Advances and Controversies in Clinical Nutrition: The Education Outcome of a Live Continuing Medical Education Course  
* Division of Gastroenterology and Hepatology,
Mayo Clinic, Jacksonville, Florida; Correspondence: James S. Scolapio, MD, Professor of Medicine and Associate Dean of CME, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224. Electronic mail may be sent to scolapio.james{at}mayo.edu. Background: The aim of this study was to assess participants' nutrition knowledge and practice behavior before and after completing a live continuing medical education (CME) nutrition course designed for practicing nutrition clinicians. Methods: Electronic surveys were sent to the first 100 registered participants before and after attending the course. The curriculum consisted of 16.75 hours of live education. The curriculum was revised when the precourse surveys identified a gap in medical knowledge or practice behavior. Knowledge change was assessed by a 15-question survey given before and 1 week after the course. Change in practice behavior was accessed by a 10-question survey administered 2 months after the course. Results: Dietitians were the predominant discipline group attending the course. Sixty-three percent of those surveyed practiced hospital nutrition, 19% outpatient nutrition, and 18% an equal mix. Forty-eight percent indicated that they write parenteral nutrition (PN) orders and 51% write enteral nutrition (EN) orders; of these, 62% indicated they are comfortable writing PN orders and 81% are comfortable writing EN orders. Twenty-three percent indicated that they manage home PN and EN patients. Twenty-six percent stated they were certified in nutrition support. Seventy-eight percent of the participants responded to survey 2; the median correct response rates were 51% pre- and 76% postcourse. Seventy percent responded to survey 3; the median positive clinical practice behavior change was 69%. Conclusion: This live CME course improved knowledge, and a majority of attendants reported changing their nutrition practice after this course. The Mayo School of Continuing Medical Education held its first live continuing medical education (CME) nutrition course in 1990. This course has been cosponsored with the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) since 1996. In April 2007, the 17th Annual Advances and Controversies in Clinical Nutrition course was completed in Savannah, Georgia. Over the past 17 years, an estimated 3000 clinicians have been educated as part of this course. In this report, we describe how the curriculum was constructed, and present results of prospectively collected outcome data used to improve the course as it was developed. Pre- and postcourse surveys were used to determine the degree of knowledge improvement and behavior change after completing the course. To the best of our knowledge, this is the first report that describes how outcome data were collected for a live CME nutrition course, and to show improved knowledge and practice behavior after practitioners attended a nutrition course.
Curriculum and Course Design During a 4-month period before this course, a program-planning committee communicated ideas for educational objectives (Table 1), content, and program design via e-mail and teleconferences. Topics were selected according to the course directors' knowledge of needs assessments from previous years' courses, other educational nutrition programs in which they had been involved, recently published topics, and common nutrition health concerns in daily clinical practice (Table 2). The curriculum consisted of 20- to 30-minute didactic lectures and small-group workshops. The course was advertised in multiple mailing lists that targeted dietitians, pharmacists, physicians, and nurses in the United States, Puerto Rico, and Canada.
Course faculty was selected according to their field of expertise, teaching experience, and speaking skills. Twenty-five faculty members participated in this 3-and-a-half-day course that offered 16.75 category 1 credits for physicians, dietitians, pharmacists, and nurses. The education curriculum included clinical case presentations, workshops, didactic lectures, and panel discussions. An audience response system (ARS) was used to elicit participant interaction during the course. ARS is a computer-based technology in which participants can enter their responses to questions via a remote keypad located at their desk. The results for the group are then instantly tabulated and projected onto a screen for immediate participant or learner feedback. This study was approved by the Mayo Clinic Institutional Review Board.
Precourse and Postcourse Surveys
The second precourse survey included 15 questions used to determine each participant's nutrition knowledge (Table 4); these questions were developed from the educational objectives and planned topics of the course. Results were reviewed by the course directors and shared with faculty members before the course. Course content was adjusted according to the survey results to address identified deficiencies. For example, participants indicated that they wanted more information on nutrition certification. Brochures were obtained from A.S.P.E.N. and distributed to the participants. Participants also indicated that they wanted up-to-date information on specific topics. Each faculty member was asked to include an "update" slide in their presentations that highlighted recent information related to their specific topic. One week after attending the course, the same 15-question survey was e-mailed to participants to determine the change in their knowledge.
Each participant was asked to complete a course evaluation on the last day of the course. This evaluation ranked the quality of each faculty presentation and the overall course content. The following scoring system was used: 1 (very poor), 2 (poor), 3 (average), 4 (good), and 5 (excellent). Two months after completing the course, a 10-question survey was e-mailed to each participant to determine whether they had changed their nutrition practice behavior as a result of attending this course (Table 5). Behavior changes were determined by participants' personal feedback and were not objectively measured.
Nutrition Experience and Education Preferences Eighty-three of the 100 participants surveyed responded to survey 1. Of these participants, 58 were dietitians, 11 physicians, 7 pharmacists, 6 nurses, and 1 physician assistant. Sixty-two percent practiced predominantly inpatient nutrition, 19% practiced predominantly outpatient nutrition, and 19% an equal mix of inpatient and outpatient nutrition. Forty-nine percent had a nutrition support team at their institution run predominantly by dietitians. Thirty-five percent indicated that they had a physician leader as part of their nutrition support team. Forty-one percent of the participants indicated that they were active members of the nutrition support team. Forty-nine percent indicated that they write orders for parenteral nutrition (PN) and 54% for enteral nutrition (EN). Of these, 63% indicated they were comfortable calculating a PN formula and safely administering it to a patient, and 84% indicated that they were comfortable calculating an EN formula and safely administering it to a patient. Twenty-three percent directly manage home PN patients and 24% manage home EN patients. Sixty-four percent were directly involved in the nutrition management of patients with obesity, 32% with pediatric patients, and 75% with patients with diabetes. Seventy-six percent stated they were comfortable in the nutrition management of patients with diabetes and 71% in the management of patients with obesity. Twenty-eight percent indicated they were certified in nutrition support, diabetes, or obesity. See data listed in Table 6.
Eighty-four percent indicated they learn best from podium lectures, 42% from panel discussions, and 36% from small group discussions. Participants' education goals included, but were not exclusive of, nutrition as it relates to gastrointestinal illness, PN and EN calculations, current updates and developments in clinical nutrition, current treatments for obesity and diabetes treatments, and preparation for nutrition certification.
Knowledge Evaluation
Course Evaluation
Changes in Nutrition Practice Behavior Examples of improved practice behavior are shown by the following responses: "I was able to inform a physician who ordered a low-calcium diet for a patient with kidney stones that it was not needed," "I've suggested gastric banding as an alternative to surgical gastric bypass in an obese patient," "I have definitely been recommending better glucose control especially in intensive care unit (ICU) patients," "I'm more precise in estimating my patients' caloric and protein needs," "I'm not restricting protein in liver patients as much as I used to," and "I'm more aggressive in using EN in patients with severe acute pancreatitis."
Although live CME courses have become a very popular method for nutrition clinicians to stay current with advances in their specialty and maintain licensure requirements, few courses actively collect outcome data of participants' knowledge and practice behavior changes after the education event. Although one may assume that knowledge increases and practice behavior improves after a CME course, these data have never been reported, to the best of our knowledge. We hope that this manuscript provides the methods needed to collect learner outcome data and the importance of this information. In the 1970s, the primary focus of nutrition CME courses was that of compounding and administration of PN. Continuing medical education courses have now shifted their focus in more recent years to obesity topics, given the current obesity epidemic in the United States, and the controversies and indications of specialized enteral formulas in specific disease states.1 The article by Kahn1 provides examples of CME programs that are available in the United States specific to nutrition. As shown in our data, dietitians are the predominant nutrition healthcare providers that attend nutrition CME courses. This fact is also reflected in the membership of A.S.P.E.N. In the authors' opinion, fewer physicians are being trained in nutrition and fewer are attending nutrition CME courses compared with dietitians and pharmacists. Reasons stated by gastroenterology trainees for not pursing specialization in nutrition include too few mentors, poor exposure, it is considered an allied health specialty, is not endoscopy focused, and poor financial reimbursement.2,3 We suspect that most hospitals are also deficient in providing the necessary nutrition education for their employees. Therefore, in most instances, nutrition clinicians must obtain their ongoing education by attending live CME courses or through journal reading. Although we acknowledge that journal reading can be a great source of education and perhaps may be more cost-effective for the participant, we believe that the live interaction between learner and teacher is invaluable.4 Studies would suggest that multimedia teaching methods enhance learning more so than 1-dimensional teaching.5,6 As shown in our data, participants indicated that they learn best in a variety of ways, including traditional podium lectures, small group discussions, and panel question-and-answer sessions. Our results would also indicate that the participants found the keypad ARS to be very helpful. Using this teaching method, participants were required to think and process educational information before responding. The ARS also enabled the participants to see how their responses compared with those of other course participants. The moderator of each session could then focus the discussion phase of the course on the recognized knowledge deficiency identified by the ARS. Although we do not have data to support that the ARS directly increases knowledge retention or behavior change, we would suggest by virtue of adding another piece of interactive teaching that it may.5,6 The results of the course have also been written to show that a CME course can have positive outcome on a learner, and the importance and method for collecting this information. We believe the methods used in this study can be applied to other CME courses as well. The Accreditation Council for Continuing Medical Education (ACCME) encourages the evaluation and collection of level 1–4 outcomes.7 Level 1 is the collection of course evaluations or participant feedback, including speaker evaluations. We suspect that most traditional CME courses collect level 1 data, but the actual application of this information may vary. Level 2 outcome refers to the evaluation of knowledge before and after attending an education course. We believe that most CME courses do not collect this information and course directors may assume the participant has learned what the lecturer has presented. This may not necessarily be the case. We would encourage that a set of questions be given to participants before attending a CME course, and then at some time interval after the course. The same questions or preferably different questions with the same concept can be administered to determine if there has been a change in knowledge. The time interval of when to have participants answer the postlecture questions is not well established in the education literature. Level 3 outcome refers to the participant's change in practice behavior after attending an education course. As highlighted in this paper, pre- and post-course electronic survey data collection can help determine if the CME course actually resulted in improved practice behavior. An example of level 3 outcome gained from this course is that the participants reported being more aggressive in the control of serum glucose levels in hospitalized patients than before attending the course. It is difficult to objectively measure this outcome, and we therefore had to rely on each participant's opinion. Level 4 outcome data refers to improved patient outcomes as a result of a clinician attending a CME course. Although this is the ultimate goal of an education course, it is more difficult information to ascertain. Methods to ascertain this information may include patient surveys, chart reviews, or having participants provide specific examples of improved patient outcome that can be directly linked to knowledge they had acquired at a CME course. Future courses should explore creative ways to collect this information. As shown in our Methods section, electronic survey tools are a valuable instrument to communicate with participants before and after a course. As we have illustrated, the education content of a course can be adjusted or tailored to fit the education needs or objectives of the real-time learner.8 Traditionally, CME courses have relied on the previous year's course evaluations to plan the following year's course. Unless the same participants attend each year, what is being taught at a current year's course may not necessary reflect the participants' needs or knowledge deficiencies. A great opportunity to positively affect education can be missed if the needs of the learner are not known before the course. In conclusion, CME courses are important in the ongoing education of nutrition clinicians, and it is imperative that course directors collect learner outcome data to determine if in fact learning and positive practice behavior changes are occurring as a direct result of the education curriculum. This manuscript provides methods that can be used to collect such information. Our course curriculum resulted in improved knowledge and practice behavior of our CME participants. We thank the following faculty members who took time from their busy practices to help educate the participants at this course: Andrew Ukleja, Ernest Bouras, Darlene Kelly, Michelle Romano, Vandana Nehra, Norman Egger, Angela Vizzini, Marcus Ferrone, John Lieske, Nina Schwenk, Peter Tebben, Juan Guarderas, Ronald Stone, Seema Kumar, Timothy Moynihan, Steven Ames, C. Daniel Smith, Anton Decker, John Miles, Gerald Fletcher, Arshag Morradian. We also thank the entire CME staff at Mayo Clinic, Jacksonville, Florida, for making this course a success. A special thanks to Paula Bowen, accreditation administrator at A.S.P.E.N., for her ongoing help and support over the years.
Nutrition in Clinical Practice, Vol. 23, No. 1,
90-95 (2008)
|
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
 |
|
|
 |
|
Top
Materials and Methods
Results