Developing Nutrition Curriculum in a Family Medicine Residency

Introductions Tufts Family Medicine Residency Boston area 24 residents 8 full time faculty

Road Map Define our problems What are the national recommendations Discuss our solutions Small group discussions

Defining the problem? Identifying the lack of nutrition education in the residency setting Identifying the lack of precepting by faculty on nutrition Identifying the lack of communication with dietitians on our staff

What are the Guidelines? American Academy of Family Physicians Association of Departments of Family Medicine Association of Family Practice Residency Directors Society of Teachers of Family Medicine.

What are the Guidelines? Attitude Nutrition is an integral part of: Health promotion and disease prevention-Mortality and morbidity could be significantly reduced through primary prevention targeting dietary risk factors throughout the life cycle. Medical treatment of disease-nutritional status has a large impact on the ability to respond to medical interventions. Diagnosis and role-appropriate management of:

What are the Guidelines? Attitude Dietary intake is influenced by a variety of patient factors, including: Culture Socioeconomic Psychosocial and mental health Knowledge General health and lifestyle

What are the Guidelines? Attitude Nutrition consultants should be utilized when appropriate to help provide counseling for at-risk patients.

What are the Guidelines? Knowledge General principles of nutrition Nutritional assessment Nutritional issues of different stages of the life cycle The role of nutrition in the prevention and treatment of specific diseases Weight loss strategies and counseling

What are the Guidelines? Knowledge Disordered eating Use of dietary supplements Preventing and recognizing and treating foodborne illness Allergies and food intolerance Physical activity and sports Community Resources

What are the Guidelines? Skills Integrating nutrition assessment and intervention into the medical history, review of systems, physical examination, laboratory evaluation and plan of care. Assessing the nutritional status and writing diet prescriptions for inpatients laboratory and metabolic studies related to nutritional assessment.

What are the Guidelines? Skills Counseling patients and family members about specific nutritional needs related to stages of the life cycle, lifestyle and habits, disease prevention and/or disease. Counseling patients on safe lifestyle approaches to weight management and balancing caloric intake and physical activity. Advising on vitamin, mineral and other dietary and botanic supplements. Collaborating with registered dieticians and certified diabetes educators

Bottomline Basically good family medicine

Nutrition Challenges in Practice Can’t know or do it all, so need to know how to refer Not strong reimbursement from Insurance Understand that much of patient’s nutrition occurs outside your office

Challenges Particular to Family Medicine in teaching nutrition Get buy in from residents that this is important Many have no training in medical school Culture of the residency

Challenges Particular to Family Medicine Teaching Nutrition Faculty Training Need buy-in of higher-ups Need buy-in of patients Where do you teach it in the curriculum

What we did at Tufts… Started a Nutrition education taskforce Got buy in from faculty Got buy in from residency director Got buy in from residents

Nutrition Curriculum Taskforce Dr. Margo Woods (Tufts school for nutrition) Erika Damon (nutritionist on staff) 2 faculty 1 resident

Nutrition curriculum goals Goal 1 – increase the precepting of nutritional interventions by our faculty Goal 2 – integrate more didactics and case based learning for the residents Goal 3 – Use standardized patients with the residents and faculty

What is the dash diet

DASH Diet

Creation of the curriculm Based on the Dash diet 3 messages Focus on 4 chronic conditions Develop scripts Develop patient information sheets Posters for patient education

What is problem Hypertension Obesity Diabetes High Cholesterol

Phase 1 Faculty Development Faculty in-services Precepting skills How DASH applies to 4 conditions Piloting with own patients scripts Piloting with their own patients the patient information sheets

Faculty Development I think we did 4 inservces Donuts to yogurt

Phase 2 Case Based Lectures Jade please list the lectures that occurred in the curriculum ???8 one-hour lectures to residents over 4 months Topics Personal nutrition assessment, usual intake, behavioral skills DM, hypertension, obesity, CVD Included case discussion, diet analysis and recommendations based on the DASH diet

Case Based Lectures Cardiovascular disease Jade what did you do for your lectures- should we give specifics for each talk or just the general outline? Or more detail on one and then general?

Case Based Lectures Diabetes Mellitus Jade what did you do for your lectures- should we give specifics for each talk or just the general outline? Or more detail on one and then general?

Case Based Lectures Obesity Jade what did you do for your lectures- should we give specifics for each talk or just the general outline? Or more detail on one and then general?

Case Based Lectures Hypertension Case example Dietary history with usual intake Analysis Practical dietary revision ideas

Fit-day.com Residents asked to keep their own record for one week. Goals: Benefits seen:

Standardized Patients Faculty Students

Physcial Exam Form changes SOCIAL - Occupation/Lives with – Tobacco  Y  N ? Quit ETOH –  Y  N CAGE Pos  Neg  Drugs /Firearms DV screen (safe?) Nutrition: ? Weight concerns Servings Fruits/veg ___ Soda____ Fiber_____ Exercise / x week UV protection/ seatbelts

Nursing Inservices BMI

Preceptors Chart Review Changed routine chart review

How did we evaluate residents Knowledge Questionnaire Attitude Questionnaire Behavior Questionnaire

Attitude Survey McGaghie, W. et al 45 items survey with 5 subscales

Behavior Survey We developed our own Jade Cut and paste a few example of some sentences

Knowledge Survey Jade cut and past Jade Cut and paste a few example of some sentences

How did we evaluate faculty Knowledge Questionnaire Attitude Questionnaire Different questionnaires Behavior Questionnaire

Obstacles

Solutions

Results residents Knowledge Questionnaire Attitude Questionnaire Behavior Questionnaire

Results faculty Jade How many predicated Any trends in their personal questionnaires ETC

Jade can you put down unique faculty facts like how many precept, how many had knowledge of nutrition How did they get that knowledge etv

Our future directions Integrating Nutrition as a Basic Skill Chart review Faculty development

Transition to small groups

Create Your Own Curriculum

Challenges in your setting?

Think Outside the Box What are your needs? Who has skills your residents need or need to know about? Who would be a good “dance partner”?

IDEAS

Resources There are lots of them out there

STFM Group on nutrition Guidelines and curriculum Web base training Model Curriculum Supporting literature

STFM Nutrition Education Integrating nutrition education within other STFM groups and maintaining resources for family medicine educators to use in enhancing nutrition education. STFM Physician's Curriculum on Clinical Nutrition The group maintains a password protected web site with new strategies for teaching nutrition in clerkships and residencies. Contact for a free ID and Listserve: contact or

ng/naa/ Nutrition Curriculum Guide For Training Physicians

Nutrition Resources Physician's curriculum in clinical nutrition- A competency based approach for primary care, Kansas City, MO: Group on Nutrition Education, Society of Teachers of Family Medicine, Manual of Clinical Dietetics, 5th edition. Chicago, IL: The American Dietetic Association, Mahan LK and Escott-Stump S. Krause's Food, nutrition and diet therapy, 10th ed. Harcourt, Brace and Co Modern Nutrition in Health and Disease, 9th Edition, Williams and Wickins, Medical Nutrition and Disease, Blackwell Science Inc., 1996