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Symposium: Innovative Teaching Strategies for Training Physicians in Clinical Nutrition

Longitudinal and Horizontal Integration of Nutrition Science into Medical School Curricula¹

Brian Tobin^*,2, Kimberly Welch^*, Marie Dent^**, Colleen Smith^*, Beulette Hooks and Robert Hash

^* Division of Basic Medical Sciences, Department of Pediatrics, ^** Department of Community Medicine, Marion Family Practice Center and Department of Family Medicine, Mercer University School of Medicine, Macon, GA 31027

²To whom correspondence should be addressed. E-mail: tobin_bw{at}mercer.edu

	ABSTRACT

TOP ABSTRACT Medical education at Mercer Year one and Year... An interdisciplinary model for... Historical rationale for... Healthy People 2000 set... Medical nutrition education... Progress to date Baseline Nutrition Attitude... Anticipated future problems and... LITERATURE CITED

 
The overall goal of our Nutrition Academic Award (NAA) medical nutrition program at Mercer University School of Medicine is to develop, implement and evaluate a medical education curriculum in nutrition and other aspects of cardiovascular disease (CVD) prevention and patient management with emphasis on the training of primary care physicians for medically underserved populations. The curriculum is 1) vertically integrated throughout all 4 y of undergraduate medical education, including basic science, clinical skills, community science and clinical clerkships as well as residency training; 2) horizontally integrated to include allied healthcare training in dietetics, nursing, exercise physiology and public health; and 3) designed as transportable modules adaptable to the curricula of other medical schools. The specific aims of our program are 1) to enhance our existing basic science problem-based Biomedical Problems Program with respect to CVD prevention through development of additional curriculum in nutrition/diet/exercise and at-risk subpopulations; 2) to integrate into our Clinical Skills Program objectives for medical history taking, conducting patient exams, diet/lifestyle counseling and referrals to appropriate allied healthcare professionals that are specific to CVD prevention; 3) to enhance CVD components in the Community Science population-based medicine curriculum, stressing the health-field concept model, community needs assessment, evidence-based medicine and primary care issues in rural and medically underserved populations; 4) to enhance the CVD prevention and patient management component in existing 3rd- and 4th-y clinical clerkships with respect to nutrition/diet/exercise and socioeconomic issues, behavior modification and networking with allied health professionals; and 5) to integrate a nutrition/behavior change component into Graduate Residency Training in CVD prevention.

KEY WORDS: • nutrition • medicine • prevention • healthcare • education • rural • underserved • Georgia

	Medical education at Mercer

TOP ABSTRACT Medical education at Mercer Year one and Year... An interdisciplinary model for... Historical rationale for... Healthy People 2000 set... Medical nutrition education... Progress to date Baseline Nutrition Attitude... Anticipated future problems and... LITERATURE CITED

 
The mission of Mercer University School of Medicine (MUSM),³ its curriculum structure and its community-based medicine networks provide the foundation for the development of an integrated curriculum in the prevention of cardiovascular disease (CVD). Specifically, the mission of MUSM is to educate physicians to meet the healthcare needs of rural and other areas of Georgia. The principal need is for physician specialists in the primary care areas of Family Practice, Internal Medicine and Pediatrics. The second major objective is to instill in Mercer physicians a commitment to lifelong learning. Mercer’s small-group approach to education has been found to enhance the skills and attitudes necessary for both self-directed learning and lifelong learning. Consistent with its mission, MUSM has developed a preclinical curriculum, which emphasizes problem-based and experiential learning, thus providing a basis from which to begin integration of nutrition education into preventive medicine. The undergraduate curriculum is tied to practicing physicians and community medicine through several programs including the preceptor network, the clerkships and the Master of Public Health Program.

	Year one and Year two

TOP ABSTRACT Medical education at Mercer Year one and Year... An interdisciplinary model for... Historical rationale for... Healthy People 2000 set... Medical nutrition education... Progress to date Baseline Nutrition Attitude... Anticipated future problems and... LITERATURE CITED

 
Biomedical Problems (BMP) Program.

In this program the basic medical sciences are learned through the study of clinical problems. This occurs in small-group tutorial sessions. Groups of six to eight students meet three half-days per week with a tutor from the faculties of the basic or clinical sciences. The tutors are responsible for maintaining positive group dynamics and keeping the discussion relevant and at an appropriate depth. During the tutorials, the students define and discuss the basic and clinical science issues fundamental to the case under consideration. Outside the tutorials, the students study independently and/or in small groups, using appropriate resources from the Library, the Learning Resources Center and the faculty. The student-oriented approach to the study of medicine is interdisciplinary and the array of biomedical problems is chosen to ensure that students are challenged to master the basic science concepts requisite to medical practice. Each unit of the curriculum is accompanied by a Study Guide, a list of learning objectives for the unit. These objectives and the suggested references provide a guide of learning for the students. The first 2 y are divided into units, the basic theme for which is the molecular, cellular and organ bases for health and disease. First-year units and their lengths in weeks are as follows: cells and metabolism, 6; genetics and development, 6; host defense, 6; hematology, 4; neurology, 7; brain and behavior, 5; and musculoskeletal, 6. For the 2nd y the units and their lengths in weeks are as follows: cardiology, 6; pulmonology, 6; gastrointestinal, 6; renal, 5; endocrinology and biology of reproduction, 7; and infectious disease, 4. Nutrition science is currently integrated across the curriculum in all Basic Sciences BMP phases for 1st- and 2nd-y medical students.

Biomedical Ethics and Humanities (BMEH) Program.

In this program medical students begin thinking about bioethical issues in their future practices as well as discussing the importance of ethics/professionalism/humanities to the social science of medicine. The BMEH Program has been developed to provide a comprehensive educational opportunity for Mercer University medical students. During the fall of the 1st y, each new medical student participates in group biomedical ethics discussion sessions. These sessions (6 total contact hours) introduce students to ethical theory, issues in biomedical ethics and the relationship of bioethics to clinical practice. Through the use of a combination of required readings and writings, personal experiences and case analysis, students discuss and analyze ethical issues that commonly arise in the practice of medicine.

Clinical Skills Program.

In this program students learn the basic skills necessary for interaction with patients. These skills include interview/medical history and physical examination techniques. Students interview and examine actual and "standardized" patients. The latter group consists of persons who have been trained to portray specific medical problems and behavioral roles, and to give constructive feedback to the students.

Community Office Practice Program (COPP).

The COPP curriculum provides medical students with the opportunity to learn and experience current administrative and business practices while observing and participating in the clinical aspects of a community-oriented, primary care medical practice. Mentors and preceptors are available at sites throughout the state of Georgia (Fig. 1 ).

View larger version (108K): [in this window] [in a new window]   FIGURE 1 Distribution of the Mercer University School of Medicine (MUSM) preceptor networks in Georgia.

This population-based program is designed to familiarize students with community medicine in a primary care medical practice in rural Georgia. Students are educated in the disciplines of disease prevention, health promotion, basic epidemiology, clinical biostatistics, research design and evidence-based medicine. The program is longitudinal and extends throughout the 4-y curriculum. It consists of small-group tutorials plus selected seminars in Phases A, B and C and community visits in Phases B, C and E.

	An interdisciplinary model for nutrition in medicine

TOP ABSTRACT Medical education at Mercer Year one and Year... An interdisciplinary model for... Historical rationale for... Healthy People 2000 set... Medical nutrition education... Progress to date Baseline Nutrition Attitude... Anticipated future problems and... LITERATURE CITED

 
We propose that the interdisciplinary and integrated paradigm of nutrition education is the most useful approach for incorporating nutrition concepts of CVD prevention and the associated conditions of obesity and diabetes into an effective medical school curriculum. The overall goal of our National Academic Award (NAA) nutrition and CVD program is to develop, implement and evaluate a medical-nutrition education curriculum in CVD prevention and patient management, with emphasis on the training of primary care physicians for medically underserved populations. These goals lend themselves well to the interdisciplinary nature of the present curriculum structure.

Full integration of nutrition into a curriculum would include its integration into both patient care and community medicine. We propose that the Health Field Concept Model is a viable tool for incorporating nutrition into medical education. The Health Field Concept Model is a general approach to preventive medicine and patient management and is thus well suited to the prevention of CVD. The etiology of CVD is multifactorial and its development depends on the interaction of several factors: lifestyle; environment; biology and genetics; and the healthcare system (1 ). The Lifestyle Component of the Health Field Concept Model refers to those risks created by the individual; it includes such factors as lack of exercise, overeating, cholesterol and/or fat consumption. The physical, social and psychological dimensions of health are encompassed in the Environment Component, which includes geographical characteristics, pollution, behavior modifications, perception and interpersonal relationships. The biological makeup of the individual (such as race, age, gender) and other uncontrollable factors are included in the Biology Component. The System of Health Care Component refers to the availability, quality and quantity of resources to provide healthcare. Within this component, there are therapeutic aspects (drugs, dental treatments, medical professionals), restorative aspects (hospital, nursing homes, ambulance services) and preventive components (health promotion and health education). Preventive medicine as a component of community medicine would include the surveillance of the health status of a community to identify unusual patterns of illness and death; provision of screening services to high risk individuals; health education and information; improved access to healthcare including information, referral and outreach; and community planning and program development.

	Historical rationale for interdisciplinary approaches

TOP ABSTRACT Medical education at Mercer Year one and Year... An interdisciplinary model for... Historical rationale for... Healthy People 2000 set... Medical nutrition education... Progress to date Baseline Nutrition Attitude... Anticipated future problems and... LITERATURE CITED

 
The importance of nutrition in the practice of medicine is supported by numerous studies that clearly demonstrate the vital role of nutrition for optimal human health and disease prevention (2 ). It has been well documented that cardiovascular disease, obesity, diabetes, hypertension and renal disease can be treated, ameliorated, delayed or prevented by proper nutritional therapy (3 ,4 ). Not only is nutrition of paramount importance, but it is cost effective as a medical intervention (5 ,6 ). All in all, the study of nutrition should be an integrated component of medical education.

Although the lack of nutrition as a distinct discipline has historically been considered a liability, the interdisciplinary clinically related nature of the nutritional sciences is an asset in the shift of emphasis in medical education to interdisciplinary teaching in a clinically relevant format. The reports from the Project Panel on the General Professional Education of the Physician (GPEP) and College Preparation for Medicine and from the Robert Wood Johnson Foundation have called for active learning, learner-centered formats, increased health promotion, increases in clinically relevant education, greater use of computer technology, interdisciplinary learning, interdepartmental faculty administration and integration of the sciences throughout the course of biomedical education (7 ). These shifts in the approach to medical student education and increased support of nutrition curriculum by federal and state agencies present new opportunities for inclusion of nutrition in clinical and basic science training and incorporation of nutrition into curricula and models for preventive medicine.

Essential nutrition concepts for the primary care/generalist physicians have been put forth in the literature (8 ). The generalist physician can both augment and enhance the services of a registered dietician and the entire allied healthcare team. In practice, the physician should seek the services and advice of a registered dietician by recognizing those medical conditions that warrant consultation. This educational paradigm was proposed in part by McLaren (9 ), who viewed nutrition science as an integral part of the basic medical sciences with dietetics and clinical applications of nutrition integrated into the clinical years. A set of desirable educational topics in medical-nutrition education adapted from reports of the American Society for Clinical Nutrition (10 ,11 ) have been used as a guideline for curriculum development at MUSM. Integration of nutrition into the BMP curriculum at MUSM and the topics included are based on national society recommendations (10 ,12 –15 ).

	Healthy People 2000 set the basis for an integrated nutrition curriculum

TOP ABSTRACT Medical education at Mercer Year one and Year... An interdisciplinary model for... Historical rationale for... Healthy People 2000 set... Medical nutrition education... Progress to date Baseline Nutrition Attitude... Anticipated future problems and... LITERATURE CITED

 
The Healthy People 2000 report offered a challenge to the U.S. population that is aimed at reducing unnecessary death and disability, enhancing the quality of life and reducing the disparity between subpopulations of the U.S. community (16 ). A major focus of the report was aimed at reducing risk-preventable illness and the associated costs, particularly in CVD and the related conditions of obesity and diabetes. According to recent statistics from the American Heart Association, 58 million Americans have one or more types of CVD, which claims more lives each year than the next seven leading causes of death combined (17 ). Coronary heart disease (CHD) is the leading cause of premature, permanent disability in the U.S. labor force, accounting for 19% of disability allowances by the Social Security Administration. The estimated 1st-y costs for by-pass surgery for the number of Americans who will require it each year is over 8 billion dollars (17 ).

In Georgia, the statistics for the incidence and cost of CVD are even more alarming (18 ,19 ). Georgia ranks 45th out of 52 states, DC and Puerto Rico in terms of mortality attributed to total CVD, and its age-adjusted death rate for stroke is 75.2 per 100,000 population, or 48th out of 52 in the United States. In Georgia, CVD accounted for 40% of all deaths. CVD events were associated with 132,947 hospitalizations with a total cost of 1.8 billion dollars. In the four behavioral risk factors for total CVD reported by the Centers for Disease Control and Prevention, Georgia ranked higher than the National Year 2000 Target in two of these, smoking and overweight. Georgia ranked higher than both the National Year 2000 Target and the Behavioral Risk Factor Surveillance System (BRFSS) in the percentage of individuals who are physically inactive and eat less than five fruits or vegetables each day (19 ).

The incidence of coronary heart disease is not evenly distributed throughout the population (16 ). For black women, the age-adjusted death rate from CHD is nearly 69% higher than for white females. The risk of death from CHD is much greater for the least-educated than for the most-educated. As many as 30% of all deaths in hypertensive black men and 20% of all deaths in hypertensive black women are attributable to high blood pressure (HBP). Blacks have a 1.3 times greater rate of nonfatal stroke and 1.8 times greater rate of fatal stroke. Thus, a curriculum in nutrition for CVD prevention must consider the needs and risks for different subpopulations in the United States. In the words of Louis Sullivan, M.D., Secretary of Health and Human Services, "Good health must be an equal opportunity, available to all Americans." Conclusively, the development of a nutrition curriculum for CVD prevention should consider the needs of at-risk individuals, the factors that place them at risk and the needs of medically underserved populations.

By more fully integrating preventive nutrition and behavior change into the clerkships and graduate medical education programs and teaching their application with the health field concept model throughout the curriculum, we will better train our physicians to serve their patients and their communities. We propose that goals enumerated in the Healthy People 2000 document can be incorporated in a patient-centered, mission-oriented medical school curriculum that includes nutrition, exercise, at-risk populations, diabetes, obesity, behavior modification, lifestyle changes, community assessment and socioeconomic issues relevant to CVD prevention. Such a curriculum would most effectively be integrated vertically into the 4 y of medical education, as well as graduate experiences, and would be horizontally integrated to include training of and with allied healthcare professionals. The allied healthcare professions are being horizontally integrated into our curriculum to include undergraduate and graduate student programs in nutrition, dietetics, nursing, exercise physiology and public health (Fig. 2 ). A system of web-based communications called the Web Based Mentoring Network (WBMN) is currently under development in a beta-test format. This program, which will be launched in Fall 2002, will allow medical students in our clinics to submit patient profiles and nutrition questions into a computerized data field. This patient evaluation will then be edited by faculty and shared with the allied healthcare network. A final case presentation will occur with input from medical students, clinical staff, basic scientists, community medicine and allied healthcare professions. It is our hypothesis that learning nutrition in a student-centered format, alongside the allied healthcare professions will promote a more comprehensive community-based medical practice in our students’ career practice plans. The WBMN is currently being designed as a transportable module, for incorporation into other medical schools that desire to incorporate this student-centered, collaborative interdisciplinary approach in their curriculum.

View larger version (17K): [in this window] [in a new window]   FIGURE 2 Longitudinal and horizontal integration of nutrition components at MUSM.

	Medical nutrition education project evaluation

TOP ABSTRACT Medical education at Mercer Year one and Year... An interdisciplinary model for... Historical rationale for... Healthy People 2000 set... Medical nutrition education... Progress to date Baseline Nutrition Attitude... Anticipated future problems and... LITERATURE CITED

The evaluation plan will be constructed and implemented at two levels: 1) the general evaluation of the project, process and progress toward Curriculum Objectives for CVD prevention by the NAA-Core Committee, and 2) the plan and product evaluation of the individual program modules by the faculty and students involved in the program, and by outside evaluators. When funding of the CVD project occurs, a detailed evaluation plan at Level 1 will be constructed. The individual program task forces will be involved in constructing the evaluation plan at Level 2. The evaluation plans will include additional specificity and operationalization of objectives; construction and modification of a detailed time line specifying all activities and completion dates; and plans to obtain or construct all evaluative surveys, questionnaires (especially the Longitudinal Progress Survey) and communication and reporting guidelines.

With regard to our approach for each of the evaluation components:

1. Context evaluation, needs assessment and problem diagnosis: On a preliminary level, this stage of evaluation has already been conducted by the NAA-Core Committee composed of the PI and Co-Investigators of the proposal through the use of published objectives and interviews with program directors and faculty. Incorporation of our faculty as stakeholders into the problem diagnosis was considered essential even before grant application.
   
2. Input evaluation including resource requirements and allocation: On a very general level, the required resources have been identified and the requirements for external funding incorporated into a budget. General internal resource allocation, such as the commitment of faculty time, has received the approval of the administration. Detailed allocation and planning, such as the WBMN, and expansion of an Allied Healthcare Network will occur this year (2002), and in years four and five.
   
3. Process evaluation: This will be an ongoing part of the formative evaluations and will include identification of problems in implementation.
   
4. Product evaluation: Each of the individual program modules is itself a product that will be individually evaluated with respect to quality (accuracy, validity with respect to addressing the needs of practicing physicians treating medically underserved and at-risk populations, utility and impact as a teaching format). In addition, student feedback into questionnaires for each of the programs will be used for evaluation and revision. In programs using the WBMN, the evaluation can be web based. Outside evaluation of the modules is anticipated through review from other NAA schools and consultants.
   
5. Impact/outcomes assessment: Proposed criteria include: a) Course modification at MUSM to incorporate Curriculum Objectives for CVD Prevention, as judged from written documentation (syllabi, BMP problems, examinations). b) Student performance of the various evaluations used in each program. c) The Longitudinal Progress Survey of Students (27 –30 ) using a multivariant design with ANOVA with covariant measures (31 ). This will be administered to students during orientation, at the end of the 2nd y, and at the end of the clerkship rotations and used to follow changes in knowledge level and attitude of the student as well as the adequacy of the overall curriculum content with respect to CVD prevention objectives. d) Increased student selection of CVD prevention topics in Community Science programs and selection of nutrition residency elective. An increase in the number of CVD-related research projects undertaken during the Clinical Research phase will be monitored. Students will be encouraged to publish their research. The publication of these projects thus provides us with an additional outcome measurement. e) Postgraduation survey on the incorporation of CVD prevention objectives into clinical practice. This survey will also be constructed by our consultant biostatistician, who has distributed similar surveys to our graduates with an over 90% return (32 ). In each successive year, we should be able to note improved performance, in that each successive class will have participated in the program for a longer period of time. The survey will have to distinguish between students who have participated in the project residencies, and those who have performed residencies elsewhere. f) Expansion and increased interaction with the programs participating in the Allied Healthcare Network, as well as expansion into continuing medical education and other programs.
   

	Progress to date

TOP ABSTRACT Medical education at Mercer Year one and Year... An interdisciplinary model for... Historical rationale for... Healthy People 2000 set... Medical nutrition education... Progress to date Baseline Nutrition Attitude... Anticipated future problems and... LITERATURE CITED

 
Knowledge domain.

Several curricular enhancements have been vertically integrated throughout undergraduate medical education. NCVD is in the process of incorporating objectives from the NAA Nutrition Curriculum Guide for Training Physicians. In Community Medicine a 2-h session on "Disease Prevention and Health Promotion" is introduced to 1st-y med students. (Sessions on primary, secondary and tertiary prevention were reviewed and revised to reflect greater emphasis on prevention.) In the Basic Science Biomedical Problems Program (BMP), nutrition for disease prevention is incorporated in all BMP phases. As an enhancement to the current case histories, several areas including Cellular Basis of Medicine, Cardiology and Endocrinology were areas chosen for enhanced inclusion. The Clinical Skills Program will include nutrition as part of medical history taking, diet and lifestyle counseling and procedures for conducting patient exams.

Practice skills domain.

In Clinical Skills a preclinical medical student wellness program is proposed in support of the NCVD prevention program. Standardized patients and clinical integration are also proposed, based on published recommendations of the Society for Teachers of Family Medicine. For our 3rd- and 4th-y students, we propose web-based learning modules, and have completed modules in Family Medicine (Breast Cancer and Nutrition), Internal Medicine (Preoperative Nutrition), Obstetrics and Gynecology (Breast Cancer and Nutrition), Pediatrics (Approach to the Overweight Child or Adolescent) and Surgery (Preoperative Nutrition). These modules are designed with respect to nutrition/diet/exercise, socioeconomic status, behavior modification and networking with allied health professionals.

The curriculum objectives for CVD prevention at MUSM were assembled by the core committee, which represented the departments of Basic Sciences, Community Medicine and Family Medicine, as well as a preceptor for rural medical practice (Fig. 1) . Once curriculum objectives were established, the core committee surveyed the current content of the 4-y medical school curriculum and the residency programs in Family Medicine, Internal Medicine and Pediatrics through examination of course syllabi and interviews with the directors of individual programs; only then did they develop the process plan. During interviews with the various directors, the goals of the project were explained and advice and suggestions were solicited to best enhance the CVD prevention component of each program.

	Baseline Nutrition Attitude Survey

TOP ABSTRACT Medical education at Mercer Year one and Year... An interdisciplinary model for... Historical rationale for... Healthy People 2000 set... Medical nutrition education... Progress to date Baseline Nutrition Attitude... Anticipated future problems and... LITERATURE CITED

 
Attitude domain.

A baseline measure for evaluation of the medical curriculum in nutrition was conducted in Fall 2001 by use of McGaghie’s (33 ) Nutrition In-Patient Care Survey (Table 1 ). All medical students, medical residents and faculty (excluding those who do not teach med students) were administered the survey at the beginning of the 2001 school year. Respondent classifications were precoded for students and were specified in items 1–4 for faculty and residents. A 45-item survey identified physician efficacy/effectiveness and patient attributes in a Likert scale. Responses for clinical care activities were dichotomous. Statistical analyses were conducted by ANOVA among student results, and T-tests were used to analyze differences between groups. These preliminary results are described below.

On average, 1st-y medical students disagree to nutrition in routine care. Their mean response is significantly different from 3rd-y med students (those entering clinical clerkships) who are more uncertain about nutrition in routine care. Second- and 4th-y med students share beliefs of both disagreement and uncertainty of nutrition in routine care.

Clinical behavior.

MUSM student means for clinical behavior show that 20% is the highest expected mean for response supporting nutrition in clinical care activities.

Physician–patient relationship.

MUSM students generally disagree to nutritional health discussions in physician–patient relationships.

Patient behavior motivation.

MUSM students are equally ambivalent to motivating patient nutrition behaviors.

Physician efficacy.

Student opinions on the physician’s constructive role in nutritional health lie between uncertainty and disagreement.

	Anticipated future problems and proposed solutions

TOP ABSTRACT Medical education at Mercer Year one and Year... An interdisciplinary model for... Historical rationale for... Healthy People 2000 set... Medical nutrition education... Progress to date Baseline Nutrition Attitude... Anticipated future problems and... LITERATURE CITED

 
With the incorporation of a nutrition component across the medical school curriculum, one can anticipate and enumerate a number of proposed obstacles. Proposed changes in curricular content encounter problems of overload, issues of control and inertia based on limited faculty time. In each of the programs discussed, faculty have indicated a willingness to increase the CVD prevention component of that program, partly because the comparison with curriculum objectives for CVD prevention illustrated the need; the modules proposed fit comfortably into existing formats; the program/clerkship directors remain in control; and the NAA-Core Committee and Resource Collaborators are providing the expertise and resources for the development and evaluation of the modules. The extensive vertical and horizontal nature of the project make it sound very complex and ambitious. There are a number of factors that will facilitate the project and contribute to its feasibility. In the teaching programs of the first 2 y, we will be enhancing the CVD prevention curriculum already in existence in formats ideally suited for the project. In the clerkships and residency training programs, program directors have requested the same type of module, one using case-based WBMN.

At MUSM, clinical and basic science faculty are already integrated into the teaching programs, an advantage of a small school where teaching is a major responsibility of the faculty. The horizontal integration with the Allied Healthcare Network will depend largely on how the faculty in external schools wish to incorporate it into their teaching programs. We can rely directly on our own personnel if their involvement becomes limited. Dissemination of modules to schools with different types of curriculum could pose a problem. Our problem-based format is an advantage in that content and specifically delineated nutrition objectives are already organized around case histories, making them relatively easy to transport into other programs that are using problem- or patient-based sessions to supplement more traditional teaching methods. The proposed features/objectives of the Clinical Skills and Community Science programs most important for CVD prevention might be the most valuable for transport into, or comparison with, curricula in other medical schools.

	FOOTNOTES

 
¹ Presented as part of the symposium "Innovative Teaching Strategies for Training Physicians in Clinical Nutrition: The Nutrition Academic Award (NAA) Medical Schools" given at the 2002 Experimental Biology meeting on April 20, 2002, New Orleans, LA. The symposium was sponsored by The American Society for Nutritional Sciences. The proceedings are published as a supplement to The Journal of Nutrition. Guest editors for the symposium were W. Allan Walker, Division of Nutrition, Harvard Medical School, Boston, MA, and Brian Tobin, Division of Basic Medical Science, Mercer University School of Medicine, Macon, GA.

³ Abbreviations used: BMEH, Biomedical Ethics and Humanities Program; BMP, Biomedical Problems Program; CHD, coronary heart disease; COPP, Community Office Practice Program; CVD, cardiovascular disease; MUSM, Mercer University School of Medicine; NAA, National Academic Award Program; WBMN, Web Based Mentoring Network.

	LITERATURE CITED

TOP ABSTRACT Medical education at Mercer Year one and Year... An interdisciplinary model for... Historical rationale for... Healthy People 2000 set... Medical nutrition education... Progress to date Baseline Nutrition Attitude... Anticipated future problems and... LITERATURE CITED

 

1. Dever, G.E.A. (1984) Epidemiology: focus on prevention. Epidemiology in Health Services Management 1984 Aspen Publishers Gaithersburg, MD.

2. National Research Council (NRC) (1989) Diet and Health: Implications for Reducing Chronic Disease Risk 1989 National Academy Press Washington, DC.

3. Public Health Service (1988) The Surgeon General’s Report on Nutrition and Health 1988 U.S. Government Printing Office Washington, DC.

4. Kretchmer, N. (1994) Nutrition is the keystone of prevention. Am. J. Clin. Nutr. 94:60-61.

5. American Dietetic Association (ADA) (1995) Position of the American Dietetic Association: Cost-effectiveness of medical nutrition therapy. J. Am. Diet. Assoc. 95:88-91.[Medline]

6. American Dietetic Association (ADA) (1995) ADA urges congress to expand Medicare coverage for medical nutrition therapy. J. Am. Diet. Assoc. 95:974.[Medline]

7. The Panel on the General Professional Education of the Physician (GPEP) and College Preparation for Medicine (1984) Physicians for the Twenty-first Century. The GPEP Report 1984 Association of American Medical Colleges Washington, DC.

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13. Weinsier, R. J., Boker, J. R. & Brooks, C. M., et al (1989) Priorities for nutrition content in a medical school curriculum: a national consensus of medical educators. Am. J. Clin. Nutr. 50:701-712.

14. Boker, J. R., Weinsier, R. L., Brooks, C. M. & Olson, K. A. (1990) Components of effective clinical-nutrition training: a national survey of graduate medical education (residency) programs. Am. J. Clin. Nutr. 52:568-571.[Abstract/Free Full Text]

15. Weinsier, R. L., Boker, J. R. & Brooks, C. M., et al (1991) Nutrition training in graduate medical (residency) education: a survey of selected training programs. Am. J. Clin. Nutr. 54:957-962.[Abstract/Free Full Text]

16. U.S. Department of Health and Human Services, Public Health Service (1990) Healthy People 2000. National Health Promotion and Disease Prevention Objectives. DHHS Publication No. PHS 91-50212 1990 U.S. Government Printing Office Washington, DC.

17. American Heart Association (1998) 1999 Heart and Stroke Statistical Update 1998 American Heart Association Dallas, TX.

18. American Heart Association and Georgia Department of Human Resources, Division of Public Health (1998) 1999 Georgia State of the Heart Report 1998 American Heart Association and Georgia Department of Human Resources Atlanta, GA.

19. Centers for Disease Control and Prevention (1998) Georgia Health Profile 1998:1998 Centers for Disease Control Atlanta, GA.

20. Stufflebeam, D. L. (1969) Evaluation as enlightenment for decision making. Walcott, A. B. eds. Improving Educational Assessment and an Inventory of Measures of Affective Behavior 1969 Association for Supervision and Curriculum Development Washington, D.C. .

21. Stufflebeam, D. L. (1971) Educational Evaluation and Decision Making 1971 Peacock Publications Itasca, IL.

22. Stufflebeam, D. L. & Shrinkfield, A. J. (1985) Systematic Evaluation 1985 Kluwer-Nijhoff Boston, MA.

23. The Joint Committee on Standards for Educational Evaluation, James R Stevens, Chair (1995) The Program Evaluation Standards 2nd ed. 1995 How to Assess Evaluations of Educational Programs. Sage Publications Newbury Park, CA.

24. University of Texas–Houston Health Science Center School of Public Health and the Texas Department of Health (1998) Evaluation of Public Health Programs Workbook 1998 The Public Health Training Network Centers for Disease Control, Atlanta, GA.

25. Rossi, P. H. & Freeman, H. E. (1989) Evaluation: A Systematic Approach 4th ed. 1989 Sage Publications Newbury Park, CA.

26. Frechtling, J. A. (1993) User-friendly Handbook for Project Evaluation in Science, Mathematics, Engineering and Technology Education 1993 Department for Education and Human Resources National Science Foundation, Washington, DC.

27. Cochran, W. G. (1977) Sampling Techniques 3rd ed. 1977 John Wiley & Sons New York, NY.

28. Fink, A. (1995) How to Ask Survey Questions 1995 Sage Publications Thousand Oaks, CA.

29. Bourque, L. B. & Fielder, E. P. (1995) How to Conduct Self-administered and Mail Surveys 1995 Sage Publications Thousand Oaks, CA.

30. Fink, A. (1995) How to Design Surveys 1995 Sage Publications Thousand Oaks, CA.

31. Morrison, D. F. (1976) Multivariate Statistical Methods 2nd ed. 1976:170-229 McGraw-Hill New York, NY.

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