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Dietary counseling of hypercholesterolemic patients by internal medicine residents

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Objective:To assess the knowledge, attitudes, and practices of internal medicine residents concerning dietary counseling for hypercholesterolemic patients. Design:Cross-sectional, self-administered questionnaire survey. Setting:Survey conducted
  Dietary Counseling of Hypercholesterolemic Patients by Internal Medicine Residents MARK A. LEVINE, MD, ROBERT S. GROSSMAN, MD, PAUL M. DARDEN, MD, SHERRON M. JACKSON, MD, JAMES G. PEDEN, MD, ALICE S. AMMERMAN, DrPH, RD, MINA L. LEVIN, MD, RICHARD D. LAYNE, MD, LAURA Q. CHARLES B. SEELIG, MD, ARTHUR T. EVANS, MD, MPH, MIRIAM B. SETTLE, PhD, SUZANNE W. FLETCHER, MD ROGERS, MD, Objective: To assess the knowledge, attitudes, and prac- tices of internal medicine residents concerning dietary counseling for hypercholesterolemic patients. Design: Cross-sectional, self-administered questionnaire survey. Setting: Survey conducted August 1989 in seven internal medicine residency programs in four southeastern and middle Atlantic states. Participants: AH 130 internal medicine residents who were actively participating in ou~atient continuity clinic. Interventions: None. Measurements and main results: Only32 of the residents felt prepared to provide effective dietary courtseiin~ and only 25 felt successful in helping patients change their diets. Residents had good scientific knowledge, but the de- gree of practical knowledge about dietary acts varied. Res- idents reported giving dietary counseling to 5896 of their hypercholesterolemic patients and educational materials to only 35 . Residents who felt more self-confident and prepared to counsel reported more frequent use of effec- tive behavior modification techniques in counseling. Forty-three percent of residents had received no training in dietary counseling skills during medical school or residency. Conclusion: Internal medicine residents know much more about the rationale for treatment for hypercholesterole- mia than about the practical aspects of dietary therapy, and they eel ineffective and ill-prepared to provide dietary counseling to patients. Received from the University of North Carolina Faculty Devel- opment Program in General Medicine and General Pediatrics, the Department of Medicine (RSG, MLL, CBS, ATE, sWF), the Area Health Education Center Program (RSG, MLL, CBS), School of Medicine, the Department of Nutrition, School of Public Health (ASA), and the Health Services Research Center (ATE, MBS), University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; the Department of General Internal Medicine, Geisinger Medical Center, Danville, Pennsylvania (MAL); he Department of Pediatrics, Medical Univer- sity of South Carolina, Charleston, South Carolina (PMD, SMJ); the Departments of Medicine and Psychiatry, East Carolina University School of Medicine, Greenville, North Carolina, (JGP); the Depart- ment of Medicine, West Virginia University School of Medicine, Mor- gantown, West Virginia (RDL); and the Department of Medicine, Medical College of Georgia, Augusta, Georgia (LQR). Presented in part at the annual meeting of the Society of General Internal Medicine, Arlington, Virginia, May 2- 4, 1990. Supported by the University of North Carolina Faculty Develop- ment Fellowship Program in General Medicine and General Pediat- rics (54004-05, Bureau of Health Professions, Washington, DC) and by grants from the Medical Foundation of North Carolina, the Georgia Affiliate of the American Heart Association, and the Geisinger Foundation. Address correspondence and reprint requests to Dr. Levine: Department of General Internal Medicine, Geisinger Medical Center, Danville, PA, 17822. Key words: Hypercholesterolemia; dietary counseling. physician counseling, internship and residency; health promotion. J GEN INTERN MEt) 1992;7:511 - 516. DIETARY THERAPY remains the initial intervention of choice for all patients with primary hypercholesterole- mia, 1 and physicians are expected to initiate dietary counseling. However, little is known about how well prepared physicians are to give such counseling. After the results of the Lipid Research Clinics Coro- nary Primary Prevention Trial were published, a 1985 National Institutes of Health (NIH) consensus confer- ence strongly advocated treatment for hypercholester- olemia. A majority (64%) of 1,2 77 physicians surveyed by telephone in 1986 thought that reducing high serum cholesterol levels would have a major effect on reducing heart disease. 2 However, only 15% felt suc- cessful in helping patients lower their cholesterol levels. Reported barriers to the successful dietary man- agement of hypercholesterolemia included lack of time, inadequately trained staff, and poor insurance reimbursement for preventive services. In 1987, the National Heart, Lung and Blood Insti- tute launched a major program, the National Choles- terol Education Program (NCEP), 1 in an attempt to im- prove the ability of health care professionals to recognize and manage hypercholesterolemia. It is un- known to what extent physicians will comply with the NCEP guidelines or whether the barriers physicians en- counter when providing nutritional assessment and counseling will be effectively dealt with by this educa- tional effort. Residency training is an optimal time for physi- cians to acquire much of the knowledge, attitudes, and skills needed to treat patients who have elevated cho- lesterol levels. Indeed, the structured learning environ- ment of a residency program would be expected to promote a greater level of adherence to proper manage- ment guidelines than has been demonstrated by prac- ticing physicians. However, this has not been pre- viously shown, and resident clinics may have their own unique barriers to the delivery of preventive care. Mad- lon-Kay reported that in a family practice training pro- gram, only 29% of hypercholesterolemic patients re- ceived any dietary therapy. 3 511  51Z Levine eta/., RESIDENT DIETARY COUNSELING OF HYPERCHOLESTEROLEMICS We hypothesized that although residents might be familiar with the current guidelines, other barriers af- fect their ability to provide dietary therapy for hyper- cholesterolemic patients. Eighteen months after publi- cation of the NCEP guidelines we surveyed a large cohort of resident physicians to determine their knowl- edge, attitudes, and reported behaviors concerning the management of hypercholesterolemic patients. METHODS Subjects and Setting One hundred thirty internal medicine residents in seven programs across four southern and mid-Atlantic states were surveyed in August 1989. The clinical set- tings ranged from community hospitals to university medical centers: New Hanover Medical Center, Wil- mington, NC; Moses Cone Memorial Hospital, Greens- boro, NC; East Carolina University School of Medicine, Greenville, NC; University of North Carolina, Chapel Hill, NC: Geisinger Medical Center, Danville, PA; West Virginia University, Morgantown, WV; and the Medical College of Georgia, Augusta, GA. All second-, third-, and fourth-year internal medicine residents were eligi- ble if they were actively involved in outpatient manage- ment. Active involvement in outpatient management was defined as seeing patients in continuity clinic for six of the succeeding ten weeks. Because first-year resi- dents rarely satisfied this requirement, they were ex- cluded from the study. Only ten (7%) of 140 residents in their second through fourth years did not meet this criterion and were excluded. All subjects were in- formed of the nature of the study and gave written con- sent. The study was approved by the institutional re- view board at each site. Cronbach alpha values of >0.70. The questionnaire was designed to evaluate resi- dents for the following: 1. Knowledge of NCEP screening guidelines, stratification of cardiovascular risk, effect of diet on blood lipids, rationale for intervention, appropriate management strategies, and practi- cal dietary knowledge. 2. Attitudes regarding preparedness to counsel di- etary change, effectiveness of dietary change in lowering serum cholesterol, confidence in counseling skills, physician responsibility for counseling, relative priority of dietary counsel- ing, and the potential barriers to counseling, including limited time, inadequate educational materials, and patient noncompliance. 3. An estimate of the proportion of hypercholes- terolemic patients counseled by each physician and a characterization of their dietary counsel- ing practices, including their use of behavior modification. 4. Demographic information such as site and level of training, prior dietary counseling training, medical school attended, and career plans. 5. Knowledge of their own serum cholesterol levels and recent personal dietary modifica- tions. The questionnaire was distributed by investigators who were general medicine faculty at their institutions. Residents who did not initially complete the survey were contacted by the authors, who personally re- quested they complete the survey. uestionnaire The study instrument was adapted from a ques- tionnaire developed by one of the authors for a prior study. 4 The measurement scales from that instrument had been formally evaluated for reliability and validity and extensively pretested. Cronbach's alpha for inter- nal consistency of scale items averaged 0.73 across all scales in a sample of 87 resident and attending physi- cians. Content validity was assessed by having all of the items reviewed by experts (physicians and nutritionists with expertise in preventive cardiology) who were aware of the intended uses of the questionnaire. Some additional questions were adapted from the National Heart, Lung and Blood Institute national physician sur- vey. 2 The revised, self-administered questionnaire in- cluded 106 predominantly closed-ended items utiliz- ing a six-point Likert scale, semantic differential, and true/false questions. Additional reliability testing was conducted with a group of graduating residents at the same institutions. All of the attitudinal scales achieved Analysis Responses across sites were tested for homogene- ity before they were analyzed in the aggregate. For the purposes of reporting, we dichotomized responses to the six-point Likert scales. Responses 1 through 3 of the scales were classified as disagreement, whereas re- sponses 4 through 6 signified agreement. Residents were classified as in agreement if the mean score on the items of an attitude scale was higher than 3.5. Residents estimated the percentage of hypercholesterolemic pa- tients offered dietary counseling, and the mean and standard deviation were calculated. Residents' selfore- ported use of a spectrum of behavior modification strat- egies for dietary assessment and counseling was mea- sured by a 23-item scale. Responses were dichotomized at the scale midpoint, and relationships between the dichotomized scales measuring knowledge, attitude, • The entire questionnaire and psychometric data regarding n- dividual scale items are available from the authors upon request.  JOURNAL OF GENERAL NTERNAL MEDICINE, Volume 7 September/October), 1992 513 and self-reported behavior were examined using the chi-square test. To ensure that collapsing our scales did not alter the apparent significance of interrelationships between variables, an ordinary least-squares computer regression model was used to analyze the srcinal, non- dichotomized scales as well. RESULTS Respondents All 130 eligible residents completed the question- naire for a 100% response rate. Fifty-one percent of the subjects were second-year residents; 40%, third-year; and 9%, fourth-year. Three-fourths (75%) were cate- gorical medicine residents; 23%, medicine/pediatrics; and 2%, medicine/psychiatry. While 45% planned to practice general medicine, 28% did not plan to and 26% were still unsure of career plans. Forty-three per- cent of residents reported receiving no training in di- etary counseling during medical school or residency. Thirty-five percent reported training in medical school and 44% during residency. Fifty-seven percent of resi- dents knew their own cholesterol levels and 57% had reduced their dietary fat and cholesterol intakes within the preceding year. Knowledge The mean percentage correct score on four ques- tions testing knowledge of NCEP guidelines for choles- terol detection and coronary risk classification was 78% (range, O- 100%). Performance on seven patient man- agement problems evaluating use of lipoprotein analy- sis, diet, and drug therapywas excellent, with the mean percentage correct 88% (range, 43-100%). Most residents (90%) understood that a 10 - 15% reduction in serum cholesterol can be expected from moderate dietary intervention in patients with hyper- cholesterolemia (Table 1). On average, 71% of the di- etary knowledge questions were answered correctly. However, responses to questions concerning specific, practical dietary items varied. Few (15%) knew that it is necessary to consume a greater volume of food to main- tain the same weight on a cholesterol-lowering diet, and only 51% realized that most margarines have no cholesterol. A substantial percentage (38%) mistakenly thought that all forms of pork must be restricted on a cholesteroldowering diet. In fact, while it is commonly assumed that pork is among the worst offenders in rais- ing serum cholesterol, the saturated fat and cholesterol profile of fresh lean pork is preferable to that of beef and superior to those of many commercially prepared foods that contain large amounts of tropical fats that are more highly saturated than meat fats. Attitudes Residents agreed that dietary counseling was the physician's responsibility and a high priority (Table 2). Most (92 %) also felt that dietary modifications could be effective in lowering coronary artery disease risk. Even though they agreed on the appropriateness of providing dietary counseling, only 32% felt prepared to do so. Even more striking, only 25% felt successful or confi- dent in the ability to help patients change their diets. Residents perceived several barriers to counseling, in- cluding poor patient compliance (82%), lack of suffi- cient time (70%), and inadequate educational mate- rials (48%). Self-reported Behavior Residents reported screening for hypercholestero- lemia in a mean of 55 + 30.43% of their continuity care patients. Although most residents (92%) discussed the TABLE 1 Resident Physicians' Knowledge about Cholesterol, Heart Disease, and Diet Percentage of Residents Who Answered Correctly (N = 130) Cholesterol and heart disease knowledge* For patients with high serum cholesterol, a 1 O- 15% reduction in cholesterol can be expected from moderate dietary intervention Potential benefit of cholesterol reduction is greatest in those individuals with multiple cardiovascular risk factors For patients with high serum cholesterol, a 10% reduction in serum cholesterol is associated with a 20% reduction in coronary heart disease risk With a combination of diet and hypolipidemic drugs, it is possible to see regression of atherosclerotic lesions Practical dietary knowledge* Foods labeled cholesterol free can raise serum cholesterol Organ meats are higher in cholesterol than other types of meat Intake of starchy foods need not be limited on a cholesterol-lowering diet All forms of pork need not be restricted on a cholesterol-lowering diet Most margarines contain no cholesterol Most cholesterol is in the lean rather than the fatty portion of the meat It is necessary to eat a greater volume of food to maintain weight on a cholesterol-lowering diet Overall mean score on specific practical dietary knowledge 90 77 64 58 96 89 87 62 51 26 15 71 *Items have been rewritten so that true is the correct response.  514 Levine eta/., RESIDENT DIETARY COUNSELING OF HYPERCHOLESTEROLEMICS TABLE 2 Resident Physicians' Attitudes and Beliefs Regarding Dietary Counseling and Bamers to Counseling Percentage of Residents Who Agree* (N = 130) Attitudes about dietary counseling Dietary counseling s the physician's responsibility Dietary counseling s a high priority I feel prepared to provide dietary counseling I feel successful or confident in my ability to improve patients' diets Factors considered o be barriers to effective counseling Poor patient compliance Inadequate ime Inadequate educational materials 82 72 32 25 82 7 48 *Each percentage reflects responses on multiple-item scales hat assessed the specific variable under consideration. Residents indicated their levels of agreement with each attitude on a six-point Likert scale from strongly disagree o strongly agree. For purposes of reporting, we dichotomized the results into agree and disagree. TABLE 3 Resident Physicians' Self-reported Dietary Counseling Skills Strategy for dietary assessment Determine patients' motivation toward making dietary changes Determine patients' confidence about making dietary changes Assess he frequency with which patients eat certain foods Assess patients' perception of taste and convenience of a cholesterol- lowering diet Strategy for dietary behavior change Point out specific problem areas in patients' diets Evaluate amily support Discuss obstacles o dietary change Positively reinforce small dietary changes made by patients Positively reinforce healthy aspects of patients' diets Individualize ecommendations Set short-term dietary goals Spread dietary counseling over several visits Schedule ollow-up specifically o discuss diet Suggest hat a cholesterol-lowering diet might taste good Percentage of Residents Using Strategy (N-- 122) 64 54 40 27 58 58 55 54 51 48 48 37 27 26 health benefits of a prudent diet with their hypercho- lesterolemic patients, residents reported providing ac- tual dietary recommendations to only a mean of 58 + 34.30% and written educational materials to just 35 + 36.40% of these patients. Only 40% of residents were likely to specifically assess dietary cholesterol and fat. Although 64% of housestaff were likely to deter mine patients' motivations for making dietary changes, only 27% were likely to assess patients' perceptions of the taste and convenience of a cholesterol-lowering diet (Table 3). Although 58% of housestaffwere likely to point out specific problem areas in the patients' diets, only 27% were likely to schedule follow-up visits specifically to discuss dietary changes. Relation among Self-reported Behavior, Knowledge, and Attitudes No significant relation could be found between knowledge and the reported frequency of dietary coun- seling (R = 0.164, p = 0.07). However, residents who felt more self-confident, felt more prepared to counsel, or perceived counseling as a high priority also reported using more counseling strategies than did those who felt less efficacious and prepared or those who felt that counseling was a lower priority (Table 4). Housestaff who had received training during resi- dency were more likely to feel prepared to counsel and more likely to engage in counseling than were those who had received no prior training (Table 5). Senior residents were no more likely to use dietary counseling than were junior residents. Residents who had recently modified their own diets, or those who knew their own serum cholesterol levels, were not significantly more likely to provide dietary counseling to their patients than were those who had made no personal dietary changes. Those who were planning careers as general- ists were no more likely to counsel patients than were those who were not. DISCUSSION Our study provides recent data describing how in- ternal medicine residents deal with hypercholes- terolemia. Residents are fairly knowledgeable about screening, classification, evaluation, rationale for in- tervention, and management of hypercholesterol- emic patients, but we found them less familiar with specific dietary advice. They accept dietary counseling as their responsibility and acknowledge its importance, but they feel ineffective and ill prepared and lack con- fidence in their skills. They use effective counseling techniques infrequently, and they miss many opportu- nities for providing dietary counseling and educational materials to their hypercholesterolemic patients. Al- most half have not received training in dietary counsel- ing in either medical school or residency. While it has been previously shown that practicing physicians feel ill-prepared and unsuccessful in counseling hypercho- lesterolemic patients, our findings, which for the first time extend these observations to residents, are partic- ularly disappointing. Our sample includes most upper-level internal medicine residents at each site, and our response rate was 100%. Questionnaire administration was timed so  JOURNAL OF GENERAL NTERNAL MEDICINE, Volume 7 September/October), 1992 S 1S that physicians had had sufficient opportunity to be- come familiar with the NCEP guidelines and to imple- ment them in their practices. Our study instrument was carefully pretested and validated. An important limitation is the self-reported nature of the practice behaviors. Direct observation of such behaviors would obviously strengthen the findings. However, we would expect self-reported findings to be biased towards more frequent reports of counseling; indeed, previous research has demonstrated that physi- cians' own estimates of performance in a variety of screening activities fall significantly below actual per- formance rates. ~,6 The fact that residents reported counseling for only 58% of hypercholesterolemic pa- tients may mean that even fewer are actually counseled. Our findings are likely to be generalizable to other housestaff training settings. The seven study sites, which range from small to large training programs throughout the eastern United States and include com- munity hospitals as well as university medical centers, are representative of internal medicine training pro- grams in the country. Comparisons between the data and findings before TABLE 5 Numbers (and Percentages) of Resident Physicians Classified by Use of Effective Dietary Counseling Skills and Personal Characteristics Use Personal Characteristic High Low p Valuer Prior training in residency Yes 34 (28) 19 (15) 0.005 No 27 (22) 43 (35) Prior training in medical school Yes 26 (21) 17 (14) 0.066 No 34 (28) 45 (37) Any prior training Yes 45 (36) 25 (20) 0.001 No 17 (14) 37 (30) Level of training PGY-2 30 (24) 34 (27) 0.472 PGY-3-4 32 (26) 28 (23) Plans career as generalist Yes 23 (25) 35 (37) 0.213 No 19 (20) 17 (18) Recent modification of own diet Yes 40 (32) 31 (25) 0.102 No 22 (18) 31 (25) Knows own cholesterol level Yes 35 (29) 37 (30) 0.796 No 26 (21 ) 25 (20) TABLE 4 Numbers (and Percentages) of Resident Physicians Classified by Use of Effective Dietary Counseling Skills and Attitudes Regarding Dietary Counseling Use* Attitude High Low p Valuer Dietary counseling s a high priority Agree 51 (42) 37 (30) 0.005 Disagree 10 (8) 24 (20) I feel confident in my ability to improve patients' diets Agree 23 (19) 7 (6) 0.001 Disagree 38 (31) 55 (44) I feel prepared to counsel Agree 24 (20) 14 (11) 0,059 Disagree 38 (31 ) 47 (38) Inadequate resources are a barrier to counseling Agree 22 (18) 38 (31) 0.004 Disagree 39 (32) 23 (19) Dietary counseling s the physician's responsibility Agree 53 (43) 49 (40) 0,447 Disagree 9 (7) 12 (10) Time is a barrier to counseling Agree 42 (34) 45 (37) 0.376 Disagree 20 (16) 15 (13) Patient compliance s a barrier to counseling Agree 49 (40) 54 (44) 0.391 Disagree 13(11) 6(5) * Residents self-reported use of a spectrum of behavior modification strategies for dietary assessment and counseling was measured by a 23- item scale with responses dichotomized at the scale midpoint into high- and low-use groups, tUsing chi-square est. * Residents' self-reported use of a spectrum of behavior modification strategies for dietary assessment and counseling was measured by a 23- item scale with responses dichotomized at the scale midpoint into high- and low-use groups. ~Using chi-square est, the NCEP suggest that there has been little improve- ment over time. In 1986, Schucker and associates 2 found that 58% of practicing physicians surveyed felt prepared to counsel, yet only 15% felt that they could change their patients' dietary habits. In our study of physicians in training, a smaller number, 32%, felt pre- pared, and 25% felt confident of the efficacy of their counseling skills. This implies that the physician edu- cational materials of the NCEP were not effective in improving residents' attitudes about their prepared- ness to counsel or confidence in their counseling skills, even though the materials were available 18 months prior to our survey. In two recent chart audit studies from family prac- tice settings, Bell and Dippe reported that only 46% of hypercholesterolemic patients received dietary coun- seling, 7 whereas Madlon-Kay found a counseling rate of 59%. 8 In a chart audit of internal medicine and family medicine residents' practices from January 1988, 48% of patients with serum cholesterol values of at least 240 mg/dL received dietary counseling or therapy. 9 Our residents' self-report, 18 months after the publication of the NCEP guidelines, of counseling 58% of hyper- cholesterolemic patients is remarkably consistent with these earlier data. Recently, family practice and internal medicine residents affiliated with one medical school agreed that
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