Clinical nutrition in primary care: An evaluation of resident physicians' attitudes and self-perceived proficiency

Summary

Background & aims

There is little information regarding the impact of clinical nutrition training among medical residents. We aimed to evaluate the attitudes, self-perceived proficiency and knowledge of Swiss residents regarding clinical nutrition.

Methods

Cross-sectional study conducted between June and September 2014 in two medical education facilities located in Lausanne, Switzerland. Attitudes, self-perceived proficiency and knowledge regarding clinical nutrition were assessed by questionnaire.

Results

Of the 88 internal medicine residents queried, 44 (50% response rate, 25 women, mean age 34 ± 4 years) answered the questionnaire. Three quarters of the residents were trained in Switzerland and one third reported receiving some training in clinical nutrition. Seven out of ten (70.5%) residents agreed that all doctors should know how to provide nutrition-based assessment, no matter what their specialty. Conversely, only one out of ten (11.4%) felt that physicians were adequately trained. No differences were found between genders or country of training regarding the answers provided.

Conclusion

Residents in Lausanne perceive clinical nutrition in primary care as a priority but lack the confidence and training to effectively use clinical nutrition in their daily practice.

Introduction

Nutrition in primary care is an effective and necessary preventive health care measure. In a study of the effects of nutrition counseling for overweight and obese patients, physicians who were using patient-centered and motivational nutrition counseling techniques were more successful in improving the fat and fiber intake scores and raising confidence to improve clinical nutrition of their patients [1]. Another study found that a computer-assisted intervention to improve physical activity and dietary behavior based in primary care setting was feasible and promising [2]. Surveys in both Switzerland and the US have found that the overwhelming majority of providers agree that preventive care should be a part of their daily practice, and that clinical nutrition is an important aspect of primary care [3], [4].

Despite the importance of nutrition in primary care, training in nutrition is often insufficient in most medical schools [5], [6], [7]. Also, the barriers to clinical nutrition in primary care are substantial, such as time restraints and challenges in patient motivation. In 1993, a survey found that fewer than 40 percent of US physicians regularly practiced at least 17 out of 50 nutrition-related “core competencies” [8]. Between 2000 and 2005, the Healthy People and US Preventive Task Force of 2010 found in their midcourse review that the proportion of office visits including clinical nutrition declined from 42 to 40 percent [4]. In Switzerland, the second-most cited barrier to clinical nutrition in primary care was the lack of training (second only to time restraints) [3]. In the US, lack of training was the most cited barrier [9], [10], and a study suggested that medical students' perception of the importance of clinical nutrition decreases during medical school [11]. Another study surveying US resident physicians found that those in the midst of their training felt that they were not receiving enough training in clinical nutrition [12].

Switzerland is a small European country with one of the best health systems worldwide [13]. The system is universal but administered on a local basis (cantons); Swiss citizens and established foreign residents must purchase individual health insurance coverage from local insurance companies. For persons covered by non-managed care insurance, services are provided of a fee-for-service basis by any primary care provider in the canton. Subjects covered by managed care insurance can opt for 1) health maintenance organizations; 2) networks of general practitioners with a contract with an insurer, and 3) a fee-for-service plan with a gate-keeping (i.e. phone consultant) system [14], [15]. Primary care is provided by doctors trained in general internal medicine. Since 2011, there is only a single specialist title for general internal medicine, including both general internal medicine physicians and family physicians. Importantly, no information was collected regarding perspectives and confidence levels of physicians toward clinical nutrition.

Thus, the aim of this study was to determine the state of clinical nutrition education and application of clinical nutrition in primary practice, by evaluating the attitudes and self-perceived proficiency of medical residents in Lausanne, Switzerland. In this study, we considered clinical nutrition as any nutritional care provided by clinicians, and nutritional counseling as a one component of clinical nutrition [16].