Development of a Clinical Nutrition Elective for an Internal Medicine Residency Program

Introduction: A foundational knowledge in nutrition is necessary for internal medicine (IM) residents to identify patients with malnutrition and translate basic nutrition guidelines to improve patient care. However, the majority of medical schools and residency programs do not offer clinical training in nutrition. Therefore, it is imperative that residents have nutrition education incorporated into their training. Methods: IM residents at our institution were surveyed to assess exposure to nutrition education, baseline knowledge in areas of nutrition, interest in learning specific nutrition topics and desire to complete a clinical nutrition elective. A two-week curriculum covering inpatient and outpatient nutrition care was developed in collaboration with the Center for Human Nutrition. Results: Forty residents completed the survey. Responders were from all years of training with various career plans after residency. 55% of residents had no prior exposure to clinical nutrition. Only 10% of residents felt they possessed the knowledge to diagnose malnutrition, and only 3% felt confident determining the nutritional needs of their patients. A minority of residents felt comfortable identifying indications for enteral nutrition (30%) and parenteral nutrition (25%), or making nutritional recommendations in a primary care setting (18%). Residents were most interested in learning how to perform a nutrition assessment and determine nutritional requirements (93%), as well as initiate and manage enteral nutrition (93%) and parenteral nutrition (85%). 90% of residents were interested in completing a clinical nutrition elective during their training (Table 1). The 2-week nutrition elective was designed to allow didactic training through e-learning modules and hands on training with registered dietitians (RD). Rotations involved working with RDs for education and direct care in the intensive care unit, regular nursing floor, enteral access team, nutrition support team and ambulatory setting. Clear objectives were developed for each nutrition area which included how to identify and diagnose malnutrition, estimate energy and protein needs and how to choose optimal nutritional interventions for patients based on their disease process. Conclusion: Internal medicine residents lack the exposure and knowledge required to address a majority of nutrition related care. Residents are interested in learning various nutrition topics. Implementing a clinical nutrition elective may be effective in addressing this gap in training. Table 1. - Clinical Nutrition Elective Needs Assessment Results N (%) Total Responses 40 (100%) Current PGY level PGY-1 16 (40%) PGY-2 11 (28%) PGY-3 13 (33%) Career plans after residency Hospital Medicine or Primary Care 6 (15%) Gastroenterology / Hepatology 13 (33%) Cardiology 9 (23%) Other Internal Medicine Subspeciality 12 (30%) Previous exposure to clinical nutrition Medical school course 14 (35%) Clinical rotation during medical school 3 (8%) None 22 (55%) I currently possess the knowledge / skills to address the following clinical scenarios: Strongly Disagree Disagree Neutral Agree Strongly Agree Diagnosing protein-calorie malnutrition 33% 43% 15% 10% 0% Determining protein, calorie and micronutrient requirements 38% 45% 15% 3% 0% Identifying indications for enteral nutrition 20% 28% 23% 30% 0% Managing complications of enteral nutrition 23% 38% 20% 20% 0% Identifying indications for parenteral nutrition 20% 25% 30% 25% 0% Managing complications of parenteral nutrition 20% 45% 28% 8% 0% Making nutritional recommendations in a primary care setting 18% 40% 25% 18% 0% Nutrition topics of interest Nutrition assessment & determination of nutritional needs 37 (93%) Inpatient general nutrition 31 (78%) Enteral nutrition: initiation & management 37 (93%) Parenteral nutrition: initiation & management 34 (85%) ICU nutrition 26 (65%) Outpatient general nutrition 27 (68%) Outpatient subspeciality nutrition (I.e., Gastroenterology, obesity) 26 (65%) Residents interested in completing a clinical nutrition elective Yes 36 (90%) No 0 (0%) Unsure 4 (10%)