Are Graduating Pediatric Residents Prepared to Engage in Obesity Prevention and Treatment?

Accepted Manuscript Are Graduating Pediatric Residents Prepared to Engage in Obesity Prevention and Treatment? Mary Pat Frintner, MSPH, Janice L. Liebhart, MS, Jeanne Lindros, MPH, Alison Baker, MS, Sandra G. Hassink, MD, MS, FAAP PII:

S1876-2859(16)00032-2

DOI:

10.1016/j.acap.2016.01.016

Reference:

ACAP 814

To appear in:

Academic Pediatrics

Received Date: 31 July 2015 Revised Date:

19 January 2016

Accepted Date: 21 January 2016

Please cite this article as: Frintner MP, Liebhart JL, Lindros J, Baker A, Hassink SG, Are Graduating Pediatric Residents Prepared to Engage in Obesity Prevention and Treatment?, Academic Pediatrics (2016), doi: 10.1016/j.acap.2016.01.016. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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Are Graduating Pediatric Residents Prepared to Engage in Obesity Prevention and Treatment?

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Mary Pat Frintner, MSPH; 1 Janice L Liebhart, MS;2 Jeanne Lindros, MPH;3 Alison Baker, MS;4 Sandra G Hassink, MD, MS, FAAP5 1

American Academy of Pediatrics, Department of Research, 141 Northwest Point Blvd, Elk Grove Village, IL; [email protected]

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American Academy of Pediatrics, Institute for Healthy Childhood Weight, 141 Northwest Point Blvd, Elk Grove Village, IL; [email protected]

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American Academy of Pediatrics, Institute for Healthy Childhood Weight, 141 Northwest Point Blvd, Elk Grove Village, IL; [email protected]

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American Academy of Pediatrics, Institute for Healthy Childhood Weight, 141 Northwest Point Blvd, Elk Grove Village, IL; [email protected]

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American Academy of Pediatrics, Institute for Healthy Childhood Weight, 141 Northwest Point Blvd, Elk Grove Village, IL; [email protected]

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Corresponding author: Mary Pat Frintner, MSPH, American Academy of Pediatrics, Department of Research, 141 Northwest Point Blvd, Elk Grove Village, IL 60007; Phone: 847434-7664; Fax: 847-434-4996; [email protected]. Key words: obesity, pediatric residents, training, motivational interviewing

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Running title: Residents’ Preparedness in Obesity Prevention and Treatment Word counts: Abstract=248 words; Text=2956

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Funding Source: American Academy of Pediatrics Financial disclosure: Ms. Frintner, Ms. Liebhart, Ms. Lindros, Ms. Baker and Dr. Hassink have no relevant financial relationships to disclose. Conflict of Interest: Ms. Frintner, Ms. Liebhart, Ms. Lindros, Ms. Baker and Dr. Hassink have no conflicts of interest to disclose.

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What’s new? This national survey of graduating pediatric residents underscores the importance of comprehensive training on overweight and obesity and the inclusion of training in

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motivational interviewing to help residents feel prepared to care for children who have

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overweight and obesity.

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ABSTRACT Background: Little information is available to gauge residents’ perceived receipt of

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comprehensive training and preparedness to manage children with obesity in practice.

Methods: National, random sample of 1,000 graduating pediatric residents surveyed in 2013 on childhood overweight/obesity and preparedness to prevent and treat obesity. Composite training

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measure was created by summing the number of areas (10 possible) where training on

overweight/obesity was received. Multivariable logistic regression explored relationships of

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resident and training characteristics to residents’ belief that their own counseling on a) prevention and b) treatment of overweight/obesity is very effective (versus somewhat/slightly/not effective).

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Results: Of 625 survey respondents (63% response), most (68-92%) reported receipt of training in each of 10 assessed areas on overweight/obesity prevention, assessment, and treatment. Most residents did not desire more training in the assessed areas; however, 54% wanted more training

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in motivational interviewing. About one-fourth believed that their own counseling on the prevention of overweight/obesity (26%) and treatment of obesity (22%) was very effective.

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Residents who rated their ability to use motivational interviewing as very good/excellent were more likely to rate their counseling on both the prevention and treatment of overweight/obesity as very effective (aOR=4.33, 95%CI=2.63-7.13; aOR=4.69, 95%CI=2.72-8.07; respectively). Residents who received training in all 10 assessed areas were also more likely to rate their counseling on both prevention and treatment as very effective (OR=2.58, 95%CI=1.61-4.14; aOR=2.41, 95%CI=1.46-3.97; respectively).

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Conclusion: Comprehensive training on overweight/obesity and inclusion of training in motivational interviewing may help residents feel better prepared to care for children with

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overweight/obesity.

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Childhood obesity continues to be a challenging health issue in the United States. Seventeen percent of children and adolescents have obesity and nearly one-third have either overweight or obesity.1 Pediatricians are on the front lines of the childhood obesity epidemic

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and can play an important role in the effective prevention, assessment, and treatment.2-6

To address healthy weight at the point of patient care, the American Academy of

Pediatrics (AAP) recommends at least a yearly assessment of weight status, including calculation

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of body mass index (BMI) for all children ages 2 years and older, as well as counseling on healthy weight and eating, physical activity, and sedentary behaviors.3 Patient-centered

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communication can play an important role in motivating families and encouraging healthy behaviors and can also be applied to the management of patients with obesity. Motivational interviewing, a specific technique for enhancing motivation to change health behavior by exploring and resolving ambivalence and using reflective listening, has

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shown promise as an effective strategy in the clinical setting.3,7-10 A recent large-scale randomized trial showed significant reductions in BMI when motivational interviewing was delivered to parents of overweight children from their primary care physicians and registered

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dieticians.9 The authors concluded that motivational interviewing can be an important and feasible component of addressing obesity and that training physicians to effectively use

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motivational interviewing warrants future research. A survey of pediatricians found that most report feeling comfortable and prepared to

counsel families on weight,11 but it was unclear whether or not they feel prepared to use motivational interviewing for issues such as healthy weight, nutrition and physical activity. Another study found that nearly two-thirds of pediatricians reported inadequate competency using motivational interviewing.12

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Medical education is beginning to include obesity assessment and management13,14 but we are not aware of any national data on pediatric training comprehensiveness or residents’ preparedness to manage children with obesity as they are leaving residency. We sought to

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address this gap by surveying a national sample of graduating pediatric residents. Research questions related to training included: Do residents a) perceive that they received training in key areas of obesity prevention, assessment, and treatment, b) feel satisfied with time devoted to

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overweight and obesity training during residency, and c) have opportunities to care for

overweight and obese patients during residency? Questions related to preparedness included: Are

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residents confident in their own ability to a) perform various skills for preventing, assessing and treating obesity, including motivational interviewing and b) effectively counsel on obesity? We also wanted to explore whether specific demographic or training characteristics were related to

METHODS

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confidence in effective counseling.

We used data from the American Academy of Pediatrics (AAP) 2013 Annual Survey of

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Graduating Residents. The sample was randomly selected from an AAP database that includes all U.S. pediatric residents. Residents who were not in their third year of a categorical pediatric

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residency and those from combined programs were excluded from the sampling frame, leaving 2,790 eligible residents. A random sample of 1,100 residents was drawn from this population. A pilot version of the survey was sent to 100 residents from this sample in March 2013, and the survey was revised based on responses (n=31). The final survey was fielded to the national sample of 1,000 third-year graduating pediatric residents, between May and August of 2013. Requests alternated between mail and email until the resident responded or a total of eight

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requests were made. Emails included a link to the online survey, and mailed surveys included a postage-paid return envelope. A $2 incentive was included in the first mailing. The AAP

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Institutional Review Board approved the protocol and survey.

Survey Content

The AAP Annual Survey of Graduating Residents has been sent to graduates each year

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since 1997 and includes core questions on residents’ demographics, training experiences, and career intentions. The 2013 Survey also included additional questions, focused on training for

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childhood overweight and obesity and preparedness to prevent and treat obesity. These questions were based on a review of the literature and expert opinion and were revised based on responses to the pilot survey administration.

Training: To assess perceived training comprehensiveness, we asked residents if they

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had been trained in 10 areas of childhood overweight and obesity (one question per area) and whether or not they wished that they had been given more training in the 10 areas. Because it seemed possible that some residents might not be familiar with motivational interviewing, we

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also included the explanatory phrase “shared decision-making strategies for behavior change” in the first question about this area. To assess satisfaction with time spent on overweight and

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obesity training during residency, we asked residents whether they thought that the amount of instruction or training time devoted to overweight and obesity was just right, too little or too much. To obtain an estimate of their experience in caring for overweight and obese children, we asked residents to report the approximate percentage of their patients during residency who had overweight (BMI > 85th and < 95th percentile) and obesity (BMI > 95th percentile).

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Preparedness: We asked residents to rate their ability to assess and counsel on overweight and obesity, including their ability to use motivational interviewing. We also asked if they are comfortable using behavior change techniques and believe that their own counseling

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on the prevention and treatment of overweight and obesity is effective.

Analysis

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Data on gender and age were available in the AAP database from which the sample was drawn. So, to assess potential response bias, we used chi-square and t-tests, respectively, to

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compare these variables for respondents and non-respondents.

Descriptive statistics were used to summarize the data. A composite overweight/obesity training measure was created by summing the number of areas (n=10) where training on childhood overweight and obesity was received.

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We used multivariable logistic regression to explore the relationship of resident and training characteristics to residents’ belief that their own counseling on the prevention and treatment of overweight and obesity is very effective (vs somewhat/slightly/not at all effective);

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one model examined very effective counseling on prevention and one examined very effective counseling on treatment. Various resident and resident training characteristics were initially

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explored using the Pearson chi-square test and included in the two models if the bivariate association with very effective counseling on prevention or very effective counseling on treatment was p<.15.

Tested variables included resident characteristics: age (<31 years or > 31 years, based on

mean), gender (male or female), race (white not-Hispanic, Asian, Hispanic, black or African American, or other), married (yes or no), and, program class size (< 15, 15-24, or > 25 residents,

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based on distribution). We also examined resident perception of the percent of patients with obesity that they cared for during residency (< 18% or >18%, based on mean), composite overweight/obesity training measure (score of 10 or < 10), and satisfaction with residency

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training time on overweight and obesity (just right or too little/too much). Percentage of patients with obesity during residency was included because of the potential for differential levels of experience. Composite training measure and satisfaction with training time were included

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because we hypothesized that training comprehensiveness and satisfaction would be associated with preparedness. Perceived ability to use motivational interviewing (very good/excellent or

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poor/fair/good) was also included because previous research has found that this technique might be effective in the clinical setting.7,9,15 The number of cases in each statistical analysis varied slightly because of missing values for specific questions.

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RESULTS

Sixty-three percent of the 1,000 graduating residents in our randomly selected sample responded to the survey (n = 625), representing 184 different training programs. There were no

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significant age or gender differences between respondents and non-respondents (p=.65 and p=.43, respectively).

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Table 1 provides characteristics of respondents. Almost three-fourths were female,

58.5% were white non-Hispanic, 21.9% were Asian or Pacific Islander, 9.6% were Hispanic, 4.5% were black, and 5.5% reported “other” race. Most graduated from a U.S. medical school (76.4%), were married (73.4%), and did not have children (65.6%).

Training

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Most residents (68-92%) reported receipt of training during residency in each of the 10 evaluated areas of overweight and obesity prevention, assessment, and treatment (Figure 1). Approximately 90% received training on the calculation of BMI and diagnosis of obesity. Fewer

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(68%) received training on motivational interviewing/shared decision-making strategies for behavior change. In general, the majority of residents did not wish for more training in the assessed areas; however, more than half (54%) wished for more training in motivational

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interviewing, and half wanted more training in the treatment of obesity-related comorbidities and treatment of overweight and obesity. The mean of the composite overweight/obesity training

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measure (based on the 10 areas assessed in Figure 1) was 8.3, with a minimum score of 0 and a maximum score of 10. Nearly half (49.1%) of the residents reported a composite score of 10, reflecting that they had received training in all 10 areas.

Most residents were satisfied with the training time on overweight and obesity during

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residency, as 73.9% said that the amount of training was just right while 21.5% said it was not enough, and 4.6% said it was too much. The mean percentages of patients with overweight (BMI > 85th and < 95th percentile) and patients with obesity (BMI > 95th percentile) that residents

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perceived having cared for during residency was 35.7% (95% Confidence Interval [CI]=34.2-

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37.1) and 18.0% (95% CI=16.9-19.0), respectively.

Preparedness

Most residents (74-87%) rated their ability to assess overweight and obesity and counsel

families on screen time, physical activity, and nutrition as very good or excellent. (See Table 2.) About half rated their ability to use motivational interviewing as very good or excellent.

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Nearly all residents were somewhat or very comfortable discussing overweight and obesity with children/adolescents and parents, with the majority feeling very comfortable. (See Figure 2.) Fewer were very comfortable using behavior change techniques in the treatment of

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obesity (35%) or monitoring behavior change goals of patients with obesity (40%). Only about one-fourth believed that their own counseling on the prevention of overweight and obesity and treatment of obesity was very effective (26% and 22%, respectively).

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Multivariable analyses (Table 3) demonstrated that residents who rated their ability to use motivational interviewing as very good or excellent were more likely to rate both their

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counseling on the prevention of overweight and obesity and their counseling on the treatment of obesity as very effective (adjusted odds ratio-aOR=4.33; 95% CI=2.63-7.13 and aOR=4.69; 95% CI=2.72-8.07, respectively). Residents who received training in all 10 assessed areas were also more likely to rate both their counseling on the prevention of overweight and obesity and their

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counseling on the treatment of obesity as very effective (aOR=2.58; 95% CI=1.61-4.14 and aOR=2.41; 95% CI=1.46-3.97, respectively). Residents who graduated from a medical school outside the U.S. were also slightly more likely to rate their counseling on the prevention of

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DISCUSSION

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overweight and obesity as very effective (aOR=1.75; 95% CI=1.06-2.90).

To our knowledge, the 2013 AAP Annual Survey of Graduating Residents is the largest

survey of pediatric residents to have examined perceived training on overweight and obesity and preparedness for caring for children who have overweight and obesity. Although the results related to receipt of training in the key areas of obesity prevention, assessment, and treatment were encouraging, those related to perceived preparedness to effectively counsel children and

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parents on obesity suggest that improvement is still needed. Results also suggest that training strategies such as motivational interviewing may improve residents’ feelings of preparedness. About half of the residents in our study reported receipt of training in all 10 areas of

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overweight and obesity prevention, assessment, and treatment that were evaluated, indicating that their training was comprehensive. These results are particularly encouraging since some earlier studies have reported a lack of training in obesity management among trainees and

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practicing physicians.12,16,17 Other studies have linked a lack of obesity training during residency to reductions in the provision of counseling on diet and exercise to patients with obesity.17 When

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training does occur, the comprehensiveness of the curricula has also been in question. For example, in 2007, a survey of residency program directors found that over 80% of the pediatric programs provided training in areas of childhood obesity prevention, diagnosis, diagnosis of complications, and management; however, only 23% of pediatric programs reported having a

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formal curriculum.13 It is possible that there has been a notable change in training since 2007 as the focus on obesity in the United States has intensified. Our results also support that as of 2013, most graduating pediatric residents are satisfied

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with the time devoted to such training during residency. However, during pediatric residency, most residents wish for more specific training in motivational interviewing, and about half would

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also prefer more training related to overweight and obesity comorbidities and treatment. Results regarding pediatric residents’ sense of preparedness regarding assessment,

prevention, and treatment of overweight and obesity were similarly encouraging, yet, also point toward areas that would likely benefit from enhancements. As noted, the AAP and Centers for Disease Control and Prevention recommend that BMI is used to screen for overweight and obesity in children and teens 2 through 19 years.4,18 Consistent with this recommendation, 9 in

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10 residents in our study reported receipt of training and felt confident in their ability to calculate BMI. Because other studies have reported that electronic health record use increases screening rates in practice11,19,20 and that pediatricians in primary care practice are increasingly using BMI

progress toward universal BMI screening.

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percentile at health supervision visits,21 our results appear to contribute to signs of favorable

Regarding other aspects of preparedness, we found that most residents feel comfortable

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discussing overweight and obesity with families. However, only half rated their ability as very good or excellent in the use of strategies for behavior change, such as motivational interviewing,

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and few considered their own counseling on the prevention and treatment of overweight and obesity to be highly effective. These results are consistent with those of Jay et al,12 who found that over half of physicians surveyed reported inadequate competency in using motivational interviewing. Some other studies have similarly found that clinicians report low proficiency in

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using behavioral management strategies.22

Our findings may also extend these findings somewhat by suggesting important potential relationships between preparedness and training. In particular, we found that residents who have

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had comprehensive training and rate their ability to use motivational interviewing as very good or excellent are significantly more confident in the effectiveness of their own counseling on the

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prevention and treatment of obesity. In fact, residents in our study who felt prepared to use motivational interviewing had over four times the odds of reporting that their counseling on the prevention of overweight and obesity and their counseling on the treatment of obesity is effective. This is consistent with AAP recommendations that pediatricians become familiar with techniques such as behavioral modification, since education of families alone is unlikely to be effective for obesity prevention.2 Results are also consistent with those from smaller studies that

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report residents who receive training in assessment and counseling feel more confident in counseling and are likely to increase the frequency of their counseling.23 Furthermore, even after accounting for the effect of motivational interviewing, residents

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who received comprehensive training (relative to those who did not) had more than twice the odds of considering their counseling for both obesity prevention and treatment as very effective. Our results support independent contributions of general training in overweight and obesity and

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specific training in motivational interviewing on perceptions of effective counseling with patients and families.

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It should also be noted that proficiency and expertise in facilitating patient and family involvement through an empowering communication approach, such as motivational interviewing, may increase further with practice. Schumacher et al24 examine the numerous competencies within the patient care domain of the Accreditation Council for Graduate Medical

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Education Program Requirements for Graduate Medical Education in Pediatrics and outline developmental milestones for these competencies. For the ACGME competency on interviewing patients and families,25 it has been suggested that there is a developmental continuum ranging

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from “doctor participation” which includes doctor-centered care and no patient and/or family involvement to “empowerment facilitation” which includes motivational interviewing,24, 26 and

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that residents are unlikely to become proficient in patient and family interviewing during residency.

The study has several limitations. The overall response rate to the survey was moderate

(63%), though similar to other surveys of pediatricians.27 No differences in demographic characteristics of respondents and non-respondents were observed, although the available data for non-respondents were limited to gender and age. Other limitations are related to the self-

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report nature of survey data, including social desirability concerns and potential variation across respondents in their interpretation of questions or response options or the accuracy of their information recall. Also, for logistical reasons, no additional data was sought to independently

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verify the specific content of training programs. In addition, some other survey questions of likely interest, such as the amount, quality, and type of training residents received on

motivational interviewing and other specific behavioral techniques, were not included in the

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survey.

Despite these limitations, this study provided a seemingly rare opportunity to assess the

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perceived training and preparedness of a national sample of graduating pediatric residents regarding assessment, prevention, and treatment of overweight and obesity. Findings underscore the importance of comprehensive training on overweight and obesity, as well as the inclusion of training in motivational interviewing, to help graduating residents feel prepared to care for

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children with overweight and obesity. Our results suggest that curricula that emphasize caring for children who have overweight and obesity should be comprehensive, and that training and experiences with patient-centered techniques, such as motivational interviewing, can be

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enhanced.

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ACKNOWLEDGMENTS

We are most grateful to the pediatric residents who completed the 2013 Annual Survey of Graduating Residents. The Annual Survey of Graduating Residents is funded by the American Academy of Pediatrics.

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27.

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%

458 167

73.3 26.7

364 136 60 28 34

58.5 21.9 9.6 4.5 5.5

379 246

60.6 39.4

458 166

73.4 26.6

214 408

34.4 65.6

476 147

76.4 23.6

220 194 209

35.3 31.1 33.5

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n

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Characteristic Gender Female Male Race/Ethnicity White, non-Hispanic Asian Hispanic Black or African American Other Age, years < 31 > 31 Marital status Married/partnered Not married/partnered Parental status Children No children Medical school location U.S. Other Program class size Small (< 15 residents) Medium (15-24 residents) Large (>25 residents)

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Table 1. Respondent Characteristics (n=625)

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87.2

Evaluate children for overweight/obesity

87.1

Begin obesity discussion in clinical visit

83.3

Counsel families on screen time

80.3

Evaluate children for obesity-related comorbidities

78.3

Measure height and weight

77.9

Take family history of overweight/obesity

78.3

Counsel families on physical activity

78.3

Counsel families on nutrition/diet Use motivational interviewing

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Counsel families on overweight/obesity

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Calculate BMI

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%

76.3

74.4

51.5

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Survey question: “How would you rate your ability to perform the following?”

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Self-perceived ability to use motivational interviewing ---

Very good/excellent Composite training measure score

Medical school location US or Canada - reference Outside US or Canada

---

4.33, 2.63-7.13

4.69, 2.72-8.07

---

---

2.58, 1.61-4.14

2.41, 1.46-3.97

---

---

1.75, 1.06-2.90

1.62, 0.96-2.74

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Score of < 10: reference Score of 10 (received training in all assessed areas

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Poor/fair/good: reference

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Table 3. Factors Associated with Pediatric Resident Perception of Being Very Effective in Counseling on the Prevention and Treatment of Obesity* (n=556) Very Effective Counseling Adjusted Odds Ratio, 95% Confidence Interval Prevention of Treatment of Obesity Obesity

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* Also included in models but not significant: gender, marriage, age, perceived percent of obese patients during residency, and satisfied with residency training time devoted to overweight and obesity (just right)

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92

Diagnosis of OB

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17 89

Diagnosis of complications of OB

39 84

Treatment of OW and OB

83

Treatment of OB-related comorbidities

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50

82

Counsel on OW and OB

44

81

Prevention of OW and OB

43

80

Accurately measure height/weight

TE D

23

Advocate for OB prevention

75

38

EP

Use MI* strategies for behavior change

0

10

Received training

AC C

SC

49

RI PT

90

Calculate BMI

20

68 54 30

40

50 60 % Wished for more training

70

80

90

100

*MI = Motivational interviewing/shared decision-making **Survey question: “For each of the following childhood obesity areas: 1) Have you had formal training? 2) Do you wish you had more training?”

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Figure 2. Preparedness: Pediatric Resident-Rated Comfort Level and Confidence in Overweight (OW) and Obesity (OB) Care (n=612)

Do you believe that your counseling on prevention of OW 5% and OB is effective?

17%

Are you comfortable using behavior change techniques in 5% the treatment of OB?

16%

53%

M AN U

TE D

Are you comfortable monitoring behavior change goals of 5% 14% obese patients?

Are you comfortable discussing OW and OB with families? 3%

AC C

EP

Are you comfortable discussing OW and OB with children/adolescents?

Not at all

3%

0% Slightly

22%

RI PT

21%

52%

SC

Do you believe that your couseling on treatment of OB is 4% effective?

44%

35%

42%

40%

29%

68%

28%

69%

20% Somewhat

40% Very

26%

60%

80%

100%