This two-day working group meeting was designed to guide future directions for implementing nutrition across the continuum of medical education and specialty training. The intended outcome was a set of recommendations to medical schools, health professional organizations, the NHLBI and other funding agencies 1) on the content and implementation of nutrition and healthy lifestyles education, training and competency testing across the continuum of medical education, and for practicing physicians and other health care providers, and 2) on integrating medical nutrition education, training and research into patient care.
The National Heart, Lung, and Blood Institute (NHLBI), Division of Cardiovascular Sciences (DCVS) convened a Working Group Meeting titled, "Future Directions for Implementing Nutrition across the Continuum of Medical Education, Training, and Research," on September 10-11, 2012, in Bethesda, Maryland. The NIH Office of Disease Prevention, and Division of Nutrition Research Coordination co-sponsored the meeting.
The purpose of the meeting was to make recommendations to a broad cross-section of groups for implementing nutrition across the continuum of medical, nursing, dental and other health professional education and specialty training. The intended outcomes from the meeting were recommendations on 1) the content and implementation of nutrition and healthy lifestyles education, training and competency testing across the continuum of medical, nursing and other health professional education, and 2) the integration of nutrition education, training and research to improve population health, patient care and health outcomes. The meeting format included presentations, panel and open discussions and breakout discussions, culminating in a series of recommendations and priorities for medical nutrition education, training and research.
The recommendations are intended to be further considered or implemented by members or teams from a broad coalition of involved entities. Additional discussions with the working group and other agencies will be needed to coordinate implementation of the recommendations by relevant partners.
Between 1998 and 2005, 21 out of 126 medical institutions participated in the Nutrition Academic Award (NAA) (1), a program funded by NHLBI in collaboration with NIDDK to develop and formally integrate required medical nutrition education into the medical school curricula. Outcomes from the awarded institutions include the development of new nutrition education and training resources for medical schools, a Nutrition Curriculum Guide that illustrated how and where nutrition was included within the medical school curriculum, the incorporation of nutrition into physicians’ clinical competencies (United States Medical Licensing Examination ®Step 1® http://www.usmle.org/step-1/ ), the establishment of collaboration with professional organizations including the American Society for Clinical Nutrition, American Heart Association, American Medical Association (AMA), Academy of Nutrition and Dietetics, and the National Board of Medical Examiners® (NBME®) -- the latter to expand and update nutrition emphasis on the Step 1® examination --, the development of nutrition assessment tools [e.g., WAVE (Weight, Activity, Variety, and Excess)], the publication of manuscripts regarding the NAA (2-4), and a case-based book on medical nutrition and disease (5).
Many medical schools have modified their curricula (e.g., problem-based learning and integrated curriculum). The Association of American Medical Colleges (AAMC) has periodically added new topics to the general medical school curriculum but has not emphasized the essential role of nutrition in the prevention of chronic disease.
Nutrition plays a major role in disease prevention and treatment, and it is widely recognized by health professionals including dietitians, clinicians, nurses, dentists, pharmacists and patients as an important foundation for clinical practice and for population health. Such health professionals are perceived by the public to be key resources for information about health. However, nutrition education in health professional training including U.S. medical schools, residency training, dental, pharmacy, and nursing programs remains inadequate (6), despite evidence supporting causal relationships between lifestyle factors and risk for chronic diseases as well as the importance of appropriate nutrition during hospitalization and an impact of nutrition on morbidity and mortality. A survey of medical schools by Adams et al. (6) noted that the percentage of medical schools that offered a dedicated nutrition course declined from 35% in 2000 to 25% in 2008. The number of hours devoted to nutrition instruction and skill building was less than the required minimum of 25 hours (19.6 hours in 2008). Institutions using online learning modules were able to provide significantly more hours of nutrition instruction (24.1 hours versus 13.7 hours) across the four-year curriculum than non-users (6). Current data (7, 8) indicate that few residents, fellows, and other clinicians are comfortable with managing nutrition problems in their patients. Nutrition training of medical students, residents, fellows, attending physicians, and other healthcare professionals as members of a multidisciplinary prevention team (e.g., consisting of pharmacists, social workers, nurses, nurse practitioners, dentists and dietitians) is fundamental to acute care management and to chronic disease prevention and treatment.
The workshop brought together experts in health professions education and training, academic and practicing physicians in the areas of family medicine, internal medicine, surgery, pediatrics, nurses, dietitians, nutrition professors, nutrition researchers, course directors, directors of nutrition and dental programs and continuing medical education (CME), representatives of various medical organizations including the American Board of Family Physicians, AMA, AAMC, American Society for Nutrition- Medical Nutrition Council, staff of the Bipartisan Policy Center, the American Society for Parenteral and Enteral Nutrition, the NBME® and NIH staff.
After a brief overview of the history of NAA and its achievements, participants devoted the first half of day one to discussing present and future nutrition education and training activities; and perspectives, barriers, and recommendations for implementing nutrition in the medical professions and for other healthcare providers (e.g., nurses and dentists). Perspectives and strategies for medical education and training from the Nutrition in Medicine Project (6) AMA, AAMC, NBME, Bipartisan Policy Center (9, 10), and CME medical educators were presented. Keynotes included presentations on how to improve training focused on outcomes, practice skills, continuous learning, patient care through collaborative multidisciplinary or inter-professional teams, competency based learning, and testing (e.g., Steps 1-3® http://www.usmle.org/step-1/; specialty boards, and CME).
Participants devoted the second half of day one to developing recommendations and meeting in three breakout sessions: 1) Medical Schools, 2) Residency/Specialty Training, and 3) Practicing Physicians and Other Health Care Providers such as Nurses, Nurse Practitioners, Dentists, and Pharmacists. Discussion points included 1) Recommendations on curriculum development and implementation, and 2) Recommendations on certification, and competency testing. Day two focused on research recommendations and reports back from the breakout sessions. The following guiding principles were additional discussion points:
These recommendations may be implemented by a broad range of organizations.
Last Updated: December 2012
Dr. Diane Bild, Associate Director, Prevention and Population Science Program, Division of Cardiovascular Sciences, NHLBI
Dr. Barry Portnoy, Senior Advisor for Disease Prevention, Office of Disease Prevention, NIH
Dr. Kris-Etherton, Working Group Chair, Professor, Penn State University
Dr. Linda Van Horn
Dr. Marilyn Edwards
Report and Recommendations: Medical Schools
Report and Recommendations from the American Society for Parenteral and Enteral Nutrition (ASPEN) 2
Bipartisan Report and Recommendations on
Nurses’ and Nurse Practitioners’ Perspectives Issues
American Medical Association (AMA), Dr. Suzen Moeller
Association of American Medical Colleges (AAMC), Dr. Carol Aschenbrener
American Board of Medical Specialties (ABMS), Mr. Tom Granatir
National Board of Medical Education (NBME), Dr. Steven Haist
Continuing Medical Education, Dr. Jann Balmer
An Overview of Strategies to Address Nutrition: The Obesity Example, Dr. William (Bill) Dietz
Breakout Sessions and Open Discussions on Moving Forward: Curriculum and Competency Recommendations
a) Medical Schools (Moderators: Drs. S. Akabas, C. Rock, and C. Bales): Room 9100/9104 (Dr. Kushner- Via Teleconference/Webinar): Tel.:1- 877 991 7960; PC 641659#
b) Residency and Specialty Training (Moderators: Drs. C. Lenders and D. Seidner) Room 9091 Tel.: 1-888 809 8852, PC 134690# 3
c) Practicing Physicians and Other Health Care Providers-Nurses, NP, Dentists, etc. (Moderators: Drs. L. Braun and C. Palmer). Room 10091: Tel.: Tel.: 1-888 809 8852, PC 134690
Discussion Points for Each Track:
1) Recommendations on Curriculum and its Implementation
2) Recommendations on Certification and Competency Testing (e.g., competency testing across the curriculum, Licensure)
Questions to Guide the Discussions
1) What process do you recommend within the medical school, especially during clinical training, to integrate nutrition content into routine patient care?
2) What structural changes are needed to integrate nutrition into patient care?
3) What competencies and what recommendations for assessing competencies before board exams are needed (e.g. OSCE -Objective, Structural Clinical Exam)?
4) Using the NAA Curriculum Guide, what recommendations can you make with respect to its revisions?
Residency and Specialty Training
Select key residency programs to target (e.g., Primary Care, Pediatrics, Internal Medicine, OBGYN).
1) What recommendations are there to provide a balance between nutrition content and more acute care?
2) What suggestions are there for assessing competencies?
3) What topic areas in the NAA Curriculum Guide need revisions? What new information is needed? What process should be used to revise the NAA Curriculum Guide for Residents/Specialty Care?
4) What structural changes are needed to integrate nutrition into specialty care?
Continuing Medical Education for Practicing Physicians and Other Health Care Providers (Nurses, Nurse Practitioners, Physician Assistants, Dentists, and Pharmacists)
1) What nutrition topics and CME training do you recommend?
2) What process should be used to provide CME and how would nutrition be incorporated in Licensure?
3) What recommendations do you have on how to go beyond CME to practice using adult learning principles, integrating practice support and clinical support systems?
Dr. Penny Kris-Etherton
Research Implementation Recommendations (addresses objective #2)
1) How do we integrate research into medical nutrition education and specialty training for patient care? What are some research recommendations?
2) How would you evaluate the impact of nutrition changes? What metric?
3) What are the incentives/disincentives for health-care providers to embrace nutrition into routine clinical practice (e.g., additional certification, practice-based HEDIS measures, third party payers)? How do we get physicians trained (e.g., certificate, MPH with nutrition emphasis, MS in nutrition before or after medical school)
Institute of Medicine/American Board of Physician
Nutrition Specialists, Dr. Douglas Heimburger
Medical Nutrition Council-ASN, Dr. Edward Saltzman
1) Medical School
3) Nurses and other Health-care Providers
Dr. Penny Kris-Etherton
Dr. Charlotte Pratt (NHLBI)