- Email: [email protected]
Case-based Nutrition Teaching for Medical Students
GEM NO. 454
Case-based Nutrition Teaching for Medical Students Ashlesha K. Dayal, MD*; Peter Van Eerden, MD; Linda Gillespie, MSEd; Nadine T. Katz, MD, Division of Undergraduate Medical Education, Department of Obstetrics and Gynecology and Women’s Health, Albert Einstein College of Medicine/ Montefiore Medical Center, Bronx, New York Lisa Rucker, MD, Division of Ambulatory Medicine, Department of Medicine, Jacobi Medical Center, Bronx, New York Judith Wylie Rosett, EdD, RD, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York ( J Nutr Educ Behav. 2008;40:191-192) *Address for correspondence: Ashlesha K. Dayal, MD, Department of Obstetrics and Gynecology and Women’s Health, Jack D. Weiler Hospital of the Albert Einstein College of Medicine, 1825 Eastchester Road, 7th Floor, Bronx, NY 10461; Phone: (718) 904-2767; Fax: (718) 904-2799; E-mail: [email protected] This paper was presented as a poster at the annual meeting of CREOG-APGO on March 2-5, 2005 in Salt Lake City, Utah.
doi: 10.1016/j.jneb.2007.09.010
INTRODUCTION Teacher-directed, case-based teaching is designed to develop problemsolving skills and to catalyze discussion. The model also prepares participants individually to consider solutions and to identify knowledge gaps and potential misunderstandings of the material.1 Weight, Activity, Variety and Excess (WAVE), which includes provider assessment tools, a self-administered questionnaire with guides for the provider, and patient self-help tools,2 can help primary care providers integrate nutrition into routine care.3
OBJECTIVES A case-based module was created for a third-year obstetrics and gynecology
and women’s health clerkship. The learning objectives for students were to develop obesity-related nutrition assessment and intervention skills that could be used within the context of a busy medical practice. The assessment skills development focused on common weight-related health issues for women: (a) during pregnancy, focusing on high risk and gestational diabetes; (b) in midlife, focusing on chronic disease risk related to the metabolic syndrome; and (c) in older age, to address multiple medical and/or social problems. The intervention skills focused on using tools related to Weight, Activity, Variety, and Excess for each age cycle and on determining when to refer for medical nutrition therapy with a registered dietitian (RD).
PROGRAM DEVELOPMENT AND DESCRIPTION Learning objectives and case content were developed and refined by an expert panel consisting of faculty (1 physician and 3 nutritionists) and 4 students (on their ambulatory medicine rotation) for a 2-hour workshop to be given in the ob/gyn clerkship. The workshop was structured to teach third-year medical students (25 per rotation, every 6 weeks) how to conduct a brief nutrition assessment and consultation using the WAVE approach and how to tailor their intervention approach based on patient age group, health condition, and key psychosocial issues. The workshop, taught by a senior faculty RD on a didactic day of the clerkship, began with a brief (5-10 minutes) didactic PowerPoint presentation to review key concepts related to each agerelated stage and the issues related to tailoring WAVE implementation. The students were divided into 3 case discussion groups corresponding to the 3 age-related stages. Each group was asked to consider the case infor-
mation, use WAVE-related material to assess issues, and present using a patient-centered Subjective/History, Objective/Observation, Assessment and Plan (SOAP) format (Table).4
EVALUATION At the initial orientation to the clerkship, students completed a survey to evaluate their own confidence and practices with regard to assessing variables of the WAVE approach prior to attending the third-year workshop. The same survey was re-administered during the ambulatory medicine rotation in their fourth year of medical school. Responses were scored using a Likert scale of 1 to 4. We evaluated responses using STATA 8.2 to analyze responses with chi-square, simple t test, and the Mann-Whitney test, as appropriate. During the third-year ob/ gyn and the fourth-year ambulatory care rotation, 113 and 151 students, respectively, completed surveys. Fourth-year students reported feeling more prepared to address WAVE elements in their assessments and reported thinking about nutrition issues with greater frequency than the thirdyear students (P ⫽ .001). Respondents were 45% male and 55% female in the third year and 54% male and 46% female in the fourth year. Compared to male students, female students reported asking about nutrition (P ⫽ .002) and assessing weight (P ⫽ .001) more frequently. Only 7.6% of third-year and fourth-years surveys indicated that students reported seeing attending or resident modeling of nutrition assessment frequently or more often.
FUTURE APPLICATION Completion of the workshop appeared to increase student knowledge and skills. The authors integrated nutrition training into
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Dayal/CASE-BASED NUTRITION TEACHING FOR MEDICAL STUDENTS
Table. Sample Questions for Student Group: Patient-Oriented SOAP Format
(S) Subjective/History: What is the history of her present illness? What are the patient’s chief concerns? (O) Objective/Observations: What objective information do you have? What are your observations? What information do you need? What tests would you want? (A) Assessment: What should you focus on in a quick nutrition assessment? Discuss the nutrition issues in relation to health risks that she may be facing. What acute nutrition-related problems is she at risk for? How should nutritional issues affect overall treatment plan? (P) Plan: Discuss potential nutrition treatment options and how you would integrate the nutritional issues into your overall plan to address acute health problems and her overall health.
based approaches are an efficient means to integrate nutrition teaching into practice-based learning.
NOTES The nutrition survey on medical students was submitted and exempted under the Einstein institutional review board in 2003. The workshop project was done under a Nutrition Academic Award from the National Institutes of Health (#5KO7HL 003953).
SUPPLEMENTARY DATA medical education during a student clerkship that focuses mostly on inpatient care. The innovative teaching module helped broaden the scope of nutrition training offered. This case-based model teaches future physicians to address and initiate the conversation about paramount nutrition issues, which will occur and recur over the patient’s lifetime. Student reporting of poor modeling of nutrition assessment by physician preceptors may be a result of the need to address lifestyle issues quickly during the patient provider interaction, particularly in the inpatient setting. These case materials address the well-known time pressures using questions to quickly assess and formulate a treatment plan. The approach presented here is designed to address multiple reasons that primary care providers do not provide nutrition counseling. Potential reasons include lack of training, confidence, and perceived proficiency,5,6 as well as less frequent nutrition assessment by male physician role models.7 The authors’ evaluation demonstrates that the retention of specific knowledge in nutrition education is possible from the third to the fourth years of medical school. These case-based training materials, includ-
ing an initial PowerPoint presentation, teaching case, and WAVE handout, which are available at the Web site http://eph.aecom.yu.edu/ web/division_details.aspx?id⫽6, can be used to integrate nutrition education into the training of graduate and postgraduate primary care providers. Other Nutrition Academic Award (NAA) materials are also available.8 To create a lasting impact on physician knowledge regarding nutrition issues, nutrition education needs to be integrated into postgraduate primary and specialty education. Realistic patient care practice issues will need to be addressed if obesity-related nutrition assessment and counseling are to become integral components of general history taking and routine care. Potential venues for incorporating this innovative case-based approach to nutrition training include postgraduate education forums such as workshops, grand rounds, and continuing medical education (CME) events, as well as initiating the approach into medical school curricula. The magnitude of nutrition-induced diseases facing present and future health care providers will dictate that undergraduate and graduate medical educators incorporate nutrition and other preventative curricula for their learners. Case-
Supplementary data associated with this article can be found within the online version of the article at www.jneb.org under the label “Add-ons.”
REFERENCES 1. Tarvik A. Revival of the case-method: a way to retain student-centered learning in a postPBL era. Med Teach. 2007:29:e32-e36. 2. Soroudi N, Wylie Rosett J, Mogul D. Quick WAVE Screener: a tool to address weight, activity, variety and excess. Diabetes Educ. 2004;30:616-640. 3. Gans KM, Ross E, Barner CW, Wylie Rosett J, McMurray J, Eaton CJ. REAP and WAVE: new tools to rapidly assess/discuss nutrition with patients. J Nutr. 2003;133: 556S-562S. 4. Donnelly WJ. Patient-centered medical care requires patient-centered medical records. Acad Med. 2005;80:33-38. 5. Taren D, Thomson CA, Koff NA, et al. Effect of an integrated nutrition curriculum on medical education, student clinical performance, and student perception of medical-nutrition training. Am J Clin Nutr. 2001;73:1107-1112. 6. Davis NJ, Emerenini A, Wylie-Rosett J. Obesity management: physician practice patterns and patient preference. Diabetes Educ. 2006;32:557-561. 7. Schulman JA, Karney BR. Gender and attitudes toward nutrition in prospective physicians. Am J Health Behav. 2003;27:623-632. 8. Nutrition Academic Award Program. NAA Products. National Heart, Lung and Blood Institute Nutrition Academic Award Program. Available at: http://www.nhlbi. nih.gov/funding/training/naa/products.htm. Accessed March 10, 2008.
Case-based Nutrition Teaching for Medical Students Ashlesha K. Dayal, MD*; Peter Van Eerden, MD; Linda Gillespie, MSEd; Nadine T. Katz, MD, Division of Undergraduate Medical Education, Department of Obstetrics and Gynecology and Women’s Health, Albert Einstein College of Medicine/ Montefiore Medical Center, Bronx, New York Lisa Rucker, MD, Division of Ambulatory Medicine, Department of Medicine, Jacobi Medical Center, Bronx, New York Judith Wylie Rosett, EdD, RD, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York ( J Nutr Educ Behav. 2008;40:191-192) *Address for correspondence: Ashlesha K. Dayal, MD, Department of Obstetrics and Gynecology and Women’s Health, Jack D. Weiler Hospital of the Albert Einstein College of Medicine, 1825 Eastchester Road, 7th Floor, Bronx, NY 10461; Phone: (718) 904-2767; Fax: (718) 904-2799; E-mail: [email protected] This paper was presented as a poster at the annual meeting of CREOG-APGO on March 2-5, 2005 in Salt Lake City, Utah.
doi: 10.1016/j.jneb.2007.09.010
INTRODUCTION Teacher-directed, case-based teaching is designed to develop problemsolving skills and to catalyze discussion. The model also prepares participants individually to consider solutions and to identify knowledge gaps and potential misunderstandings of the material.1 Weight, Activity, Variety and Excess (WAVE), which includes provider assessment tools, a self-administered questionnaire with guides for the provider, and patient self-help tools,2 can help primary care providers integrate nutrition into routine care.3
OBJECTIVES A case-based module was created for a third-year obstetrics and gynecology
and women’s health clerkship. The learning objectives for students were to develop obesity-related nutrition assessment and intervention skills that could be used within the context of a busy medical practice. The assessment skills development focused on common weight-related health issues for women: (a) during pregnancy, focusing on high risk and gestational diabetes; (b) in midlife, focusing on chronic disease risk related to the metabolic syndrome; and (c) in older age, to address multiple medical and/or social problems. The intervention skills focused on using tools related to Weight, Activity, Variety, and Excess for each age cycle and on determining when to refer for medical nutrition therapy with a registered dietitian (RD).
PROGRAM DEVELOPMENT AND DESCRIPTION Learning objectives and case content were developed and refined by an expert panel consisting of faculty (1 physician and 3 nutritionists) and 4 students (on their ambulatory medicine rotation) for a 2-hour workshop to be given in the ob/gyn clerkship. The workshop was structured to teach third-year medical students (25 per rotation, every 6 weeks) how to conduct a brief nutrition assessment and consultation using the WAVE approach and how to tailor their intervention approach based on patient age group, health condition, and key psychosocial issues. The workshop, taught by a senior faculty RD on a didactic day of the clerkship, began with a brief (5-10 minutes) didactic PowerPoint presentation to review key concepts related to each agerelated stage and the issues related to tailoring WAVE implementation. The students were divided into 3 case discussion groups corresponding to the 3 age-related stages. Each group was asked to consider the case infor-
mation, use WAVE-related material to assess issues, and present using a patient-centered Subjective/History, Objective/Observation, Assessment and Plan (SOAP) format (Table).4
EVALUATION At the initial orientation to the clerkship, students completed a survey to evaluate their own confidence and practices with regard to assessing variables of the WAVE approach prior to attending the third-year workshop. The same survey was re-administered during the ambulatory medicine rotation in their fourth year of medical school. Responses were scored using a Likert scale of 1 to 4. We evaluated responses using STATA 8.2 to analyze responses with chi-square, simple t test, and the Mann-Whitney test, as appropriate. During the third-year ob/ gyn and the fourth-year ambulatory care rotation, 113 and 151 students, respectively, completed surveys. Fourth-year students reported feeling more prepared to address WAVE elements in their assessments and reported thinking about nutrition issues with greater frequency than the thirdyear students (P ⫽ .001). Respondents were 45% male and 55% female in the third year and 54% male and 46% female in the fourth year. Compared to male students, female students reported asking about nutrition (P ⫽ .002) and assessing weight (P ⫽ .001) more frequently. Only 7.6% of third-year and fourth-years surveys indicated that students reported seeing attending or resident modeling of nutrition assessment frequently or more often.
FUTURE APPLICATION Completion of the workshop appeared to increase student knowledge and skills. The authors integrated nutrition training into
192
Dayal/CASE-BASED NUTRITION TEACHING FOR MEDICAL STUDENTS
Table. Sample Questions for Student Group: Patient-Oriented SOAP Format
(S) Subjective/History: What is the history of her present illness? What are the patient’s chief concerns? (O) Objective/Observations: What objective information do you have? What are your observations? What information do you need? What tests would you want? (A) Assessment: What should you focus on in a quick nutrition assessment? Discuss the nutrition issues in relation to health risks that she may be facing. What acute nutrition-related problems is she at risk for? How should nutritional issues affect overall treatment plan? (P) Plan: Discuss potential nutrition treatment options and how you would integrate the nutritional issues into your overall plan to address acute health problems and her overall health.
based approaches are an efficient means to integrate nutrition teaching into practice-based learning.
NOTES The nutrition survey on medical students was submitted and exempted under the Einstein institutional review board in 2003. The workshop project was done under a Nutrition Academic Award from the National Institutes of Health (#5KO7HL 003953).
SUPPLEMENTARY DATA medical education during a student clerkship that focuses mostly on inpatient care. The innovative teaching module helped broaden the scope of nutrition training offered. This case-based model teaches future physicians to address and initiate the conversation about paramount nutrition issues, which will occur and recur over the patient’s lifetime. Student reporting of poor modeling of nutrition assessment by physician preceptors may be a result of the need to address lifestyle issues quickly during the patient provider interaction, particularly in the inpatient setting. These case materials address the well-known time pressures using questions to quickly assess and formulate a treatment plan. The approach presented here is designed to address multiple reasons that primary care providers do not provide nutrition counseling. Potential reasons include lack of training, confidence, and perceived proficiency,5,6 as well as less frequent nutrition assessment by male physician role models.7 The authors’ evaluation demonstrates that the retention of specific knowledge in nutrition education is possible from the third to the fourth years of medical school. These case-based training materials, includ-
ing an initial PowerPoint presentation, teaching case, and WAVE handout, which are available at the Web site http://eph.aecom.yu.edu/ web/division_details.aspx?id⫽6, can be used to integrate nutrition education into the training of graduate and postgraduate primary care providers. Other Nutrition Academic Award (NAA) materials are also available.8 To create a lasting impact on physician knowledge regarding nutrition issues, nutrition education needs to be integrated into postgraduate primary and specialty education. Realistic patient care practice issues will need to be addressed if obesity-related nutrition assessment and counseling are to become integral components of general history taking and routine care. Potential venues for incorporating this innovative case-based approach to nutrition training include postgraduate education forums such as workshops, grand rounds, and continuing medical education (CME) events, as well as initiating the approach into medical school curricula. The magnitude of nutrition-induced diseases facing present and future health care providers will dictate that undergraduate and graduate medical educators incorporate nutrition and other preventative curricula for their learners. Case-
Supplementary data associated with this article can be found within the online version of the article at www.jneb.org under the label “Add-ons.”
REFERENCES 1. Tarvik A. Revival of the case-method: a way to retain student-centered learning in a postPBL era. Med Teach. 2007:29:e32-e36. 2. Soroudi N, Wylie Rosett J, Mogul D. Quick WAVE Screener: a tool to address weight, activity, variety and excess. Diabetes Educ. 2004;30:616-640. 3. Gans KM, Ross E, Barner CW, Wylie Rosett J, McMurray J, Eaton CJ. REAP and WAVE: new tools to rapidly assess/discuss nutrition with patients. J Nutr. 2003;133: 556S-562S. 4. Donnelly WJ. Patient-centered medical care requires patient-centered medical records. Acad Med. 2005;80:33-38. 5. Taren D, Thomson CA, Koff NA, et al. Effect of an integrated nutrition curriculum on medical education, student clinical performance, and student perception of medical-nutrition training. Am J Clin Nutr. 2001;73:1107-1112. 6. Davis NJ, Emerenini A, Wylie-Rosett J. Obesity management: physician practice patterns and patient preference. Diabetes Educ. 2006;32:557-561. 7. Schulman JA, Karney BR. Gender and attitudes toward nutrition in prospective physicians. Am J Health Behav. 2003;27:623-632. 8. Nutrition Academic Award Program. NAA Products. National Heart, Lung and Blood Institute Nutrition Academic Award Program. Available at: http://www.nhlbi. nih.gov/funding/training/naa/products.htm. Accessed March 10, 2008.