How can nutrition education contribute to competency-based resident evaluation? 1 4

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1 How can nutrition education contribute to competency-based resident evaluation? 1 4 Darwin Deen ABSTRACT The Curriculum Committee of the Nutrition Academic Award (NAA) has created a consensus document of knowledge, skills, and attitude learning objectives for medical nutrition education. To evaluate the impact of nutrition education in residency training, it is necessary to specify the goals and objectives of that education in terms of specific learner outcomes. To make the NAA objectives more user friendly for graduate medical education faculty, they must be translated into measurable competencies. The Accreditation Council for Graduate Medical Education has proposed a schema for organizing resident competencies. This article illustrates one way that the NAA curriculum objectives can be translated into specific competencies to demonstrate medical knowledge, patient care, practice-based learning, interpersonal and communication skills, professionalism, and systems-based practice. Am J Clin Nutr 2006;83(suppl):976S 80S. KEY WORDS Graduate medical education, GME, medical nutrition education, learning objectives, competency-based assessment INTRODUCTION The objectives of this article are 1) to briefly review the Accreditation Council for Graduate Medical Education (ACGME) domains of competency (1) used for resident evaluation, 2) to discuss the rationale for using the provision of nutritional care as a method of documenting residents progress in achieving competence in specific domains, 3) to demonstrate how the Nutrition Academic Award (NAA) objectives (2) can be used to define competence, and 4) to provide information on how to monitor resident progress in achieving selected nutritional care competencies. The purpose of this process is to assist residency program faculty seeking to use the NAA objectives to establish competency-based evaluation of their residents nutrition knowledge, skills, and attitudes. Competency-based assessment of residents nutrition education is key for several reasons. Tests have a powerful influence on learning, and as a result, the development of evaluation methods that will further residents educational goals is important: It is in the evaluationsystemthatthe real objectivesofanyprogramaredisplayed, and the truly important values become apparent (3). The dimensions of clinical competence include the relevant abilities of the physician, problem-solving tasks, the nature of the illness, and social and psychological aspects (4). Relevant abilities of the physician include knowledge and interpersonal and technical skills. Problem-solving tasks related to clinical competence include data gathering, diagnosis, and continuity of care. Scope of care and practice setting are elements vital to clinical competence related to the nature of the illness. Social and psychological skills are related to diagnosis and management. Within each discipline, faculty must determine the body of nutrition knowledge required for practice within their specific specialty. Competency-based nutritional care is at the forefront of resident education for several reasons. Physicians are increasingly recognizing the importance that diet and exercise play in influencing the prevention, risk, and management of a variety of chronic diseases. Providing good nutritional care to patients is a part of the professional responsibility of every physician. Residency program faculty may seek to integrate nutritional care into their efforts to address the ACGME domains. Demonstration of proficiency in nutritional care can be used to reflect competency in each of the ACGME domains: patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice. APPLYING NUTRITION TO ACGME COMPETENCIES Nutrition education satisfies multiple ACGME competencies. The following is a brief description of the ACGME domains and the ways in which nutrition objectives can reflect each of those domains (Table 1). The first ACGME competency stipulates that patient care should be compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Nutrition objectives that relate to this competency include engaging patients in discussions about dietary change and the impact of lifestyle on health promotion and disease prevention (Table 2). A second ACGME competency, medical knowledge, requires that physicians be in command of medical knowledge about 1 From the Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, NY. 2 Presented at the symposium An Evidence-Based Approach to Medical Nutrition Education, held at Experimental Biology 2005 in San Diego, CA, 2 April Supported by NIH grant #K07-HL and by a grant from the NHLBI (HL ). 4 Address reprint requests to D Deen, Director of Medical Student Education, Department of Family and Social Medicine, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY deen@aecom.yu.edu. 976S Am J Clin Nutr 2006;83(suppl):976S 80S. Printed in USA American Society for Nutrition

2 COMPETENCY-BASED RESIDENT NUTRITION EDUCATION 977S TABLE 1 Summary of nutrition learning objectives for each Accreditation Council of Graduate Medical Education (ACGME) competency ACGME competency definition Patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Medical knowledge about established and evolving biomedical, clinical, and cognate (eg, epidemiologic and social-behavioral) sciences and the application of this knowledge to patient care. Practice-based learning and improvement that involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care. Interpersonal and communication skills that result in effective information exchange and teaming with patients, their families, and other health professionals. Professionalism, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. Systems-based practice, as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value. Types of nutrition learning objectives Nutrition objectives that relate to the method of engaging patients in discussions about dietary change and the impact of lifestyle on health promotion and disease prevention. Nutrition objectives that relate to the knowledge of appropriate nutritional interventions for specific disease states. Evaluation of meeting the nutrition competencies; for example, feedback from preceptors regarding the frequency with which given nutrition competencies are achieved will demonstrate practice-based learning and if tracked over time can be used to document improvement. Use of the Stages of Change model to assess patients readiness to make changes and making appropriate referrals to dietitians or when required occupational or physical therapists to assist patients with lifestyle change goals. Nutritional care for patients demonstrates professionalism by acknowledging that it is the responsibility of the physician to prevent as well as treat disease and to help empower patients to take control of their health care and disease management. Use of community resources such as knowledge about and referral to Meals-on-Wheels and senior center congregate meals programs and WIC programs as well as acknowledgement of major public health nutrition efforts like the Dietary Guidelines and the 5-A-Day program. established and evolving biomedical, clinical, and cognate (eg, epidemiologic and social-behavioral) sciences and be able to apply this knowledge to patient care. Nutrition objectives that relate to the knowledge of appropriate nutritional interventions for specific disease states will demonstrate a physician s competency in medical knowledge (Table 3). The practice-based learning and improvement competency involves the investigation and evaluation of a physician s own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care. The use of best-available evidence-based nutritional guidelines for patient care and incorporation of new information will demonstrate this competency. TABLE 2 Nutrition learning objectives that reflect patient care 1) Resident uses the health maintenance visit as an opportunity to assess patients diet and exercise habits and makes appropriate recommendations for modifying both. 2) Resident describes a stage-appropriate intervention considering the patient s current diet. 3) When evaluating patients with hypertension, diabetes, hyperlipidemia, etc, resident asks about patient s dietary and exercise habits and when appropriate does a 24-h dietary recall. 4) Resident is aware of the prevalence of iron deficiency and other nutritionally related pathology in the patient populations he or she serves. 5) Resident includes questions about the use of dietary supplements in his or her routine histories. 6) Resident uses evidence-based approaches to determine the effectiveness of weight reduction programs and complementary and alternative medicines. 7) When evaluating a patient with hypertension, the resident will evaluate the patient s dietary intake (including alcohol) and activity level with sensitivity to cultural norms. 8) Resident effectively screens obese patients for cardiovascular disease and recommends appropriate therapy when identified. Evaluation of residents abilities to satisfy nutrition competencies will include, for example, feedback from preceptors regarding the frequency with which given nutrition competencies are achieved and will demonstrate practice-based learning if evaluations are tracked over time and are used to document improvement. A fourth ACGME competency requires that physicians engage in effective interpersonal and communication skills that result in efficient information exchange when teaming up with patients, their families, and other health professionals. Including nutritional care as part of health maintenance visits, use of the Stages of Change model to assess patients readiness to make changes, and making appropriate referrals to dietitians (or others) to assist patients with lifestyle change goals will document interpersonal and communication skills in teaming with patients and other health professionals (Table 4). The ACGME professionalism competency is manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. By developing and maintaining nutrition knowledge, physicians are demonstrating professionalism, and by providing patients with evidence-based nutritional information, they are adhering to the ethical principles of the profession (Table 5). Gaining knowledge about the various cultural aspects of their patients diets will allow residents to demonstrate cultural competence and professionalism. Nutritional care for patients demonstrates professionalism by acknowledging that it is the responsibility of the physician to prevent as well as treat disease and to help empower patients to take control of their health care and disease management. Residency programs have a responsibility to train residents in the common cultural eating patterns of the diverse patient populations that they provide care for. The systems-based practice competency is evident through actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of

3 978S TABLE 3 Nutrition learning objectives that reflect medical knowledge 1 DEEN TABLE 5 Nutrition learning objectives that reflect professionalism 1) Resident knows the food groups included in the Food Guide Pyramid and how to characterize a well-balanced diet. 2) Resident understands the limitations of the current Food Guide Pyramid. 3) Resident can state the TLC diet recommended by the NCEP-ATP III. 4) Resident can state the DASH diet and lifestyle modifications recommended by JNC VII. 5) Resident can give an explanation of what data caused them to formulate that opinion. 6) Resident asks age-appropriate questions regarding the child s diet and provides accurate information to parents regarding healthy intake for children of different ages. 7) Resident is aware of the prevalence of iron deficiency and other nutritionally related pathology in the patient populations he or she serves. 8) When evaluating a patient with hypertension, the resident will evaluate the patient s dietary intake (including alcohol) and activity level with sensitivity to cultural norms. 9) Resident can discuss dietary management of a patient with hypertension and recognize the roles of the major important nutrients (Na, K, Ca). 10) Resident is aware of the NHLBI practice guidelines for management of obesity and considers secondary effects of obesity in recommending weight-management modalities. 11) Resident is prepared to answer questions that his or her patients ask about dietary supplements. 12) Resident uses evidence-based approaches to determine the effectiveness of weight-reduction programs and complementary and alternative medicines. 1 TLC, Therapeutic Lifestyle Changes; NCEP-ATP III, National Cholesterol Education Program Adult Treatment Panel III; DASH, Dietary Approaches to Stop Hypertension; JNC VII, Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; NHLBI, National Heart, Lung, and Blood Institute. optimal value. Use of community resources such as knowledge about and referral to Meals-on-Wheels and senior center congregate meal programs and WIC programs will demonstrate the systems-based practice competency as related to nutrition (Table 6). TABLE 4 Nutrition learning objectives that reflect interpersonal and communication skills 1) Resident can state the stages of change and demonstrates what questions to ask to determine the patient s current stage. 2) Resident recognizes when patient s weight-loss goals are unrealistic and is able to provide appropriate guidance on more appropriate goals. 3) Resident asks age-appropriate questions regarding the child s diet and provides accurate information to parents regarding healthy intake for children of different ages, including portion sizes, fruit juices, use of lower-fat dairy products, etc. 4) Resident is knowledgeable about the pharmacologic agents available to assist in the management of obesity, knows the indications for bariatric surgery, and can effectively answer patients questions regarding obesity management. 5) Resident effectively answers patients questions about the role of lifestyle behavior changes in the management of hypertension, diabetes, and other chronic diseases. 6) Resident can assess patient s literacy level and target communications appropriately. 1) Resident describes a stage-appropriate intervention considering the patient s current diet. 2) When evaluating a patient with hypertension, the resident will evaluate the patients dietary intake (including alcohol) and activity level with sensitivity to cultural norms. 3) Resident includes questions about the use of dietary supplements in his or her routine histories. 4) Resident asks parents about their infant and toddler feeding practices. 5) Resident acts to remedy identified deficiencies in his or her medical knowledge, attitudes, or skills in nutrition-related patient care. For the purposes of illustration, several NAA objectives have been rewritten as ACGME competencies. These include objectives in the areas of community and population health, behavioral principles, nutritional assessment, pediatrics, and hypertension (Tables 2 6). The first NAA community and population health objective involves the provision of effective preventive nutrition counseling appropriate for any well or diseased individual. The corresponding ACGME competencies would require that the resident know the food groups included in the new My Pyramid (5) and understand the method of accessing the pyramid and how it can be used to characterize a well-balanced diet. This competency addresses medical knowledge. Also related to medical knowledge and community and population health, residents should be able to state the Therapeutic Lifestyle Changes (TLC) diet recommended by the National Cholesterol Education Program Adult Treatment Panel III (6) and characteristics of the DASH (Dietary Approaches to Stop Hypertension) diet and lifestyle modifications recommended by the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (7). A second NAA community and population health objective involves residents ability to recognize the importance of nutrition and community nutrition services in health promotion, disease prevention, and disease management. To satisfy this ACGME competency, the resident must be able to use the health maintenance visit as an opportunity to assess patients diet and exercise habits and be able to make appropriate recommendations for modifying both. This also addresses patient care. In the arena of systems-based practice, a resident must be able to appropriately refer patients with identified nutritional needs to a registered dietitian. TABLE 6 Nutrition learning objectives that reflect systems-based practice 1) Resident appropriately refers patients with identified nutritional needs to a registered dietitian or other available source for nutrition counseling (eg, certified diabetes educator). 2) Resident appropriately refers patients to WIC, senior meals programs, and Meals-on-Wheels. 3) Resident utilizes community resources to assist patients interested in weight loss. 4) Resident assesses patient s ability to access referrals on the basis of insurance coverage or ability to pay for services. 5) Resident uses available patient education materials in his or her efforts to counsel patients.

4 COMPETENCY-BASED RESIDENT NUTRITION EDUCATION 979S An NAA objective related to behavioral principles addresses the resident s need to be competent in assessing a patient s readiness for change and matching the counseling intervention to the patient s current stage in the continuum of change. A resident who satisfies the corresponding ACGME competency can state the stages of change and demonstrate what questions to ask to determine the patient s current stage (8). This objective relates to the interpersonal and communication skills of the resident. A resident must also be able to explain what data caused them to formulate that opinion to satisfy medical knowledge requirements. A second NAA objective related to behavioral principles deals with the requirement that the resident be able to effectively counsel patients to set realistic nutritional goals and timelines for behavioral change. The complementary ACGME competency stipulates that residents must be able to describe a stageappropriate intervention that considers the patient s current diet. This competency particularly addresses the resident s abilities in patient care and professionalism. In the areas of interpersonal and communication skills, a resident should be able to recognize when a patient s goals are unrealistic and be able to provide appropriate guidance on realistic goals. The NAA s nutritional assessment objective specifies that residents be able to perform a complete nutritional assessment on all ambulatory and hospitalized patients, including those with acute or chronic disease as well as healthy individuals of all ages. Corresponding ACGME competencies related to patient care might require that residents ask about the dietary and exercise habits of all patients with hypertension, diabetes, or hyperlipidemia, and, when appropriate, do a 24-h dietary recall. Residents should also be expected to evaluate patients height, weight, body mass index, waist circumference, and risk factors. An NAA objective in pediatrics states that physicians must effectively counsel families with children to develop and maintain healthy eating habits. The ACGME competency might require that the resident ask age-appropriate questions regarding the child s diet and provide accurate information to parents regarding healthy intake for children of different ages (9) in addressing medical knowledge and interpersonal and communication skills. A second competency could be that the resident must be aware of the prevalence of iron deficiency and other nutritionally related pathology in the patient populations he or she serves. This competency falls within the domains of patient care and medical knowledge. An NAA objective related to hypertension states that a physician must be able to provide effective individualized dietary counseling for hypertensive patients that focuses on body weight, energy balance, and dietary intake of fruit, vegetables, sodium, potassium, calcium, magnesium, total fat, and saturated fat. The corresponding ACGME competencies could require that when evaluating a patient with hypertension, the resident assess the patients dietary intake (including alcohol) and activity level with sensitivity to cultural norms. This would address the patient care, medical knowledge, and professionalism competencies. A second competency could state that a resident must be able to discuss dietary management with a patient with hypertension and be able to recognize the roles of the major important nutrients. This competency addresses medical knowledge as well as patient care. In the evaluation of overweight or obese children, adolescents, or adults, residents should be able to perform an appropriate physical examination, measure the patient s body weight and waist circumference, determine the percentage body fat, calculate the body mass index, estimate the patient s body fat distribution, and evaluate the patient for other signs and symptoms of weight-related morbidity (10). The ACGME competencies required in the evaluation of overweight or obese individuals involve the resident being aware of the NHLBI practice guidelines for the management of obesity and consideration of secondary effects of obesity when recommending weight-management modalities. This addresses the competency of medical knowledge. Residents should be able to effectively screen obese patients for cardiovascular disease and recommend appropriate therapy. This addresses the competency of patient care. In addition, residents should utilize community resources to assist patients interested in weight loss. This addresses the competency of systems-based practice. Finally, residents must be knowledgeable about the pharmacologic agents available to assist in the management of obesity, know the indications for bariatric surgery, and effectively answer patients questions regarding obesity management. This relates to the competencies of interpersonal and communication skills. NAA objectives addressing contemporary trends require that physicians effectively communicate with patients the benefits and effects of various popular dietary supplements, complementary and alternative medicines, and commonly used weightreduction programs. Appropriate counseling in these areas would reflect the following ACGME competencies: patient care, medical knowledge, and professionalism. Practice-based learning and improvement involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care. Evaluation of meeting the nutrition competencies, for example, and feedback from preceptors regarding the frequency with which given nutrition competencies are achieved will demonstrate practice-based learning and if tracked over time can be used to document improvement. Residents can also be expected to identify and rectify their own nutrition knowledge deficits and remedy them. This will also reflect professionalism. Suggestions on how to incorporate these competencies into recorded observations in the residents evaluation folders include creating a checklist for different types of visits or including nutrition on a computer-based evaluation form within dropdown menus organized by diagnosis. Suggestions for ensuring consistency in faculty expectations include observed precepting and require faculty development. The ACGME has provided a toolbox of potential evaluation methods (11) that can be used to assist in documenting and following resident progress in achieving competence in each of the domains (by substituting nutrition objectives for existing disease-specific objectives). I gratefully acknowledges the NAA principle investigators and the members of the NAA Curriculum Committee, whose ideas are reflected in this article; various faculty from the Albert Einstein Residency Program in Social Medicine, who contributed ideas during a faculty development session at which these issues were discussed; and Katherine Kolasa, Lisa Hark, and Alice Fornari for review of the objective-to-competency translations. The author had no conflicts of interest to report. REFERENCES 1. Accreditation Council for Graduate Medical Education. Internet: (accessed 1 November 2005).

5 980S DEEN 2. Nutrition Curriculum Guide for Training Physicians. Nutrition Academic Award Internet: training/naa/curr_gde/index.htm (accessed 1 November 2005). 3. Neufeld VR. Assessing clinical competence. New York, NY: Springer Publishing, 1985:7. 4. Epstein RM, Hundert EM. Defining and assessing professional competence. JAMA 2002;287: US Department of Agriculture. My Pyramid Internet: mypyramid.gov/ (1 November 2005). 6. Third report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. National Cholesterol Education Program Internet: (accessed 1 November 2005). 7. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) Internet: (accessed 1 November 2005). 8. Zimmerman GL, Olsen CG, Bosworth MF. A stages of change approach to helping patients change behavior. Am Fam Physician 2000; 61: US Department of Agriculture. The Food Guide Pyramid for Young Children Internet: (accessed 1 November 2005). 10. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults. National Heart, Lung, and Blood Institute Internet: ob_home.htm (accessed 1 November 2005). 11. American Council for Graduate Medical Education. Outcome project: toolbox of assessment methods. Internet: outcome/assess/toolbox.asp (accessed 1 November 2005).