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Tracking Knowledge Growth across an Integrated Nutrition Curriculum

Both the academic literature and the popular press continually report the importance of nutrition for health. One example is the increasing prevalence of obesity in the United States and the concomitant popularity of diet books and untested remedies. A 1985 National Academy of Sciences report warned of the lack of nutrition education and the need for a required curriculum for all medical students in U.S. medical schools. Results from annual Association of American Medical Colleges (AAMC) Graduation Questionnaires reinforce this conclusion. In 1995, 63% of students reported that they had received inadequate nutrition in their medical school curricula. In 1998, nothing had changed; 64% of students still reported inadequate nutrition education. Following the 1985 National Academy of Sciences report, funding from the National Cancer Institute (NCI) stimulated development of nutrition curricula at a number of medical schools. In one study, the use of a multimedia program to teach nutritional assessment and counseling was evaluated. The authors found that, following exposure to the multimedia nutrition program, first-year students were more likely to use a food-frequency form while interviewing a standardized patient compared with previous students who had not received the intervention. A majority of students (51%) who completed the curriculum reported that observing a physician model nutritional assessment and counseling in the multimedia program had been helpful. In another study, the evaluation of a two-year integrated nutrition curriculum implemented during the basic sciences indicated increased knowledge for those students who had completed the curriculum. Although limited in scope, these studies are promising. They imply that, even when nutrition is not a major aspect of the medical school curriculum, firstand second-year students’ knowledge can increase and they may apply their knowledge to patient care. The increase of nutrition knowledge following exposure to the clinical curriculum is potentially of greater importance than is the nutritional content of the basic science curriculum, since clinical exposure may be more likely to lead to application in practice. Many studies report physicians’ lack of knowledge and confidence in using nutritional concepts in their practices. The paucity of physicians who model the use of nutrition concepts in their practices could have a negative effect on students’ acquisition of knowledge and their application of that knowledge to patient care. At our institution, cognitive learning theory (i.e., actively engaging students in learning) guided the development of a new nutrition curriculum. The curriculum’s goals were to increase students’ (1) learning and retention of nutritional concepts; (2) skills, such as diet-assessment methods; and (3) application of content to patients’ care. To accomplish this, we planned to increase opportunities for practice with nutritional concepts throughout the fouryear curriculum using active learning methods such as laboratory exercises, a dietary self-assessment, interviews with standardized patients, and discussions in small-group problem-based learning (PBL) sessions. In 1992, we started the curricular planning process by conducting a nutrition needs assessment. We received funding of an NCI R25 grant (NCI PAR 94-005) in 1994, and a Nutrition Education Committee was formed to develop and implement the new nutrition curriculum. The Committee established goals and objectives (outlined on our Web site ^http://apps.medsch.ucla.edu/nutrition/ objectives.html&), reviewed existing courses and clerkships, and implemented changes in years one, two and three of the curriculum. New instructional and examination materials were developed to foster accomplishment of nutrition proficiencies outlined on the Web site above. The development of ongoing curricular review and evaluation processes tracked growth of nutritional knowledge in those students exposed to the revised curriculum. Modification of targeted courses to emphasize proficiency with nutritional concepts was the primary strategy of the curricular change. The nutrition curriculum is concentrated in the first-year course, Human Biochemistry and Nutrition Laboratory. A number of nutrition-related cases are also included in two first-year PBL courses. Nutrition is included in approximately ten lectures of the second-year course, Pathophysiology of Disease. New curricular material was incorporated into the required third-year family medicine clerkship and the Doctoring 3 curriculum, where students interview standardized patients. Numerous fourth-year nutrition electives are offered, but their impact is limited because very few students take these electives. In this study, we examined the effect of changes in the nutrition curriculum on students’ knowledge over four years of medical school. Based on earlier findings, and further development and implementation of nutritional content in the clinical curriculum, we hypothesized that students completing an integrated four-year nutrition curriculum would demonstrate, on a Nutrition Progress Survey, a continual increase in their nutrition knowledge over time. We also hypothesized that they would demonstrate more confidence in their responses through a decrease in their use of ‘‘don’t know’’ as a response to survey questions.