Lin, Henry C.*; Kahana, Doron†; Vos, Miriam B.‡; Black, Dennis§; Port, Zack||; Shulman, Robert¶; Scheimann, Ann#; Mascarenhas, Maria R.*
See “Considerations for Physician Training in a New Era of Medical Education” by Robson on page 111.
Malnutrition is center stage in today's health epidemics, as both undernutrition and overnutrition can lead to healthcare problems. Childhood malnutrition adversely influences the overall lifelong health of individuals by affecting growth and development. Globally, malnutrition contributes to over half of all deaths in children younger than 5 years (1) and is associated with shorter adult height, decreased offspring birth weight, and a reduced capacity to learn resulting in lower educational outcomes and reduced adult income (2–4). Overnutrition in the form of obesity and related disease is increasing in prevalence and is directly correlated with heart disease, diabetes, stroke, liver disease, and cancer, among others (5). Proper nutrition is integral for disease prevention as well as treatment, but there exists a shortage of physicians practicing nutrition medicine (6).
This need for physicians to address nutrition, and specifically obesity, with patients has been highlighted as an objective of Healthy People 2000 and 2010 (7,8) and more recently by the Let's Move campaign to fight childhood obesity; however, there exists a gap between the desire for nutrition counseling and actual physician practice, as only approximately one-third of physicians routinely discussed nutrition during the clinical visit (9). This disparity between patient desire and actual physician practice is confounding because even physicians agree that nutrition assessment should be a part of primary care visits. Physicians identify nutrition counseling as a clinical obligation (10) and believe that patients would benefit from nutrition counseling, citing the role of nutrition in health maintenance as a key reason (11). In spite of these good intentions, physicians do not perceive themselves as adequately trained to provide nutrition counseling (10) and some perceive a lack of effect of counseling on patient behaviors (12,13), thus creating a clinical void that needs to be filled. For example, management of obesity and its related complications has become a necessity in pediatrics, but most health care providers also do not perceive themselves as adequately equipped to deal with the pediatric obesity epidemic (14). Perhaps most telling is that despite the existence of numerous community-targeted obesity education programs (15), some physicians still perceive themselves as undertrained to treat obesity (16).
There is a clear need for improving physician comfort with obesity management and nutrition counseling. Historically, there has been a lack of emphasis on nutrition education during both medical school and residency, and the overall quality of nutrition training during medical school has been perceived as inadequate by physicians (17). Multiple studies since the 1950s have reinforced this physician perception on nutrition education (18). Surveys have shown that interest in and the perceived relevance of nutrition decline throughout medical school (19), and this waning interest extends into clinical practice (20). To combat this lack of interest as well as inadequate knowledge base among medical students (21), there was a push for more structured nutrition education (22); however, a study of the effects of structured nutrition education for second-year medical students showed no improved nutrition knowledge or clinical application on assessment (23). It is likely that despite structured nutrition education, the nature, content, and duration of nutrition education in medical school varies greatly. In 1997, only 25.8% of the accredited medical schools reported a required nutrition course (24), and increased to 30% in a 2004 survey. The length of the nutrition course also varied from 2 to 70 hours (25).
More recently, there has been a renewed emphasis on nutrition education, with the goal of creating a more comprehensive curriculum and fully integrating nutrition education into medical training (17,26,27). Strategies to improve exposure to nutritional education including computer-based nutrition curriculums and nutrition seminars (28,29). A study from England documented that directed training for medical students in the form of an intensive weekend workshop led to improved and sustained nutrition knowledge on assessment (30). The acceptability and apparent effectiveness of these education strategies for medical students is encouraging.
The challenges of nutrition education extend to residency training. Most of the existing nutrition training during pediatric residency is knowledge based, with limited training in counseling skills. A lack of educational resources, space in the curriculum, and trained faculty has previously been identified as a perceived barrier to the development of additional education resources (13). With the increasing prevalence of childhood obesity, the development and use of effective training strategies should be a priority. Residents seem receptive to alternative education opportunities, as a recent study demonstrated the effectiveness of training residents in a specific behavioral intervention for obesity in coordination with a community health initiative (31). These successful initiatives suggest recognition of the importance of and a renewed emphasis on nutrition education.
Although both interest and training can be detriments to effective nutrition training, it would seem that for physicians who choose to specialize in pediatric gastroenterology, interest should not be a limiting factor. Pediatric gastroenterology, hepatology, and nutrition is the only medical subspecialty in the United States that includes nutrition as part of its official curriculum and objective, but remarkably, even pediatric gastroenterology fellows believe that their baseline knowledge and training in nutrition is suboptimal (32). Contributing factors to inadequate nutrition training include inadequate exposure to nutrition fundamentals during medical school and residency, as well as an outdated perception of an insufficient market. Nevertheless, with an increasing demand for nutrition counseling combined with a shortage of physicians who are comfortable practicing nutrition medicine, there is a need for optimizing nutrition education. Consequently, there has been an emphasis to improve the structure of nutrition training for pediatric gastroenterology fellows (32–35).
The purpose of our survey was to assess the perceived effectiveness of present nutrition training among pediatric gastroenterologists, identify areas of need for additional education resources, and determine the role of the gastroenterologist in obesity management.
This study had a cross-sectional design. The Nutrition Committee and Obesity Task Force of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) developed items for the survey that was sent to members and fellows of NASPGHAN via e-mail. The overall goal was to assess the need for material in nutritional topics that are of importance to NASPGHAN members. Specifically goals were to identify nutrition topics of high priority for further educational emphasis, to assess the need for obesity-related educational resources, and to determine the perceived role of pediatric gastroenterologists in obesity management.
The survey comprised 3 parts: demographic information, consisting of 1 question; assessment of general nutrition education, consisting of 4 questions; and obesity management and educational needs, consisting of 8 questions (supplemental Fig 1, http://links.lww.com/MPG/A134).
The general nutrition education questions assessed baseline knowledge in 14 nutrition topics and then identified topics with a need for additional continuing medical education (CME), the format of CME, and the need of additional resources. The 14 topics included the following:
1. Basic nutritional physiology: Starvation, stress, age-related changes, energy estimates
2. Nutritional assessment: Dietary history, clinical assessment, nitrogen balance, energy expenditure, body composition, markers of nutrition
3. Infant feeding: Physiology of lactation, composition of human milk and infant formulas, requirements of preterm infants
4. Special feeding programs: Cleft palate, swallowing dysfunction, food aversion, dysphagia
5. Failure to thrive/growth failure: Differential diagnosis, management, outcomes
6. Nutritional requirements in specific gastrointestinal (GI) diseases: Acute gastroenteritis, inflammatory bowel disease, pancreatitis, celiac disease, nonalcoholic steatohepatitis, eosinophilic disorders, liver failure, intestinal failure
7. Nutritional support in non-GI disease: Inborn errors of metabolism, cystic fibrosis, diabetes, renal failure, anorexia nervosa, food allergy, marasmus, kwashiorkor
8. Role of diet in development of chronic disease: Rickets, obesity, insulin resistance, cardiovascular disease
9. Nutritional aspects of special diets: Ketogenic, vegetarian, low-fat, gluten-free, lactose-free
10. Enteral nutrition support: Indications, infusion devices, feeding tubes, enteral nutrition formulas, formula modification, drug interactions
11. Parenteral nutrition support: Indications, composition, administration, metabolic effects, complications
12. Refeeding syndrome: Edema, hypokalemia, hypophosphatemia
13. Micronutrient requirements: Vitamin D, omega-3 fatty acids, iron, zinc
14. Sports nutrition
The obesity questions were designed to assess the perceived role of pediatric gastroenterologists in the management of obesity. Specific questions focused on the role of pediatric gastroenterologists in the assessment, management, and prevention of obesity as well as the role in weight management. In addition, interest in a postgraduate course on obesity with specific obesity-related topics was surveyed.
A Web-based survey tool, Survey Monkey, was used to provide participants with electronic access to the survey. Subjects were invited to participate in the study by means of the central NASPGHAN office, which sent out an e-mail announcement that included the URL link to the survey. A reminder e-mail to complete the survey was sent after 2 weeks. Responses were collected and study enrollment was closed after 1 month.
Results were collected and tallied in Survey Monkey. The data were exported into a spreadsheet and tabulated manually. Answers to questions were indicated by a response to a 5-point scale. Statistical significance level was set at P < 0.05.
A total of 272 responses were received during the course of 1 month, from April 27, 2010 through May 27, 2010. With a total of active NASPGHAN members at 1563 physicians and 221 fellows, the overall response rate was 15.2% (272/1784). The response rate for fellows was only 12.7% (28/221). Of the 272 respondents, the majority were academic physicians from university medical centers, representing 63.2% of the respondents. Physicians in private practice represented 18.4%, fellows represented 10.3%, and 8.1% of the respondents reported an affiliation with industry, a community clinic, a children's hospital, or a health maintenance organization (HMO), or reported being retired (Table 1).
Nutritional Knowledge Base
Respondents were asked to self-assess their nutritional knowledge base. Responses were stratified among 5 categories: excellent, above average, average, below average, and poor (Table 2). The vast majority of responders reported having average or above-average knowledge base in all nutritional topics. Responders reported to have the strongest knowledge base (either above average or excellent) in failure to thrive/growth failure (81.4%, 218/268), nutritional requirements in specific GI disease (74.6%, 200/268), and enteral nutrition support (71.4%, 192/269). Despite this high rate of excellent knowledge base among the responders, failure to thrive was the only topic in which >50% of fellows reported an excellent or above-average knowledge base.
Assuming that an excellent or above-average response reflects a comfortable knowledge base, the responses for these 2 categories were combined to assess for differences in the knowledge base between pediatric gastroenterologists in private practice versus academics. Using this combined value, 3 topics had >10% difference between physicians in private practice versus academics. More pediatric gastroenterologists in academics reported an excellent or above-average knowledge base for the topic of nutritional assessment (66%–54%), whereas a higher percentage of physicians in private practice reported a comfortable knowledge base with special feeding programs (67%–53%) and nutritional aspect of special diets (52%–41%).
Few responders reported poor knowledge for any of the topics, but some did report having a below-average knowledge base for some topics. Specifically, responders reported to be least knowledgeable (either poor or below average) in sports nutrition (41.4%, 109/263), nutritional support in non-GI disease (19.6%, 53/270), and nutritional aspects of special diets (14.4%, 39/271). Among fellows, >40% of fellows reported poor or below-average knowledge base in the topics of sports nutrition and nutritional support in non-GI diseases.
Desirable CME Topics in Nutrition
Respondents were asked to identify desirable nutritional topics for CME to see whether there was a correlation between knowledge base and the desire for CME. Responses were divided into 5 categories: extremely important, very important, important, less important, and not important at all (Fig. 1, supplemental Table 1 [http://links.lww.com/MPG/A135]). The vast majority of respondents expressed a strong interest in a CME module on nutritional requirements in a specific GI disease, with 82.3% (220/267) indicating the topic to be either extremely or very important. Educational material was also greatly desirable in failure to thrive/growth failure (71%, 188/265), parenteral nutrition support (70.4%, 188/267), and micronutrient requirements (67.1%, 177/264). The topic of sports nutrition was notable for having the most responses for being either less important (19.3%, 50/259) or not important at all (2.7%, 7/259). Fellow responses generally mirrored the overall responses, with the same 4 topics being the most desirable CME topics.
Desirable CME Format
For each topic, the preferred format of CME was surveyed (supplemental Table 2, http://links.lww.com/MPG/A136). The available formats included Web-based, review course, postgraduate breakout session, meet-the-professor luncheon, clinical cases, journal article, or review book. In general, a review course (34.9%) and Web-based modules (34%) were the most desirable formats for CME for all topics. A meet-the-professor luncheon (6.9%) was the least desirable CME format, and the preference for other CME formats included journal articles (19.1%), review book (185), postgraduate breakout session (16.7%), and clinical cases (15.3%).
Among the topics, there were different preferences as to the modality of CME. Nutritional assessment of a specific GI disease was a greatly favored topic for a review course. Special feeding programs was noted to be a good topic for a postgraduate breakout session; journal articles were favored for topics such as refeeding syndrome and nutritional aspects of special diets. Although few responders favored a meet-the-professor luncheon (2.4%–10.9%), the topics that received some interest for a meet-the-professor luncheon were role of diet in development of chronic disease and sports nutrition.
Desirable Additional Resources
To determine whether the present CME resources for the nutritional topics were sufficient, the need for additional CME resources was surveyed based on a 5-point scale: high priority, moderate priority, neutral, low priority, and not at all. The highest priority for additional CME resources was noted for nutritional requirements in specific GI diseases; 34% (82/241) of responders indicated a high priority for this topic. Other topics of high priority include parenteral nutrition (20.2%, 49/243), failure to thrive (19.9%, 48/241), nutritional support in a non-GI disease (18.9%, 46/243), and role of diet in development of chronic disease (18.6%, 45/242). Topics that received the most responses for having either a low priority or no need for additional resources included sports nutrition, infant feeding, failure to thrive, and basic nutritional physiology (Fig. 1, supplemental Table 3 [http://links.lww.com/MPG/A137]).
CME in Obesity
Approximately 67% of responders indicated that they would be either very or somewhat interested in pediatric obesity as a main topic for postgraduate 1 day educational course (postgraduate course), with only 17% not interested (Table 3). The most popular obesity topic for the postgraduate course was for pharmaceutical approaches to weight management, as either a didactic or a discussion forum. Other topics of interest for the postgraduate course included nutritional deficiencies, bariatric surgery, and pharmaceutical approaches to treat hyperlipidemia. Fellows favored the topic of nutritional deficiencies in obesity for both didactic and discussion over all others, whereas private practice physicians favored the topic of pharmacological approach to weight management (Table 4).
Role of Pediatric Gastroenterologist in Obesity Management
As respondents identified a need for additional CME in obesity, respondents were surveyed for their perception of the role of the pediatric gastroenterologists in obesity management. There was not a strong consensus on the primary physician for obesity management with the following type of physicians identified: pediatric gastroenterologist (39%), pediatric endocrinologists (36.4%), obesity program (34.6%), pediatric obesity specialist (30.1%), and primary care physician (21%). Most respondents felt that the management of obesity in children should require collaboration among multiple pediatric subspecialists, but most physicians surveyed did not have an obesity center devoted to this care.
The main identified role of the pediatric gastroenterologist was to treat the GI and hepatic comorbidities of obesity (93.4%). Other identified roles for the pediatric gastroenterologist in obesity management included managing obesity comorbidities (36%), performing nutritional assessment (29.4%), and managing weight (19.1%). Most pediatric gastroenterologists selected that pediatric gastroenterologists play a supporting role in preventing, assessing, and managing pediatric obesity, not a main role or leadership role (Fig. 2).
Nutrition is an integral part of medical care. With the challenges of obesity and other causes of malnutrition, physicians recognize the importance of effective nutrition counseling. A nationwide survey of family physicians reported that a majority of physicians believe that nutrition plays either a most important (21%) or a major (73%) role in treating and managing illness and disease. Moreover, a striking majority (96%) of the physicians surveyed reported that nutrition was either the most important or of major importance in preventing illness and disease (9). This perception of the importance of patient nutrition education is reflected by government initiatives such as Healthy People 2010, with a specific objective to increase the proportion of patient nutrition counseling during primary care visits to 75%; however, there continues to be a disparity between the proportion of patients identified who would benefit from nutrition counseling and those who actually receive it. Potential barriers to providing nutrition counseling include a lack of adequate training, time, resources, and compensation (7).
Adequate training remains a key obstacle toward the practice of nutrition medicine. Despite the perceived importance of nutritional training, in general, nutrition training has been lacking at all levels of education from medical school to residency to fellowship training (10,17,32,36). Surveys of medical students indicate that students are not confident in their ability to address specific nutritional requirements across the life cycle or the role of nutrition in the treatment of disease, and that more time needs to be dedicated to nutrition education (36). It is concerning that the physicians of tomorrow do not have confidence in their nutrition education, as clinicians should possess baseline nutrition knowledge to be effective patient advocates.
Pediatric gastroenterologists, who receive specialized nutrition education, also share this lack of knowledge, as our survey confirms the perceived need for additional exposure to topics in nutrition among pediatric gastroenterologists. Of the 14 topics in nutrition, failure to thrive was the only topic in which >75% of pediatric gastroenterologists noted excellent or above-average knowledge base. Practice setting does not seem to affect perceived knowledge base, as subgroup analysis reveals similar responses between physicians working in a private practice versus academic setting with the exception of 3 topics: special diets, special feeding programs, and nutrition assessment. Fewer physicians in academics reported a comfortable knowledge base in special diets and special feeding programs, perhaps reflecting the nature of being in an academic setting, wherein specialized nutrition support may more readily available. Furthermore, >50% of all respondents report average or below-average knowledge base in 5 of 14 nutrition topics including micronutrient requirements, role of diet in chronic disease, and special diets. These findings are concerning as being in a subspecialty that practices nutrition, pediatric gastroenterologists should possess an above-average knowledge base in nutrition.
This perception of inadequate nutrition training begins at the fellowship level, but seems to persist into practice, as the majority of respondents also wish for additional CME in nutrition. Although there are no specific studies among pediatric gastroenterology fellows, studies have measured the exposure to and baseline knowledge of nutrition of gastroenterology fellows in Canada. One study identified knowledge gaps among gastroenterology fellows as the majority of the fellows had no exposure to obesity, outpatient, or inpatient nutrition (33). Similarly, a survey of 32 gastroenterology fellows in Canada indicated that fellows perceived their knowledge of nutrition as suboptimal, specifically in obesity, micronutrients, and macronutrients. An objective test to evaluate nutrition knowledge confirmed this perception (32). These findings mirror our study observations among pediatric gastroenterology fellows, as there was no nutritional topic in which >15% of fellows reported an excellent knowledge base. Conversely, there were 4 topics in which more than one-third of fellows reported a below-average or poor knowledge base—sports nutrition, micronutrient requirements, nutritional aspects of special diets, and nutritional support in non-GI diseases. This average knowledge base illustrates the need for additional training and CME in nutrition.
Although respondents also reported a high level of desire for additional CME, there exists a dichotomy between the responses for the perceived knowledge base and need for additional CME. Specifically, the nutrition topics identified as least comfortable knowledge base did not correlate with topics identified as a need for additional CME. Although responders reported the lowest knowledge base in the topics of nutritional aspects of special diets, nutritional support in non-GI disease, and sports nutrition, these same 3 topics were among the 5 least important topics identified for additional CME. Furthermore, sports nutrition and nutritional aspect of special diets were also listed among the 5 least important topics for having additional resources. It is possible that the topics identified as important for additional CME are topics that pediatric gastroenterologists encounter more frequently in clinical practice. In this setting, the desire for additional CME may reflect the goal to stay abreast of issues important for clinical management. Another possibility is that the desire for additional CME is simply a reflection of the perpetual learning nature of medicine and respondent perceptions of inadequate knowledge may not directly correlate with functional knowledge base and knowing where to obtain the required information for patient directed care.
One topic that was identified both as desirable for additional CME and in need for additional resources was the topic of nutritional requirements in a specific GI disease, which includes obesity. With two-thirds of respondents expressing interest in a postgraduate course on obesity, the respondents seem to recognize that management of obesity is becoming part of their clinical practice. There certainly exists a need for more comprehensive teaching on healthy diet and activity for all of the children, improved recognition of overweight and obesity, and ongoing communication skills development (37). Childhood obesity is one of the most common conditions affecting children today and obesity-related comorbid conditions place additional burden on the health care system and suggest a need for improved nutritional care, raising the combined medical costs associated with treatment of these preventable diseases by an estimated $48 to $66 billion per year (5,19,38). As more patients turn to their physicians for nutrition counseling, there is a need to ensure that physicians are appropriately trained in the management of obesity and its comorbidities.
In our data, we found a dichotomy regarding the perception obesity management by pediatric gastroenterologists. Although most respondents did not believe that pediatric gastroenterologists should play a main or leadership role in obesity management, most respondents also desired more education and resources on pediatric obesity, suggesting that pediatric gastroenterologists need additional training in obesity management and nutrition. It has been suggested that 3 factors are needed to promote physician management of obesity: recognition of obesity as a medical problem; willingness to provide interventions; and adequate training and resources (39). Based on the survey responses as well as prior studies, it seems that health care workers identify obesity as a problem, recognize the need for additional education resources, and desire effective management solutions (16,40–42). Physician training tools have been shown to be effective (43,44) as physicians trained in an evidence-based obesity prevention/treatment tool displayed a willingness to implement these tools, which resulted in an increased counseling frequency (44). These successes suggest that physicians are overcoming the perceived lack of effect of nutrition counseling.
To address the growing need for physicians comfortable practicing nutrition medicine, physicians must first overcome self-imposed barriers to improving educational opportunities (6,7). Perceived barriers to curriculum development include a lack of space in the curriculum, few trained faculty, and insufficient educational materials (13). To develop more effective CME, alternative teaching strategies should also be considered (20,29), as an ongoing challenge is identifying a suitable format for teaching these topics. Prior studies have suggested that didactic lectures, the format of most CME programs, are not as conducive for adult learning compared with interactive, hands-on learning or self-directed learning (45,46). These beliefs were somewhat reflected by the survey as the preferred educational format depended on the topic, but in general, a review course and Web-based modules were the most preferred modalities.
Limitations of the studies include the overall response rate. Although having a response rate of 15.2% may not reflect a representative sample of the entire NASPGHAN membership, the demographics of the respondents (63.2% in academia and 18.4% in private practice) were similar to what was reported in a 2003–2004 workforce survey (56% in academia and 23% in private practice) (47). Fellow responses represented 10.3% of the sample, which is similar to the NASPGHAN fellow representation of 14%. This similarity suggests that the survey respondents should reflect an accurate sampling of the pediatric gastroenterology population. By limiting the survey distribution to NASPGHAN members, it is possible that there is selection bias, but >95% of pediatric gastroenterologists are members within NASPGHAN, again suggesting a reflective sampling. The possibility of population bias must also be considered as it is possible that physicians with a keen interest in nutrition may be more likely to respond.
There still exist deficiencies in nutritional knowledge and training for pediatric clinicians. Among pediatric gastroenterologists, there is a perceived need for additional exposure to nutrition topics. The format of this desired training depends on the topic, with a review course and Web-based modules being the most desirable formats for CME. With the nutrition challenges of today and a need for improved baseline knowledge in nutrition among fellows, the focus of nutrition should be at the fellowship level.
The authors appreciate the input of the 2010 NASPGHAN Nutrition Committee members in the development, distribution, and analysis of the survey.
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