary Fats and Cholesterol Update'. Chi- care? cago, IL: American Dietetic Association, Chicago, IL. The answers to these questions will help the medical Anon (1996A): Nutrition DISCovery Personalized CD-ROM Diet Assess- nutrition educator decide if he=she should adopt others ment Program. Am. J. Preventive Nutrition. 12, 232. courseware and=or develop their own. Anon (1996B): Nutrition. Recommended core educational guidelines for family practice residents. Am. Fam. Physician. 54, 379 ± 380. 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