Improving residents' clinical approach to obesity: impact of a multidisciplinary didactic curriculum

Academic half days, noon conferences and classroom-based education in postgraduate medical education: a scoping review

BACKGROUND

Classroom-based education (CBE) is ubiquitous in postgraduate medical education (PGME), but to date no studies have synthesized the literature on the topic. We conducted a scoping review focusing on academic half days and noon conferences.

METHODS

We searched 4 databases (MEDLINE [OVID], Embase [OVID], ERIC [EBSCO] and Web of Science) from inception to December 2021, performed reference and citation harvesting, and applied predetermined inclusion and exclusion criteria to our screening. We used 2 frameworks for the analysis: "experiences, trajectories and reifications" and "description, justification and clarification."

RESULTS

We included 90 studies, of which 55 focused on resident experiences, 29 on trajectories and 6 on reification. We classified 44 studies as "description," 38 as "justification" and 8 as "clarification." In the description studies, 12 compared academic half days with noon conferences, 23 described specific teaching topics, and 9 focused on resources needed for CBE. Justification studies examined the effects of CBE on outcomes, such as examination scores (17) and use of teaching strategies in team-based learning, principles of adult learning and e-learning (15). Of the 8 clarification studies, topics included the role of CBE in PGME, stakeholder perspectives and transfer of knowledge between classroom and workplace.

INTERPRETATION

Much of the existing literature is either a description of various aspects of CBE or justification of particular teaching strategies. Few studies exist on how and why CBE works; future studies should aim to clarify how CBE facilitates resident learning within the sociocultural framework of PGME.

Primary Care Clinicians' Perceived Role in Addressing Childhood Obesity in the Southern United States

OBJECTIVES

Primary care is an opportune setting to promote healthy behaviors for children and families. In 2007, an expert committee recommended that pediatric primary care clinicians assess nutrition and physical activity at wellness visits and offer recommendations; however, little is known about what pediatric primary care clinicians perceive their role as in childhood weight management. This qualitative study aimed to describe the perceived role of pediatric primary care clinicians in the prevention and treatment of childhood obesity in South Carolina, a state in the southern United States with high rates of childhood obesity.

METHODS

Pediatric primary care clinicians (n = 23) from South Carolina were recruited for two focus groups. Participants were asked semistructured, open-ended questions, and audio recordings were transcribed verbatim. Themes and subthemes were identified through an iterative coding and consensus-building process with two coders. Excerpts coded under the parent code of "clinician role" centered on three themes: conducting assessments, making referrals, and providing education.

RESULTS

Pediatric primary care clinicians in South Carolina coalesced around the important role of addressing childhood obesity within primary care. Notably, clinicians primarily discussed treatment rather than prevention strategies and described changes in the scope of their practice over time as a result of the increasing numbers of pediatric patients with obesity.

CONCLUSIONS

Addressing childhood obesity within primary care is a critical component of obesity prevention and treatment in the southern United States. Effective, sustainable prevention and treatment within primary care will depend on the involvement of pediatric clinicians, thus emphasizing the importance of understanding how they perceive their role within this setting.

Comprehensive Obesity Education for Family Medicine Residents

Background

Family medicine residents receive limited education on obesity management and obesity bias. Weight stigmatization is prevalent in primary care providers and trainees, and early mitigation is critical to optimize patient-centered care. Recent Provider Competencies for the Prevention and Management of Obesity include obesity bias. This report is intended to fill a current gap in obesity education for family medicine residents.

Methods

An interprofessional obesity teaching half day for family medicine residents incorporated the Provider Competencies and focused on five modules that addressed complexities of obesity and its clinical management. The obesity bias module focused on both explicit and implicit bias, assessment of implicit bias, preferential language usage, and mitigation strategies. An obesity-simulation empathy suit was available, and a public health expert described successful obesity care in a patient-centered medical home. Family medicine residents were surveyed prior to, immediately after the half-day of obesity teaching, and 15 months later.

Results

Survey results indicated 39.3% of residents had no previous biopsychosocial obesity education. Residents believed the content moderately (68.8%) or mostly (12.5%) impacted their approach to working with patients with obesity. Residents' comfort in working with patients with obesity as well as their perceived understanding of their own biases increased immediately after the intervention and was sustained 15 months later.

Conclusions

Our results suggest that a half day of obesity teaching can have a positive and sustained impact on family medicine residents. Additionally, this educational experience allowed for greater individual awareness building and insight regarding implicit bias. Such education for family medicine residents fills an identified gap in obesity education.

Obesity education in medical schools, residencies, and fellowships throughout the world: a systematic review

Obesity is pandemic throughout the world, and there is concern that physicians are inadequately trained to treat their patients with obesity despite its prevalence. This review explores obesity education in medical students, resident, and fellow physicians throughout the world from 2005 to 2018. Previous reviews on obesity education were conducted before 2011, focused solely on medical students, and only explored obesity education in the United States. We systematically searched MEDLINE, EMBASE, PsycINFO, and ERIC databases for studies which included the search terms "obesity education" AND either "medical students", "residency", or "fellowship" that met PICOS (Population, Interventions, Comparators, Outcomes, Study Design) criteria for articles published in English for obesity education and evaluation of outcomes. Our initial search yielded 234 articles, and 27 studies met criteria for our review. We described and analyzed these studies for their study design and graded quality, quantity, and consistency for each measured outcome. We applied an evidence grading system that has been previously applied in the literature in which each outcome measure was graded on a scale from A to D. We evaluated obesity education programs for outcomes regarding implicit and explicit bias, changes in attitude towards obesity, weight change, obesity knowledge, counseling confidence, intent to counsel, and counseling quality. There was a significant degree of heterogeneity in the studies included. While obesity knowledge was most frequently studied, counseling confidence was the only outcome with an overall grade A. There is currently a paucity of obesity education programs for medical students, residents, and fellow physicians in training programs throughout the world despite high disease prevalence. However, these programs often improve outcomes when they are administered. Our review suggests that more obesity education should be administered in undergraduate and graduate medical education to ensure optimal treatment of patients with obesity.

The Resident Experience of an Obesity-Focused Home Visiting Curriculum

BACKGROUND

The prevalence of obesity in the USA has risen to 39.8% of adults and 18.5% of children, yet there has not been a compensatory rise in residency training to reflect this epidemic.

OBJECTIVES

To examine pediatric residents' lived experiences of completing a novel home visitation curriculum for children with obesity in resource-poor areas of Washington, DC.

METHODS

Pediatric residents completed a home visiting curriculum consisting of four modules followed by two home visits to families with a child struggling with obesity. Within 2 weeks of completing the curriculum, individual interviews were conducted with participants about their experience. Inductive coding was used to analyze the data, followed by clustering and theming.

RESULTS

Saturation was reached after individual interviews with 13 residents between 2013 and 2015. Five themes emerged describing the residents' experiences: (1) enhanced understanding of home and community life, (2) awareness of personal biases and assumptions, (3) challenges of losing control and not being intrusive, (4) deeper relationship and enhanced empathy with patient and family, and (5) changes in delivery of care.

CONCLUSIONS

The findings from this study suggest that an obesity-focused home visiting curriculum may provide residents with a deeper understanding of social determinants of obesity and the opportunity to gain other necessary skills that may help them better care for individuals with obesity.

Intervention Descriptions in Medical Education: What Can Be Improved? A Systematic Review and Checklist

PURPOSE

Many medical education studies focus on the effectiveness of educational interventions. However, these studies often lack clear, thorough descriptions of interventions that would make the interventions replicable. This systematic review aimed to identify gaps and limitations in the descriptions of educational interventions, using a comprehensive checklist.

METHOD

Based on the literature, the authors developed a checklist of 17 criteria for thorough descriptions of educational interventions in medical education. They searched the Ovid MEDLINE, Embase, and ERIC databases for eligible English-language studies published January 2014-March 2016 that evaluated the effects of educational interventions during classroom teaching in postgraduate medical education. Subsequently, they used this checklist to systematically review the included studies. Descriptions were scored 0 (no information), 1 (unclear/partial information), or 2 (detailed description) for each of the 16 scorable criteria (possible range 0-32).

RESULTS

Among the 105 included studies, the criteria most frequently reported in detail were learning needs (78.1%), content/subject (77.1%), and educational strategies (79.0%). The criteria least frequently reported in detail were incentives (9.5%), environment (5.7%), and planned and unplanned changes (12.4%). No article described all criteria. The mean score was 15.9 (SD 4.1), with a range from 8 (5 studies) to 25 (1 study). The majority (76.2%) of articles scored 11-20.

CONCLUSIONS

Descriptions were frequently missing key information and lacked uniformity. The results suggest a need for a common standard. The authors encourage others to validate, complement, and use their checklist, which could lead to more complete, comparable, and replicable descriptions of educational interventions.

Application of mini-clinical evaluation exercise for assessing the integrated-based learning during physical diagnostic course

Medical education paradigm has been questioned for the requirements of improving the quality and quantity of medical students. This study was to explore the efficiency of integrated-based learning (IBL) used mini-clinical evaluation exercise (mini-CEX) during physical diagnostics course. One hundred and eleven volunteered students were randomly divided into three groups: lecture-based learning (LBL), case-based learning (CBL), and IBL. Nephrotic syndrome was the teaching content. In the IBL group, students were provided the guideline and additional interpretation from the instructor about the basic knowledge related to disease as vertical integration curriculum. Their performance was evaluated by mini-CEX and theoretical examination, respectively. All subjects have completed the study. The difference of five factors (medical interview, physical examination, clinical judgment, organizational effectiveness, and competence) in mini-CEX between IBL, CBL, and LBL were statistically significant (p <0.05). Sample sizes of below, meets, and above the expectations of mini-CEX in different instructional groups were statistically significant (X² =17.842, p =0.001). The final exam scores in IBL group and the CBL group were significantly higher than that of LBL group (F =41.553, p =0.000). And the relationship of final exam score only in the IBL group was positive existed with medical interview (R =0.466, p =0.004), physical examination (R =0.328, p =0.048), professional attitude (R =0.366, p =0.026), and communication skill (R =0.412, p =0.011). Therefore, our study revealed the effect of IBL on the medical students' skills. It highlights IBL could improve the physical examination, organizational effectiveness, and competence and the application of basic knowledge. © 2018 International Union of Biochemistry and Molecular Biology, 46(5):417-423, 2018.

Assessing and counseling the obese patient: Improving resident obesity counseling competence

OBJECTIVE

To evaluate obesity counseling competence among residents in a primary care training program METHODS: We delivered a 3h obesity curriculum to 28 Primary Care residents and administered a pre-curriculum and post curriculum survey looking specifically at self-assessed obesity counseling competence.

RESULTS

Nineteen residents completed both the pre curriculum survey and the post curriculum survey. The curriculum had a positive impact on residents' ability to ascertain patient's stage of change, use different methods to obtain diet history (including 24h recall, food record or food frequency questionnaire), respond to patient's questions regarding treatment options, assist patients in setting realistic goals for weight loss based on making permanent lifestyle changes, and use of motivational interviewing to change behavior. When looking at the 5As domains, there was a significant improvement in the domains of Assess, Advise, and Assist. The proportion of residents with a lower level of self-assessed obesity counseling competence reduced from 75% before the curriculum to 37.5% (p=0.04) after the curriculum.

CONCLUSION

Our curriculum addressing weight loss counseling using the 5As model increased obesity counseling competence among residents in a primary care internal medicine residency program.

Effect of didactic lectures on obesity documentation and counseling among internal medicine residents

Background

Screening adult patients for obesity and offering appropriate counseling and treatment for weight loss is recommended. However, many healthcare providers feel ill-equipped to address this topic.

Objective

We examined whether didactic presentations lead to increased obesity documentation and counseling among internal medicine (IM) residents.

Methods

We reviewed medical records of patients seen at the IM Resident Continuity Clinic during April 2015. Residents were provided feedback at two didactic presentations during May 2015. To examine the effect of this intervention, we repeated medical record review during June 2015. For both reviews, we abstracted patient-specific (i.e., age, body mass index [BMI], race, sex, and number of comorbid diagnoses) and resident-specific (i.e., sex and training level) data as well as evidence of obesity documentation and counseling. We used logistic regression models to examine the effect of intervention on obesity documentation and counseling, adjusting for patient- and resident-specific variables.

Results

Of the 278 patients with BMI≥30 kg/m², 139 were seen before and 139 after the intervention. Intervention had no effect on obesity documentation or counseling with or without adjustment for confounding variables (both P>0.05). In adjusted post-hoc analyses, each additional comorbidity increased the odds of obesity documentation by 8% (OR=1.08; 95% CI=1.05–1.11; P<0.001). In addition, as compared to postgraduate year (PGY) 1 residents, PGY-3 residents were 56% (OR=0.44; 95% CI=0.21–0.95; P=0.03) less likely to counsel obese patients.

Conclusions

Obesity is inadequately addressed in primary care settings, and didactic presentations were unable to increase obesity documentation or weight loss counseling. Future research to identify effective interventions is needed.

Comparison of Lecture-Based Learning vs Discussion-Based Learning in Undergraduate Medical Students

OBJECTIVE

To compare lecture-based learning (LBL) and discussion-based learning (DBL) by assessing immediate and long-term knowledge retention and application of practical knowledge in third- and fourth-year medical students.

DESIGN

A prospective, randomized control trial was designed to study the effects of DBL. Medical students were randomly assigned to intervention (DBL) or control (LBL) groups. Both the groups were instructed regarding the management of gastroschisis. The control group received a PowerPoint presentation, whereas the intervention group was guided only by an objectives list and a gastroschisis model. Students were evaluated using a multiple-choice pretest (Pre-Test MC) immediately before the teaching session, a posttest (Post-Test MC) following the session, and a follow-up test (Follow-Up MC) at 3 months. A practical examination (PE), which tested simple skills and management decisions, was administered at the end of the clerkship (Initial PE) and at 3 months after clerkship (Follow-Up PE). Students were also given a self-evaluation immediately following the Post-Test MC to gauge satisfaction and comfort level in the management of gastroschisis.

SETTING

University of Iowa Hospitals and Clinics and the Carver College of Medicine, Iowa City, IA.

PARTICIPANTS

A total of 49 third- and fourth-year medical students who were enrolled in the general surgery clerkship were eligible for this study. Enrollment into the study was completely voluntary. Of the 49 eligible students, 36 students agreed to participate in the study, and 27 completed the study.

RESULTS

Mean scores for the Pre-Test MC, Post-Test MC, and Follow-Up MC were similar between the control and intervention groups. In the control group, the Post-Test MC scores were significantly greater than Pre-Test MC scores (8.92 ± 0.79 vs 4.00 ± 1.04, p < 0.0001), whereas the Follow-Up MC scores were significantly lower than Post-Test MC scores (7.17 ± 1.75 vs 8.92 ± 0.79, p = 0.005). In the control group, the Follow-Up MC scores were significantly greater than Pre-Test MC scores (7.17 ± 1.75 vs 4.00 ± 1.04, p < 0.0001). Analysis of variance for all control group MC examinations had a p < 0.0001. In the intervention group, the Post-Test MC scores were significantly greater than Pre-Test MC scores (8.33 ± 1.23 vs 4.60 ± 1.55, p < 0.0001), whereas the Follow-Up MC scores were significantly lower than Post-Test MC scores (7.13 ± 1.77 vs 8.33 ± 1.23, p = 0.04). In the intervention group, the Follow-Up MC scores were significantly greater than Pre-Test MC scores (7.13 ± 1.77 vs 4.60 ± 1.55, p = 0.0002). Analysis of variance for all intervention group MC examinations had a p < 0.0001. Mean scores for the Initial PE were significantly higher for the intervention group compared with the control group's score (7.47 ± 1.68 vs 5.25 ± 2.34, p = 0.008). Mean scores for the Follow-Up PE were significantly higher for the intervention group compared with the control group's score (7.87 ± 1.77 vs 5.83 ± 2.04, p = 0.005). A comparison of Initial PE vs Follow-Up PE was not significant in either group. Students in the intervention group were more comfortable in the immediate management of gastroschisis and placement of a silo and felt that the educational experience was more worthwhile than students in the control group did.

CONCLUSIONS

After a single instructional session, there was a significant difference in the students' scores between the control and the intervention groups on both administrations of the PEs. There were no significant differences between the 2 groups in any administration of the MC examinations. This seems to suggest that DBL may lead to better practical knowledge and potentially improved long-term knowledge retention when compared with LBL. Students in the DBL group also felt more comfortable with the management of gastroschisis and were more satisfied with the educational session.

Communication between the obese patient and bariatric surgeon

Communication between the bariatric surgeon and the obese patient is very important as it influences the expectations of patients with regard to surgery, aim of the surgery and the understanding of the mechanisms of failure of surgery. Furthermore, the incidence of certain psychopathology in these patients makes it necessary for the surgeon to have the ability to communicate to the patient the need for motivation and the maintenance of healthy life habits. Although the topic is subjective, in this article we review several useful recommendations to optimize communication before and after surgery. Finally, we emphasize the need to create workshops to train the bariatric surgeon in these issues that we consider so important.