fp and ophthalmology caring to screen in diabetes - the focused quality improvement project

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

BottomlineBasically 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 ? QuitETOH – Y N CAGE Pos Neg Drugs /FirearmsDV screen (safe?)Nutrition: ? Weight concerns Servings Fruits/veg ___ Soda____ Fiber_____Exercise / x weekUV 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 kolasaka@mail.ecu.edu for a free ID and password.

Listserve: contact dbehan@usd.edu or rshewmake@usd.edu.

http://www.nhlbi.nih.gov/funding/training/naa/

http://www.nhlbi.nih.gov/funding/training/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, 1995.

Manual of Clinical Dietetics, 5th edition. Chicago, IL: The American Dietetic Association, 1996.

Mahan LK and Escott-Stump S. Krause's Food, nutrition and diet therapy, 10th ed. Harcourt, Brace and Co. 1999.

Modern Nutrition in Health and Disease, 9th Edition, Williams and Wickins, 1999.

Medical Nutrition and Disease, Blackwell Science Inc., 1996