Committee
Report
John
R Boker,
Roland
ABSTRACT American Society cal/Dental cal residency
programs
and
Residency nutrition
programs.
by content
Directors
and
in the
ceived
nutrition
importance
level.
involve
more
An
for
educators
ofthe
components
WORDS
dency
training,
to asin mcdi-
for residency
that
were
in residency
from
were
surveyed
en-
training.
important
national
knowledge or behavior that are important for the trainee to acquire in both preclinicaland clinical-training programs. Although a consensus about the core content in clinical nutrition is emerging, there is a dearth ofinformation about the context in which clinical nutrition is typically taught. Consequently, there is a lack ofconsensus among medical educators as how to provide the most effective training in clinical nutri-
residen-
tion.
the
The clinical
the
extent
per-
to which
identified
need
faculty
members
1990;52:568-7
is to train
and
1. nutrition
lack of information and consensus about training in nutrition is more problematic for residency training programs because of several mitigating factors. First, lack of control over the training curriculum is more pronounced in residency
programs
resi-
tion into the care oftheir ing in clinical nutrition
mands
survey
ofeach
activities
Introduction Clinical
nutrition
interfaces
every field ofclinical directly influences Nutrition
intervention
many common vascular disease, ineffectively
of Western mellitus, the
and
The nutrition of clinical
is a component
diseases diabetes
approach
significantly
medicine. the outcome
is to risk an increase
health-care Despite
costs ofhospitalized the acknowledged
with
status of patients interventions (1).
of first-step
therapy
for
society including cardioand obesity. To exclude or
nutrition
sentations
relevantly
correlates
in morbidity,
patients importance
of disease
pre-
mortality,
and
(2, 3). of clinical
nutrition,
there is evidence to indicate that the clinical-nutrition training of medical students is inadequate in both quality and quantity (4). Most curricula do not provide a clearly identifiable period oftraining their
in clinical
postgraduate
nutrition medical
(4, 5). Likewise, training
as residents
physicians rarely
have
I
or
mingham.
1990:52:568-7
specialty
(1 3). Thus,
in residency
schools
programs
(6,
7). Also,
of residents may how to incorporate
individual patients must be tailored
help renutri-
(8). Finally, trainto the practice de-
effective
must
From the Office ofEducational
ofNutrition
,
Am J C/in Nuir
it is in medical
nutrition-training
certainly
exist
but
these
have yet to be effectively identified and studied. A recent unpublished survey of medical-nutrition educators conducted by The American Society for Clinical Nutrition (ASCN) revealed that high priority should be given to learning more about nutrition training in residency training programs. Based on general accreditation guidelines and criteria for residency programs ( 14), a set of recommended nutrition-training components was developed by the authors and endorsed by the ASCN Committee on Medical/Dental School and Residency Nutrition Education and by other experts in the field. The present nationwide survey ofresidency directors and nutrition educators was conducted by this committee to assess the extent to which these recommended components were present and
in
take advantage ofthe opportunity to learn about clinical nutrition (6-8). Finally, some researchers found a significant negative correlation between knowledge of clinical-nutrition concepts and principles and years since graduation from medical school (9, 10). The solution to the above dilemma is to increase awareness through the training of medical students and residents regarding the importance and practical significance of the concepts and principles ofclinical nutrition. To that end, recent investigations ( 1 1 12) attempted to identify basic competencies in 568
than
the rigorous clinical responsibilities duce the amount oftime for learning
in residency
training,
Olson
either
to determine and
Clinical-nutrition
Kenneth
all accredited
actually present. The eight components for exemplary nutrition training at the
Am J Clin Nutr
KEY
Education
inclusion
andA
by The on Mcdi-
is provided
components
clinical-nutrition
programs.
Brooks,
guidelines
nutrition
States
the components were appear to be relevant residency
Nutrition training
Accreditation
eight experts
United
C Michael
survey was conducted Nutrition’s Committee
in which
suggested
dorsed cies
A national for Clinical
School
sess the context
L Weinsier,
2
This
Sciences, study
was
University done
Development ofAlabama
on behalfofthe
and the Department School
Committee
ofMedicine, on
Bir-
Medical/Den-
tal School and Residency Nutrition Education ofthe American Society for Clinical Nutrition. 3 Supported by the American Society for Clinical Nutrition, the NATIONAL DAIRY COUNCIL, and National Dairy Promotion and Research Board. 4 Address reprint requests to RL Weinsier, Department of Nutrition Sciences, University of Alabama at Birmingham, Birmingham, AL 35294. Received May 1 1, 1990.
Accepted 1. Printed
for publication in USA.
May 16, 1990.
© 1990 American
Society
for Clinical
Nutrition
Downloaded from https://academic.oup.com/ajcn/article-abstract/52/3/568/4650936 by McMaster University Library user on 05 February 2019
Components of effective clinical-nutrition training: a national survey of graduate medical education (residency) programs1
NUTRITION TABLE 1 Percentages
of residency-program
and as important
directors
for exemplary
and nutrition
RESIDENCY
educators
indicating
569
TRAINING
various
nutrition-training
components
as present
Nutrition-training
Present
component
clinic
with
of4 wk)
physician-provided
services
Outpatient nutrition clinic with registered dietitian-provided services Regular nutrition conferences/didactics 4
“Important”
thought
was
defined
as either
to be important
present ASCN
survey directed
nutrition
quite
important
in residency
is part of a larger at the expansion
or extremely
training
programs.
important
The
set of related activities of the and improvement of clinical-
Important
23 17 43 68 29
41 63 55 83 47
47 44 49 73 51
74 90 65 90 80
17
37
46
69
70 37
80 60
81 55
84 83
on the
rating
Methods
ties ofinterest were provided by the American Medical ation. The data-collection period lasted 12 wk; there
Associwas no
attempt
respon-
quencies
A written survey was developed and importance of recommended components. No specific unique to clinical nutrition
to contact
to assess both clinical-nutrition
guidelines in residency
or
criteria training.
the presence training exist that are The Directory
importance
dency programs in Internal Gynecology, Pediatrics, and
Results
effective
guidelines resulted be used if programs
for
components,
Medicine, Family
accreditation.
each
From
of which
clinical-nutrition
School
and
Obstetrics and Review and ad-
in the development in clinical nutrition
of criwere
these
major
criteria
was thought
training,
mended (Table 1) for inclusion concept and proposed methods for endorsement and approved Medical/Dental
Surgery, Medicine.
were
to be indicative identified
in residency for the study by the ASCN’s
Residency
eight and
of
recom-
programs. The were presented Committee on
Nutrition
Education.
A field-test version ofthe self-administered survey was developed and sent to 20 nutrition educators involved in residency education.
Respondents
were
also
asked
to
have
the
survey
evaluated by residency-program directors with whom they worked. The survey was revised slightly on the basis ofthe recommendations made during the field test; no new components thought to be indicative ofeffective nutrition training were suggested. The final survey consisted oftwo parts. In the first part the respondents simply indicated whether or not each of the eight
nutrition
components
was
present
in their
residency
pro-
grams. In the second part, ratings were made as to how important each nutrition component was to an exemplary residency training
program.
from “not important” The survey was nutrition educators Respondents were the United States.
Ratings
were
made
on
a four-point
scale
to “extremely important.” mailed to 1797 residency directors and 610 who were involved in residency education. from all accredited residency programs in Listings of programs in the various special-
Because
all survey
it was impossible to compare responfor any type ofresponse bias. were coded for computer analysis. Freto each
survey
item
were
were made ofthe percentages that each nutrition component programs and 2) selected each
rating
the responses vs educators,
evaluated
nonrespondents.
of responses
and computations who 1) indicated their residency
ofGraduate MedicalEducation Programs, 1 988-89 (14), however, contains published guidelines for the accreditation of resi-
aptation ofthese teria that could
scale.
dents were anonymous, dents and nonrespondents The survey responses
training.
Important
Present
scale.
Chi-square
of different and directors
tests
groups within
were
determined,
of respondents was present in category on the done
of respondents each specialty
to compare
(ie, directors group).
Usable survey data were received from 787 residency-program directors(44%)and 238 nutrition educators(39%). When residency directors were classified by specialty, the response rates were 52% (200 of 38 1) for family medicine, 45% for both internal
medicine
(including
general
and
preventive
medicine)
and pediatrics (209 of 464 and 101 of 224, respectively), 44% for surgery(l 24 of283), 38% for obstetrics and gynecology( 107 of 280), and 28% (46 of 165) for combined, transitional-year programs, which provide training in all of the above specialty areas except family medicine. Within the nutrition-educator group, 80% were currently active in residency training at their respective institutions. The percentages of residency-program directors and nutrition educators who indicated that each recommended nutrition-training
component
was
present
in
their
programs
are
shown in Table 1. For the nutrition educators, the results mdicate that 44% to 8 1% of their residency programs had at least one ofthe eight recommended nutrition-training components. Furthermore, each of the components was identified as being present in about one-halfor more ofall programs, according to the nutrition educators. Among residency-program directors, however, a different pattern emerged. Only two components, multidisciplinary
nutrition
support
service,
and
outpatient
nu-
trition clinic with registered dietitian-provided services, were reported by directors to be present in > 50% oftheir programs. Also shown in Table 1 are the percentages of respondents
Downloaded from https://academic.oup.com/ajcn/article-abstract/52/3/568/4650936 by McMaster University Library user on 05 February 2019
Distinct administrative nutrition unit Qualified and active nutrition-faculty member Nutrition lab services Multidisciplinary nutrition support service Clinical nutrition rotation/elective (minimum nutrition
programs
Nutritio n educators
Progra m directors
Outpatient
in their
programs4
570
BOKER
who rated
each
a rating
value
portant)
for
nutrition-training ofeither
inclusion
discrepancies
component
3, quite in an
as important
important, exemplary
between
the extent
actually directors
present and and nutrition
their rated educators.
centage
of respondents
who
program.
im-
There
to which
all components
importance For each
by both component
rated
(ie,
or 4, extremely
it as important
were were
residency the per-
exceeded
the
and active
nutrition
percentage
points
ings
faculty between
ofimportance.
centage
points
patient
nutrition
regular
nutrition
there
both
clinic
ofbeing
were
groups
with
educators
for two
one-outpatient vided services.
did
to rate
the
did agree
about
the
registered
and
that among tance were
the components with distinct administrative
nutrition
component’s
directors.
relative
im-
The
differ-
support
clinic
with
services,
service.
Both
the residency
directors’ components
nu-
of the
1) qualified nutrition and 3) multi-
groups
also
agreed
the lowest relative impornutrition unit and outpa-
physician-provided
area,
six ofthe
importance
components: 2) outpatient
dietitian-provided
nutrition
When
services
clinic with registered dietitian-proresidency-program directors and
disciplinary
specialty
components-out-
every
residency
three highest rated nutrition-training and active nutrition faculty member,
tient
rat-
20 per-
by chi-square analysis, were statistically sigp value < 0.01) for all components except
nutrition However,
educators
with
and
of
physician-provided
tended
than
ences, investigated nificant (minimum
clinic
present
discrepancies
services.
responses had
were
analyzed
significant
by
differences
p-value < 0.01) for the percentage who indicated that each component was present in their programs. There were no differences among specialties for two components, nu(minimum
trition lab services and tered dietitian-provided ily medicine, obstetrics
outpatient nutrition clinic with regisservices. Residency programs in famand gynecology, and the transitional
year were less likely than were other specialties to have the majority ofthe six remaining training components. ings of importance there were significant differences
present On ratamong
specialties
p value
on all eight
< 0.01).
atrics
The
general
trend
gave the highest
ily medicine gave tion components.
training
components
was
that
residency
importance
the lowest
(minimum
ratings,
ratings
directors
in pedi-
and directors
to the majority
in fam-
ofthe
programs rated each of the training components as relatively more important than did residency-program directors. Also, nutrition educators were more likely to be involved in a training-program environment that included each of the training components. This is not surprising in that the very presence of such
an
individual
program ertheless,
nutri-
training
future
incorporated
in
residency
programs.
The
eight
survey were established on the basis of the for the accreditation of residency programs published in the Directory ofGraduateMedicalEducation Programs, 1988-89 (14). Although the relative importance of each component varied among residency-program directors and nurelevant training
educators,
the data
considerations programs
In general,
suggest
in graduate
nutrition
that
for establishing educators
medical
who
all eight
components
exemplary
nutrition-
education.
participate
residency
regarding
their
perceptions
Nevand of the
clinicians
qualified
ratings
of importance
to
to teach
clinical
nutrition.
specialties, it should be noted that gave the highest across-the-board the
eight
clinical-nutrition
training
ership
in clinical-nutrition
education
(15).
However,
the
pres-
ent data suggest that family-medicine training programs were not likely to incorporate these eight components. This suggests, as may be anticipated, that the perceived needs offamily mcdicine for clinical-nutrition education may differ from those of other clinical specialties. In summary, this survey identified eight components for consideration in organizing residency programs to include adequate clinical-nutrition training. Three components received the highest priority by both residency-program directors and nutrition educators. Having a qualified and active nutritionfaculty member was found to be most lacking, in terms of the observed
discrepancy
between
reported
presence
in programs
and perceived importance. This finding highlights the need for stronger medical-nutrition education programs and to attract more nutrition-faculty members to participate in postgraduate medical education. Additional follow-up studies are planned ASCN
The authors ofthe
to identify
nutrition
committee
that
specific are
residency-training
exemplary,
and
programs to gain
the specific features exemplary programs.
ofthe
gratefully
the cooperation
acknowledge
eight
training
better
in-
compoU
and assistance
members.
components
identified in this general guidelines
trition
of the
in the curriculum. nutrition educators
components. By contrast, family-medicine directors gave the components the lowest across-the-board ratings. In terms of what components are actually incorporated into residency training, both family medicine and obstetric and gynecobogic programs were least likely to provide the eight nutrition-training components. Family medicine is recognized for their lead-
sight regarding nents in these of literature exists on what comtraining should be considered or
directors
On examining each ofthe pediatric program directors
in clinical
Discussion
a commitment
training between
three most important nutrition-training components for an effective residency training program. These included 1) a qualifled nutrition faculty member, 2) a multidisciplinary nutrition support service, and 3) an outpatient clinic with services provided by a registered dietitian. Among these three components, the largest discrepancy between reported presence in a program and perceived importance was in having a qualified faculty member. This finding importantly underscores the need for
by the
To our knowledge a dearth ponents of clinical-nutrition
indicates
to include nutrition there was agreement
residency-program
of 46
conferences/didactics.
higher
trition
a discrepancy
indications
Also, within
Nutrition portance
member-had
AL
in residency
are
References 1. Harvey KB, Moldawer LL, Bistrian BR, Blackburn GL. Biological measures for the formulation ofa hospital prognostic index. Am I Clin Nutr 198 l;34:2013-22. 2. Weinsier RL, Hunker EM, Krumdieck CL, Butterworth CE Jr. Hospital malnutrition: a prospective evaluation ofgeneral medical patients during the course of hospitalization. Am J Clin Nutr 1979;32:4l8-26. 3. Weinsier RL, Heimburger DC, Samples CW, Dimick AR, Birch
Downloaded from https://academic.oup.com/ajcn/article-abstract/52/3/568/4650936 by McMaster University Library user on 05 February 2019
percentage who reported that it was present in their programs. Within both groups ofrespondents, one component-qualified
ET
NUTRITION R. Cost containment: 4.
5.
7. 8. 9.
ofaggressive
nutritional
sup-
port in burn patients. I Burn Care Rehab 1985:6:436-41. Weinsier RL, Boker JR. Feldman EB, Read MS. Brooks CM. Nutrition knowledge ofsenior medical students: a collaborative study ofsoutheastern medical schools. Am I Clin Nutr 1986:43:959-65. Committee on Nutrition in Medical Education, Food and Nutrition Board, National Research Council. Nutrition education in US medical schools. Washington. DC: National Academy Press, 1985. Moore SA, Larsen IC. Nutrition teaching for family practice residents.J Fam Pract 1983:16:1149-53. Geyman AP. Nutrition teaching in medical education: a case of chronic neglect. I Fam Pract 1984: 18:193-4. Dappen A, Gessert C. Walsh I. Nutrition education for family practice residents. I Med Educ 1986;61:837-9. Cooper-Stephenson C, Theologides A. Nutrition in cancer: physicians’ knowledge, opinions and educational needs. I Am Diet Assoc 1981;78:472-6.
571
TRAINING
10. Mlodinow 5G. dents’ knowledge
Barrett-Connor ofnutrition.
E. Physicians’ Academic Med
and medical 1989;64:105-6.
stu-
1 1 . Chamberlain VM, Mays MH, Cummings MN. Competencies in nutrition that US medical students should acquire. Academic Med I989:64:95-8. 12. Weinsier RL, Boker JR. Brooks CM et al. Priorities for nutrition content in a medical school curriculum. Am I Clin Nutr 1989: SO: 707- 12.
13. Swanson AG. 84(editorial).
Nutrition
education.
Academic
Med
1989:64:
14. American Medical Association. Directory ofgraduate medical education programs, 1988-89. Chicago: American Medical Association, 1988. 15. Nuhlicek DR. Simpson DE, Lillich DW, Borman Ri. Teaching and funding nutrition education in family practice education. Acedemic Med 1989;64:103-4.
Downloaded from https://academic.oup.com/ajcn/article-abstract/52/3/568/4650936 by McMaster University Library user on 05 February 2019
6.
a contribution
RESIDENCY
Report
John
R Boker,
Roland
ABSTRACT American Society cal/Dental cal residency
programs
and
Residency nutrition
programs.
by content
Directors
and
in the
ceived
nutrition
importance
level.
involve
more
An
for
educators
ofthe
components
WORDS
dency
training,
to asin mcdi-
for residency
that
were
in residency
from
were
surveyed
en-
training.
important
national
knowledge or behavior that are important for the trainee to acquire in both preclinicaland clinical-training programs. Although a consensus about the core content in clinical nutrition is emerging, there is a dearth ofinformation about the context in which clinical nutrition is typically taught. Consequently, there is a lack ofconsensus among medical educators as how to provide the most effective training in clinical nutri-
residen-
tion.
the
The clinical
the
extent
per-
to which
identified
need
faculty
members
1990;52:568-7
is to train
and
1. nutrition
lack of information and consensus about training in nutrition is more problematic for residency training programs because of several mitigating factors. First, lack of control over the training curriculum is more pronounced in residency
programs
resi-
tion into the care oftheir ing in clinical nutrition
mands
survey
ofeach
activities
Introduction Clinical
nutrition
interfaces
every field ofclinical directly influences Nutrition
intervention
many common vascular disease, ineffectively
of Western mellitus, the
and
The nutrition of clinical
is a component
diseases diabetes
approach
significantly
medicine. the outcome
is to risk an increase
health-care Despite
costs ofhospitalized the acknowledged
with
status of patients interventions (1).
of first-step
therapy
for
society including cardioand obesity. To exclude or
nutrition
sentations
relevantly
correlates
in morbidity,
patients importance
of disease
pre-
mortality,
and
(2, 3). of clinical
nutrition,
there is evidence to indicate that the clinical-nutrition training of medical students is inadequate in both quality and quantity (4). Most curricula do not provide a clearly identifiable period oftraining their
in clinical
postgraduate
nutrition medical
(4, 5). Likewise, training
as residents
physicians rarely
have
I
or
mingham.
1990:52:568-7
specialty
(1 3). Thus,
in residency
schools
programs
(6,
7). Also,
of residents may how to incorporate
individual patients must be tailored
help renutri-
(8). Finally, trainto the practice de-
effective
must
From the Office ofEducational
ofNutrition
,
Am J C/in Nuir
it is in medical
nutrition-training
certainly
exist
but
these
have yet to be effectively identified and studied. A recent unpublished survey of medical-nutrition educators conducted by The American Society for Clinical Nutrition (ASCN) revealed that high priority should be given to learning more about nutrition training in residency training programs. Based on general accreditation guidelines and criteria for residency programs ( 14), a set of recommended nutrition-training components was developed by the authors and endorsed by the ASCN Committee on Medical/Dental School and Residency Nutrition Education and by other experts in the field. The present nationwide survey ofresidency directors and nutrition educators was conducted by this committee to assess the extent to which these recommended components were present and
in
take advantage ofthe opportunity to learn about clinical nutrition (6-8). Finally, some researchers found a significant negative correlation between knowledge of clinical-nutrition concepts and principles and years since graduation from medical school (9, 10). The solution to the above dilemma is to increase awareness through the training of medical students and residents regarding the importance and practical significance of the concepts and principles ofclinical nutrition. To that end, recent investigations ( 1 1 12) attempted to identify basic competencies in 568
than
the rigorous clinical responsibilities duce the amount oftime for learning
in residency
training,
Olson
either
to determine and
Clinical-nutrition
Kenneth
all accredited
actually present. The eight components for exemplary nutrition training at the
Am J Clin Nutr
KEY
Education
inclusion
andA
by The on Mcdi-
is provided
components
clinical-nutrition
programs.
Brooks,
guidelines
nutrition
States
the components were appear to be relevant residency
Nutrition training
Accreditation
eight experts
United
C Michael
survey was conducted Nutrition’s Committee
in which
suggested
dorsed cies
A national for Clinical
School
sess the context
L Weinsier,
2
This
Sciences, study
was
University done
Development ofAlabama
on behalfofthe
and the Department School
Committee
ofMedicine, on
Bir-
Medical/Den-
tal School and Residency Nutrition Education ofthe American Society for Clinical Nutrition. 3 Supported by the American Society for Clinical Nutrition, the NATIONAL DAIRY COUNCIL, and National Dairy Promotion and Research Board. 4 Address reprint requests to RL Weinsier, Department of Nutrition Sciences, University of Alabama at Birmingham, Birmingham, AL 35294. Received May 1 1, 1990.
Accepted 1. Printed
for publication in USA.
May 16, 1990.
© 1990 American
Society
for Clinical
Nutrition
Downloaded from https://academic.oup.com/ajcn/article-abstract/52/3/568/4650936 by McMaster University Library user on 05 February 2019
Components of effective clinical-nutrition training: a national survey of graduate medical education (residency) programs1
NUTRITION TABLE 1 Percentages
of residency-program
and as important
directors
for exemplary
and nutrition
RESIDENCY
educators
indicating
569
TRAINING
various
nutrition-training
components
as present
Nutrition-training
Present
component
clinic
with
of4 wk)
physician-provided
services
Outpatient nutrition clinic with registered dietitian-provided services Regular nutrition conferences/didactics 4
“Important”
thought
was
defined
as either
to be important
present ASCN
survey directed
nutrition
quite
important
in residency
is part of a larger at the expansion
or extremely
training
programs.
important
The
set of related activities of the and improvement of clinical-
Important
23 17 43 68 29
41 63 55 83 47
47 44 49 73 51
74 90 65 90 80
17
37
46
69
70 37
80 60
81 55
84 83
on the
rating
Methods
ties ofinterest were provided by the American Medical ation. The data-collection period lasted 12 wk; there
Associwas no
attempt
respon-
quencies
A written survey was developed and importance of recommended components. No specific unique to clinical nutrition
to contact
to assess both clinical-nutrition
guidelines in residency
or
criteria training.
the presence training exist that are The Directory
importance
dency programs in Internal Gynecology, Pediatrics, and
Results
effective
guidelines resulted be used if programs
for
components,
Medicine, Family
accreditation.
each
From
of which
clinical-nutrition
School
and
Obstetrics and Review and ad-
in the development in clinical nutrition
of criwere
these
major
criteria
was thought
training,
mended (Table 1) for inclusion concept and proposed methods for endorsement and approved Medical/Dental
Surgery, Medicine.
were
to be indicative identified
in residency for the study by the ASCN’s
Residency
eight and
of
recom-
programs. The were presented Committee on
Nutrition
Education.
A field-test version ofthe self-administered survey was developed and sent to 20 nutrition educators involved in residency education.
Respondents
were
also
asked
to
have
the
survey
evaluated by residency-program directors with whom they worked. The survey was revised slightly on the basis ofthe recommendations made during the field test; no new components thought to be indicative ofeffective nutrition training were suggested. The final survey consisted oftwo parts. In the first part the respondents simply indicated whether or not each of the eight
nutrition
components
was
present
in their
residency
pro-
grams. In the second part, ratings were made as to how important each nutrition component was to an exemplary residency training
program.
from “not important” The survey was nutrition educators Respondents were the United States.
Ratings
were
made
on
a four-point
scale
to “extremely important.” mailed to 1797 residency directors and 610 who were involved in residency education. from all accredited residency programs in Listings of programs in the various special-
Because
all survey
it was impossible to compare responfor any type ofresponse bias. were coded for computer analysis. Freto each
survey
item
were
were made ofthe percentages that each nutrition component programs and 2) selected each
rating
the responses vs educators,
evaluated
nonrespondents.
of responses
and computations who 1) indicated their residency
ofGraduate MedicalEducation Programs, 1 988-89 (14), however, contains published guidelines for the accreditation of resi-
aptation ofthese teria that could
scale.
dents were anonymous, dents and nonrespondents The survey responses
training.
Important
Present
scale.
Chi-square
of different and directors
tests
groups within
were
determined,
of respondents was present in category on the done
of respondents each specialty
to compare
(ie, directors group).
Usable survey data were received from 787 residency-program directors(44%)and 238 nutrition educators(39%). When residency directors were classified by specialty, the response rates were 52% (200 of 38 1) for family medicine, 45% for both internal
medicine
(including
general
and
preventive
medicine)
and pediatrics (209 of 464 and 101 of 224, respectively), 44% for surgery(l 24 of283), 38% for obstetrics and gynecology( 107 of 280), and 28% (46 of 165) for combined, transitional-year programs, which provide training in all of the above specialty areas except family medicine. Within the nutrition-educator group, 80% were currently active in residency training at their respective institutions. The percentages of residency-program directors and nutrition educators who indicated that each recommended nutrition-training
component
was
present
in
their
programs
are
shown in Table 1. For the nutrition educators, the results mdicate that 44% to 8 1% of their residency programs had at least one ofthe eight recommended nutrition-training components. Furthermore, each of the components was identified as being present in about one-halfor more ofall programs, according to the nutrition educators. Among residency-program directors, however, a different pattern emerged. Only two components, multidisciplinary
nutrition
support
service,
and
outpatient
nu-
trition clinic with registered dietitian-provided services, were reported by directors to be present in > 50% oftheir programs. Also shown in Table 1 are the percentages of respondents
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Distinct administrative nutrition unit Qualified and active nutrition-faculty member Nutrition lab services Multidisciplinary nutrition support service Clinical nutrition rotation/elective (minimum nutrition
programs
Nutritio n educators
Progra m directors
Outpatient
in their
programs4
570
BOKER
who rated
each
a rating
value
portant)
for
nutrition-training ofeither
inclusion
discrepancies
component
3, quite in an
as important
important, exemplary
between
the extent
actually directors
present and and nutrition
their rated educators.
centage
of respondents
who
program.
im-
There
to which
all components
importance For each
by both component
rated
(ie,
or 4, extremely
it as important
were were
residency the per-
exceeded
the
and active
nutrition
percentage
points
ings
faculty between
ofimportance.
centage
points
patient
nutrition
regular
nutrition
there
both
clinic
ofbeing
were
groups
with
educators
for two
one-outpatient vided services.
did
to rate
the
did agree
about
the
registered
and
that among tance were
the components with distinct administrative
nutrition
component’s
directors.
relative
im-
The
differ-
support
clinic
with
services,
service.
Both
the residency
directors’ components
nu-
of the
1) qualified nutrition and 3) multi-
groups
also
agreed
the lowest relative impornutrition unit and outpa-
physician-provided
area,
six ofthe
importance
components: 2) outpatient
dietitian-provided
nutrition
When
services
clinic with registered dietitian-proresidency-program directors and
disciplinary
specialty
components-out-
every
residency
three highest rated nutrition-training and active nutrition faculty member,
tient
rat-
20 per-
by chi-square analysis, were statistically sigp value < 0.01) for all components except
nutrition However,
educators
with
and
of
physician-provided
tended
than
ences, investigated nificant (minimum
clinic
present
discrepancies
services.
responses had
were
analyzed
significant
by
differences
p-value < 0.01) for the percentage who indicated that each component was present in their programs. There were no differences among specialties for two components, nu(minimum
trition lab services and tered dietitian-provided ily medicine, obstetrics
outpatient nutrition clinic with regisservices. Residency programs in famand gynecology, and the transitional
year were less likely than were other specialties to have the majority ofthe six remaining training components. ings of importance there were significant differences
present On ratamong
specialties
p value
on all eight
< 0.01).
atrics
The
general
trend
gave the highest
ily medicine gave tion components.
training
components
was
that
residency
importance
the lowest
(minimum
ratings,
ratings
directors
in pedi-
and directors
to the majority
in fam-
ofthe
programs rated each of the training components as relatively more important than did residency-program directors. Also, nutrition educators were more likely to be involved in a training-program environment that included each of the training components. This is not surprising in that the very presence of such
an
individual
program ertheless,
nutri-
training
future
incorporated
in
residency
programs.
The
eight
survey were established on the basis of the for the accreditation of residency programs published in the Directory ofGraduateMedicalEducation Programs, 1988-89 (14). Although the relative importance of each component varied among residency-program directors and nurelevant training
educators,
the data
considerations programs
In general,
suggest
in graduate
nutrition
that
for establishing educators
medical
who
all eight
components
exemplary
nutrition-
education.
participate
residency
regarding
their
perceptions
Nevand of the
clinicians
qualified
ratings
of importance
to
to teach
clinical
nutrition.
specialties, it should be noted that gave the highest across-the-board the
eight
clinical-nutrition
training
ership
in clinical-nutrition
education
(15).
However,
the
pres-
ent data suggest that family-medicine training programs were not likely to incorporate these eight components. This suggests, as may be anticipated, that the perceived needs offamily mcdicine for clinical-nutrition education may differ from those of other clinical specialties. In summary, this survey identified eight components for consideration in organizing residency programs to include adequate clinical-nutrition training. Three components received the highest priority by both residency-program directors and nutrition educators. Having a qualified and active nutritionfaculty member was found to be most lacking, in terms of the observed
discrepancy
between
reported
presence
in programs
and perceived importance. This finding highlights the need for stronger medical-nutrition education programs and to attract more nutrition-faculty members to participate in postgraduate medical education. Additional follow-up studies are planned ASCN
The authors ofthe
to identify
nutrition
committee
that
specific are
residency-training
exemplary,
and
programs to gain
the specific features exemplary programs.
ofthe
gratefully
the cooperation
acknowledge
eight
training
better
in-
compoU
and assistance
members.
components
identified in this general guidelines
trition
of the
in the curriculum. nutrition educators
components. By contrast, family-medicine directors gave the components the lowest across-the-board ratings. In terms of what components are actually incorporated into residency training, both family medicine and obstetric and gynecobogic programs were least likely to provide the eight nutrition-training components. Family medicine is recognized for their lead-
sight regarding nents in these of literature exists on what comtraining should be considered or
directors
On examining each ofthe pediatric program directors
in clinical
Discussion
a commitment
training between
three most important nutrition-training components for an effective residency training program. These included 1) a qualifled nutrition faculty member, 2) a multidisciplinary nutrition support service, and 3) an outpatient clinic with services provided by a registered dietitian. Among these three components, the largest discrepancy between reported presence in a program and perceived importance was in having a qualified faculty member. This finding importantly underscores the need for
by the
To our knowledge a dearth ponents of clinical-nutrition
indicates
to include nutrition there was agreement
residency-program
of 46
conferences/didactics.
higher
trition
a discrepancy
indications
Also, within
Nutrition portance
member-had
AL
in residency
are
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6.
a contribution
RESIDENCY
