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Getting nutrition education into medical schools: a computer-based approach^1,2,3,4

¹ From the Department of Nutrition, School of Public Health, School of Medicine, University of North Carolina at Chapel Hill.

² Presented at a symposium held at Experimental Biology ‘99, in Washington, DC, April 17, 1999.

³ Supported in part by grants from the NIH (National Cancer Institute R25 5-53169, and Office of Dietary Supplements), the US Department of Agriculture (5-36322), American Institute for Cancer Research, Baxter Healthcare Corporation, Bristol-Myers Squibb Company, Clintec International Inc, Dannon Institute, Egg Nutrition Board, Kellogg Company, National Cattlemen's Beef Association, National Dairy Council, Nestlé USA Nutrition Division, New York Community Trust, Quaker Oats Foundation, The University of North Carolina at Chapel Hill, and Wyeth-Ayerst Laboratories.

⁴ Address reprint requests to SH Zeisel, Department of Nutrition, University of North Carolina at Chapel Hill, CB#7400, Chapel Hill, NC 27514-7400. E-mail: steven_zeisel{at}unc.edu.

	ABSTRACT

TOP ABSTRACT INTRODUCTION COMPUTERIZED EDUCATION IN... Rationale for Nutrition in... Description of the modular... IMPLEMENTATION OF NIM AT... EFFICACY TESTING USE OF NIM WITH... IMPLEMENTATION SUGGESTIONS INSTRUCTOR SUPPORT CONCLUSION REFERENCES

 
Despite awareness of the importance of nutrition as part of medical student's education, numerous barriers exist to incorporating nutrition education into the medical school curriculum. Chief among such barriers is that most medical schools do not have faculty trained specifically in nutrition. A curriculum is needed that can deliver comprehensive nutrition information that is consistent across medical schools. One way to deliver this information is to use computer-assisted instruction (CAI). To meet the different needs of medical schools and provide a consistent base of nutrition information, we developed a series of interactive, multimedia educational programs (Nutrition in Medicine) that teach the basic principles of nutritional science and apply those principles in a case-oriented approach. Curriculum content is derived from the American Society for Clinical Nutrition consensus guidelines. These modules offer the advantages of accessibility, self-paced study, interactivity, immediate feedback, and tracking of student performance. Modules are distributed free to all US medical schools. Preliminary data from surveys gathered by our team at the University of North Carolina at Chapel Hill indicate that 73 US medical schools use, or are planning to use, these modules; more schools are currently evaluating the programs. Successful implementation of CAI requires easy program access, faculty training, adequate technical support, and faculty commitment to the programs as a valuable resource. CAI fails when the program is just placed in the library and students are told to use it when they can find the time.

Key Words: Medical education • nutrition education • computer-assisted instruction • curriculum • problem-based learning • medical students • clinical competence

	INTRODUCTION

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Medical school graduates must master many skills and concepts before their training is complete. They must become proficient in basic science concepts and clinical decision-making and must possess sufficient knowledge to begin assessing patients and providing basic therapy for the treatment of identified problems. Although diet plays a significant role in the onset and progression of 5 of the 10 leading causes of death (1), nutrition knowledge has not always been included in the catalog of required medical skills and competencies. The need to incorporate nutrition into the medical school curriculum has been widely recognized (2–8) and the urgency of this issue has led many organizations to call for change in medical school curricula (1, 3, 6, 9–13). The federal government decreed that nutrition education be an integral component of medical education [the National Nutrition Monitoring and Related Research Act (14) mandates that 50% of the physician pool be adequately trained in nutrition]. The Dietary Supplements Health Education Act of 1994 (15) and the Public Health Service's Year 2000 Objectives for the Nation (16) also called for medical student education in nutrition. Efforts have increased to ensure adequate coverage of nutrition in the US medical licensing examination (9, 11), providing a powerful incentive for medical schools to cover nutritional knowledge.

In 1991, despite awareness of the importance of nutrition as part of medical students' education, the Association of American Medical Colleges (AAMC) reported that of 128 US medical schools, only 23% (29 schools) had a required nutrition course, with an average of <6 h of class time; 25% of schools failed to offer any formal nutrition education (17). In the past decade progress has been slow. The AAMC raw data for the 1997–1998 academic year reported that 26% of schools had a required nutrition course whereas 25% of schools still did not require or could not quantify nutrition education in their programs (3). There is reason to believe, however, that this is an underestimate of the extent of nutrition education in US medical schools. Preliminary data from a survey conducted by our team at the University of North Carolina at Chapel Hill (UNC-CH) indicate that, of responding medical schools (95 responding of 119 surveyed), 70 now offer some nutrition education (Table 1; K Adams, H Morehouse, C Plaisted, unpublished observations, 1998–1999). The schools that require nutrition education report that they provide, on average, 6 h of this education. Although there has been some improvement during this decade, far more work remains to be done.

	COMPUTERIZED EDUCATION IN MEDICINE

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Computerized instruction is fast becoming a large component of education, including medical education. Educational instruction has progressed from using computers as an adjunct to teaching, to delivering core material to students, to offering entire (nonmedical) degrees online (18). Currently, information technology allows students to access electronic syllabuses, medical journals, and libraries of images; learn science concepts in an interactive medium; listen to digitized heart rhythms and breath sounds; and even simulate practice of surgical techniques. Case study presentations are changing too, from a lecturer giving a history of a patient and asking students questions, to virtual cases in which the students make the decisions and witness the (virtual) outcomes.

There are many reasons medical institutions should embrace computer technology. CAI offers advantages of accessibility, consistency, self-paced study, interactivity, immediate feedback, and tracking. Online testing is beginning to be used; this year marks the first year that the medical licensing exams were given as a computer-based test (19).

A policy requiring students to have computers has been adopted at many institutions, a trend that is expected to continue in medical schools (18). However, it is important to note that it is our experience as well as that of others (20–23) that institutional commitment beyond the requirement for hardware and software purchasing is requisite for successful implementation of CAI in any medical school curriculum. Faculty need to be shown how to use and integrate CAI into their existing courses, adequate support in terms of training and technical problem-solving must be available to users, access to CAI must be easy, and the CAI or other online resources should be perceived as valuable. CAI fails when it is just placed in the library and students are told to use it when they can find the time, or when the program is given to students to do on their own without guidance or class involvement. Including content from CAI when testing and incorporating the material in class discussions underscores the relevance and importance of the content to students.

	Rationale for Nutrition in Medicine

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To meet the widely different needs of medical schools and to provide a consistent base of nutrition information, the Nutrition in Medicine (NIM; copyright UNC-CH) programs were developed. This fully electronic curriculum allows for the implementation of nutrition education into the medical school curriculum without depending entirely on a comprehensive group of nutrition educators, which does not exist at most medical institutions. The NIM modules were designed to teach the basic principles of nutritional science and to apply those principles in a case-oriented approach with the goal of presenting nutrition information in an understandable and enjoyable way that will enhance learning (24). The NIM modules represent an independent nutrition curriculum. Widespread dissemination of nutrition principles throughout other courses is not ideal: unless the relevance and unique aspects of nutrition are made evident, it is easy for students to complete a course and to be unaware that they learned about nutrition (25). Because the series is comprehensive, medical faculty who may not have expertise in a specific area of nutrition can still cover all relevant topics. By helping to fill in gaps, the NIM curriculum can serve as an alternative to a multi-instructor course. The modules are distributed free to all US medical schools, specifically to the faculty member who is responsible for teaching nutrition (for information see www.med.unc.edu/nutr/nim).

Medical educators, expert nutrition panels, and medical students themselves, have published guidelines for topics and scope of nutrition coverage that medical students should master (5, 9, 26). The American Society for Clinical Nutrition consensus guidelines were instrumental in the development of the NIM curriculum (27). In addition, within our own department at UNC-CH we have a full range of curricula in nutrition for undergraduate, graduate, and medical training. Our faculty provides comprehensive nutrition expertise; many of our faculty members have contributed to the development and implementation of the NIM curriculum and serve as valuable resources to the project. Further, an advisory board of nutrition experts from academia, government, and industry has been instrumental in providing ongoing review and guidance throughout the development and implementation process. For example, the advisory board provided valuable feedback for the development of the program interface. The first approach used a hypercard (index card) user interface accessed via a map of the course. The advisory board cited problems such as linearity of learning, lack of flexibility in navigation, and poor integration with multimedia. The design was then modified in response to the initial reviews and first user reports. We developed an innovative and flexible educational format that took advantage of the interactive capabilities of technology as reflected in the current structure of the NIM modules.

The goals of the NIM curriculum are as follows:

1. Motivate students to consider nutritional factors in medical decision-making.
   
2. Teach the role of nutrition in prevention and treatment of disease.
   
3. Familiarize students with criteria to use to distinguish between sound nutrition and food faddism.
   

There are 3 topic series in the NIM programs; asterisked titles in the list below indicate that the module has been released to medical schools, the rest are in production for release in 2000–2002. Titles include The Disease Series (Nutritional Anemias*; Nutrition and Stress*; Nutrition and Cancer*; Diet, Obesity and Cardiovascular Disease*; and Diabetes and Weight Management: Aberrations in Glucose Metabolism*) (28–32); the Lifecycle Series (Maternal and Infant Nutrition* (33), Nutrition and Growth*, and Nutrition for the Second Half of Life), and the Special Topics In Nutrition Series (Nutrition Supplements and Fortified Foods, and Sports Nutrition).

An overview of the content and video case study of each topic is listed in Table 2 and the scope of nutrition information across the entire series is provided in Table 3. When the entire series is complete, all the basic nutrition concepts, from function and sources of a particular nutrient to counseling patients on dietary changes, will be covered in the curriculum.

	Description of the modular elements of the NIM series

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The student then studies the first lesson topic; each section opens up with the learning objectives for that section. Lessons present the basic science of nutrition within the context of a disease, life cycle stage, or other relevant setting. Students are presented with visual and audio information, medical illustrations, and animations. The material is interspersed with interactive exercises that test knowledge or allow further exploration of the topic. Sample screens from the programs are shown in Figure 1. At the end of a series of lessons, the key concepts from the lessons are displayed to emphasize the take-home messages. Before returning to the virtual patient case, a short text-based case study is presented. Students are asked to respond to 3 questions and then receive immediate feedback to their response.

View larger version (111K): [in this window] [in a new window]   FIGURE 1. . Selected screens from Nutrition in Medicine. Four examples of instructional approaches used in various modules: top left, illustrations link the nutrients in foods to their specific metabolic role; top right, illustrations of nutritionally important metabolic relations; bottom left, the video case models the role of nutrition in clinical decision-making; bottom right, key concepts are reinforced with interspersed quizzes.

Students can use the 3 board-type exams provided with each CD-ROM as a pre- or posttest or as a study guide. An electronic glossary, index, and reference section provide additional user resources. For example, the reference section offers the following components: anthropometric procedures, nutrient allowances, diagnostic tests, nutritional assessment, food labeling, further readings, and bibliography.

An optional tracking feature records test scores, measures time spent, and monitors which parts of the program were viewed and then stores these data on a floppy disk. The latest modules (versions 2.5 and later) in the series allow this function to be set by instructors who wish to monitor student use and performance. Another feature bookmarks the sections that have been viewed already; this is particularly useful when viewing the programs in multiple sessions.

New way of teaching
Whereas CAI is becoming more widely used and is shown to be efficacious (34–36), it represents quite a departure from the more traditional teaching method of lectures, seminars, and problem-based learning. Limitations of more traditional methods of teaching include requirement of significant faculty time, limited portability, and a high degree of variation between instructors and between institutions. Advantages and disadvantages of CAI are listed in Table 4. Students and faculty often prefer the direct contact provided by the traditional lecture and seminar formats because it helps instructors to tailor their presentation to a particular audience and to respond with great flexibility to the individual needs of students. CAI provides consistency of information across presenters and institutions, allows instructors to focus on advanced topics, and permits faculty to spend more time working with students on synthesis and application of the learned concepts.

	IMPLEMENTATION OF NIM AT UNC-CH

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Computer-based nutrition instruction of medical students has been used at UNC-CH since 1994. The first module, Nutritional Anemias, was used by freshman medical students who volunteered to participate in a formative evaluation study. Since 1995 computer-based instruction of the class with >160 first-year students has been an integral and required part of the nutrition course. Starting this academic year, 1999–2000, the course is given to second-year students and includes modules from the entire NIM disease series. The other modules will be used during the third and fourth years.

Over the years, several issues have emerged that have significantly affected the delivery of instruction: computer platform, faculty support, time requirements, student acceptance, and note-taking ability. The following observations relate to the use of NIM at UNC-CH in 1997, unless noted otherwise.

Computer platform
Initially, NIM programs were accessible at all times on 10 dedicated computers located both at a central computer lab and at the students' labs. Network delivery of the programs was available, but at peak times was too slow to deliver to more than a few students simultaneously. It proved more practical to provide the complete set of CDs for each computer. In 1997 the UNC-CH medical school introduced a uniform computer requirement. All students were required to have the same laptop computer model preloaded with identical system software and other programs, including the NIM modules. Medical school staff provided introductory training for using the various hardware and software components. The provision of full technical support reduced barriers to rapid attainment of competent and effective utilization of the offered electronic resources.

Faculty support
The course directors provided an introduction of the nutrition modules to small groups of students and explained the role of the programs in the course. A weekly discussion group headed by a faculty member was instituted to provide support to instructional content and technical issues. E-mail was an efficient and vital support element for the implementation of the nutrition computer modules. Messages were sent frequently to remind students of deadlines, provide updates on technical issues, respond to frequently asked questions, and send supporting instructional material (such as key concepts and sample questions). Students also used e-mail as the preferred method of contacting faculty. About one-third of the students e-mailed questions about the instructional content of the nutrition modules that were generally answered on the same day.

Time requirements
Representative program use was tracked for the Nutrition and Cancer module and recorded on local floppy disks. Of the 163 students taking the course, 116 turned in their disks with readable tracking data and 91 of these had completed all sections. Use time (which included all idle times) varied widely, ranging from 1.2 to 15.5 h with a median of 4.8 h. The 8 students who did not take any of the practice exams spent a median of 2.7 h with this module and the 16 students who completed only 1 of the 3 practice exams (20 questions each) spent a median of 3.5 h with the module. Anecdotal comments from students who took longer to complete the cancer program indicated that they viewed sections more than once and made use of the optional resources (eg, general information on recommended intakes, assessment techniques, and biomarkers).

Student acceptance
Our course was offered in August and, as incoming freshmen, many students felt overwhelmed by their other course work and considered the need to use their computers for studying an extra burden. They were almost equally divided in their opinion of the usefulness of the computer modules. The most common complaint was the time requirement. On the other hand, many students liked that they could view the presentation at a time of their own choosing, usually in several sessions, learn at their own pace, and have control over the sequence in which to use the sections within a program. Several students commented that studying the material changed their own dietary habits and that they subsequently teased each other about any unfavorable food selections.

Note-taking ability
Students still have little experience with computer-based instruction and their learning habits are often based on the traditional model of note-taking during lectures and then reviewing these notes at a later time. When surveyed at the end of the course, more than half of the students responded that taking notes was indispensable. We now provide a half-page sized space for notes on printed handouts (available for printing on the CD-ROMs). These handouts summarize overall module objectives and key concepts for each major topic section and help those students who later want to be able to quickly review the core content on paper.

	EFFICACY TESTING

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Thus far, the efficacy of use of the computer programs to teach nutrition concepts has been evaluated most extensively at UNC-CH with the Nutrition and Cancer module. In 1996 the 160 incoming medical students were invited to participate in a voluntary study. The 65 students who volunteered were randomly assigned either to a group who would use the computer module for studying or to a control group who were presented with the same material in a traditional 85-min lecture by one of the authors of the program. Learning efficacy was tested by comparing performance on nonidentical, written, 20-item exams before and 1 wk after the lecture. The computer group's average score increased slightly more than the score of the lecture group (38% compared with 14%; P < 0.01). Note that in 1996 the grade on this exam was not used in calculating the course grade.

In 1997 the gain in test performance of the entire class was tested (36), this time without a control group and with a repetition of the test items. Correct responses increased from an average of 22% before using the program to 86% immediately after completion of the module, and then fell to 62% on the retention test 3 mo later. Note that in 1997 the grade on this exam was used in calculating the course grade. The students' subjective learning experience was evaluated on a 5-point Likert scale (2 = disagree that I am knowledgeable, 4 = agree that I am knowledgeable). Confidence in their knowledge about nutritional issues involving cancer increased from an average 1.9 to 3.5. Students also felt more confident in their ability to give advice to patients about nutritional cancer prevention (scores increased from 1.8 to 3.6). These data show that the tested module is an effective tool for teaching basic principles of nutrition to our medical students.

	USE OF NIM WITH STUDENTS OTHER THAN MEDICAL STUDENTS

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Additional experience relevant to the implementation of NIM into a course was obtained using a modified version of the modules with 2 undergraduate college nutrition classes. Three modules were used and integrated into the course syllabus. An attitudinal survey was administered before and after viewing the modules. Eighty-eight percent of students looked forward to using the modules before use and 76% reported that they felt the modules were an effective way to learn upon completion of module use (K Cooksey and K Adams, unpublished observations, 1999). In addition, 32% of students reported feeling knowledgeable about a specific topic in nutrition before viewing the corresponding module. After module use, this number increased to 76%. The time spent (self-reported) using the module varied considerably, with the mode at 3–4 h (56% of class). At the end of the semester, a focus group session provided additional feedback. The students positively reviewed the nutrition applications and "experiences" in the virtual patient case. They felt the presentation of the material helped them to learn to apply and remember the information, and they particularly noted the immediate feedback features. In addition, they cited the freedom of navigation, organization, and ease of use as other positive aspects. They felt that a preliminary orientation, direction from the course instructor, and direct correlation to the course material were key in the use of the module being a success. Helpful information gathered from the focus group included the need for a study guide or workbook and the need to know what students were responsible for in terms of module material, as well as a recommendation for in-class discussions. Unsolicited positive comments also appeared on the class evaluation at the end of the semester; with the most common negative comment related to the length of the module, an issue we plan to address with future modules.

	IMPLEMENTATION SUGGESTIONS

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From our experiences with both medical and general students using these modules, we have learned valuable information about implementing CAI. When NIM is implemented as an option available in the library with no other institutional or faculty support, busy medical students do not use it. When it is implemented with appropriate support, it is an excellent and valued part of the medical curriculum. As shown in Table 5, several elements are critical for successfully establishing the use of CAI in any course, as supported by the experience of others (21, 22).

Independent study
The modules can be used to supplement in-class lecture material. Students can complete a module as part of their outside work or as a lecture replacement. Although many of today's students are computer literate, the following measures help to ensure a smooth start: instructions on how to access the programs (eg, computer lab, library environment, or personal computer), in-class demonstration of how to get started and navigate through the program, suggestions regarding the amount of time to spend on the modules, and a description of precisely what the students are responsible for. If the entire module is assigned, we recommend students view it in several sessions. The advantage with independent study is that the students can go through the material at their own pace, continuously test their knowledge, and review sections of the program as needed. It is essential to link module content tightly into lecture material and plan follow-up sessions upon completion.

Class discussion
Portions of the module can be shown in class and a discussion can be built around the topic. If presentation software is used (eg, POWERPOINT; Microsoft Corporation, Redmond, WA), the instructor can jump directly to the modules using a run-program button. There are numerous ways to incorporate the modules into a class discussion. For example, specific topics can be emphasized (eg, dietary factors that increase risk of a disease entity) and students can then discuss and prioritize contributing factors. Or, one of the animated sequences can demonstrate a physiologic or metabolic process followed by questions on how dietary changes may affect the process. At the University of Nevada, Reno, student leaders are assigned modules, which they go through with their classmates during a multihour class (37).

Group assignment
Another method of implementation that has been useful is to assign small groups (2–4 students) of students to view the module together. Small group interaction allows for different perspectives, interpretations, and fosters discussion. After completing the module, the class meets as a whole to review and discuss the main concepts presented.

Case study presentation
The patient case, or an integrated practice case, may be presented as a case study. The patient case is typically 30 min. At the end of most major topic sections, a text-based practice case challenges the user's newly learned competency. The integrated practice presents a case scenario, followed by 3 multiple choice questions. Presentation of additional case problems in class greatly facilitates student learning and acceptance (37).

	INSTRUCTOR SUPPORT

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As described earlier, the instructor can track and statistically analyze information about program use and student performance, including exam scores, question responses, and time spent to complete the program via the data analyzer. The data analyzer utility, located on version 1.0 modules and now on the NIM Web site, automates the grading and data collection process. In addition, the instructor module allows instructors to add custom notes for students to each subtopic shown on the menu. It functions as a basic word processor and lets the instructor add, edit, or delete notes. The notes must then be provided to each user or station via a floppy disk. When the student navigates to a portion of the program where a note has been added, they can see the note before entering that lesson. The instructor can use this feature to highlight specific points within the lesson, add new information or reference material, emphasize or deemphasize sections, identify portions that are optional, or add other useful information. As a result, the instructor module permits some degree of tailoring to better meet each instructor's objectives.

To facilitate instructor implementation of the NIM technology-based instructional materials, registered NIM users can obtain an instructor's pack. This package is designed to help instructors become acquainted with the programs and to understand some of the many ways in which they can be implemented into the teaching setting. The pack presents detailed outlines of each program complete with learning objectives, video virtual case descriptions, and handouts. Key graphics will be posted to the instructor support Web site for registered NIM users to download and use in their teaching.

Included on each CD-ROM is a file entitled "Handouts" that lists the module objectives, key concepts, and key concept summaries for each module, along with space for taking notes. In addition, information on all the necessary steps to get started (eg, Quickstart sheets) are provided on the CD-ROM.

In addition to the instructor's pack, the NIM Web site (www.med.unc.edu/nutr/nim) offers a detailed instructor support section, as mentioned above. Instructors can download utilities, documentation, and instructions to help them use the modules more effectively. An e-mail link for technical support is available for issues not already answered on the Web site.

Finally, Nutraquiz is an on-line examination creator and searchable databank of test questions that can be accessed by NIM-registered nutrition educators. Instructors can use the program to create their own tests of original questions, incorporate questions from the database, or create tests with a combination of the 2 options. They may choose to donate their questions for use by other instructors or not, and can limit access time for students. Nutraquiz serves as a computer-based test site for instructors who wish to use it in this way. Instructors can request their own unique password and access by logging on to http://152.2.58.2/ nutraquiz/index.htm or by following the link on the NIM Web site. Preliminary survey information was obtained in the summer of 1999 from medical school instructors who are using NIM modules. Our survey results indicate that medical school instructors would be interested in using this databank; 38% of respondents reported writing 50 test questions per semester and all said they would be willing to donate questions to the databank (P Morris, K Adams, K Cooksey, unpublished observations, 1999).

	CONCLUSION

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Successful implementation of CAI, specifically of the NIM series of programs, requires effort on the part of the teaching institution and faculty, as detailed in this article. Not only has faculty and user feedback been a vital component of our development process, it has been key to developing guidelines for incorporation of these modules into medical schools. The finest software achieves little if it is not appropriately implemented and modified to satisfy user needs. We believe the strategies and implementation suggestions shared here will allow successful incorporation of this series of nutrition education modules into the medical school curriculum, resulting in a consistent base of nutrition knowledge for medical students.

	REFERENCES

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