Recognizing the requirement that lifestyle medicine should be an integral and integrated part of the medical education curriculum, we undertook an in-depth mapping process with the aim of determining the scope of LM teaching in our Faculty. , together with the impact on the attitudes of medical students. and confidence towards BI counselling, and staff perceptions of the importance of BI teaching.
We learned that, in practice, students received 58 hours of LM instruction throughout the four-year program, and very little in the clinical years. It was disappointing to find that the teaching fell primarily into our core spiral lifestyle medicine curriculum and did not significantly extend into other courses. Compared to “gold standard” LM curricula such as the University of South Carolina Greenville School of Medicine, which provides 86.5 hours of LM instruction in its curriculum. [10]We have a lot of room for improvement. Although nutrition is the most widely taught LM subject in our curriculum, at 6 p.m. we still fall short of the National Academy of Sciences recommendation of 25 hours of nutrition education in medical schools. [16]. Our curriculum only includes 7 hours of physical activity instruction, which is less than the average 8-hour training in American medical schools. [25]. This is worrisome, since physical inactivity and a sedentary lifestyle are key modifiable risk factors for the development of chronic diseases. [26]. Other areas that need significant improvement in our curriculum are smoking, stress, sexuality, and alcohol.
All course coordinators in the preclinical years and heads of clinical departments recognized the importance of lifestyle medicine. However, while they were supportive, they reported time constraints as a major challenge for LM teaching. Some also indicated the need to bring in outside experts to teach lifestyle medicine. They only commented that LM is a preventative rather than a curative treatment. Furthermore, they saw the community as the arena where LM should be taught.
The students also recognized the importance of lifestyle medicine and, by the time they completed their rotation in internal medicine, had positive attitudes regarding the importance of the physician’s lifestyle and the responsibility of physicians to provide lifestyle advice. life instead of leaving it in the hands of paraprofessionals. However, self-perceived levels of confidence in giving lifestyle medicine advice were low.
As lifestyle medicine leaders at the College, we spend a lot of time planning and implementing lifestyle medicine education. We were disappointed to see that self-perceived confidence levels were not higher, probably due to inadequate opportunities to practice lifestyle counseling in the clinical years and a lack of role models by medical staff. More opportunities are needed through experiential learning, such as simulations and role-plays during the preclinical years and hands-on with patients during the clinical years.
Strengths and limitations
Our research is novel in that we mapped the entire curriculum at our medical school through observation of teaching, rather than simply through a survey of curricula and syllabuses. This was done in real time by medical students sitting through lectures and teaching sessions over a 2-year period using a tool specifically designed for this purpose. It was an arduous but invaluable exercise in understanding the field in practice and allowed us to determine what is being taught in practice rather than relying on syllabi that may reflect teaching intentions rather than reality. It also exposed the lack of competency-based teaching, at a time when competency-based medical education is at the forefront, with lifestyle medicine and skills being an explicit requirement. For example, the UK General Medical Council requires that trainee doctors must “demonstrate the basic principles of public health, including the promotion of health and well-being, nutrition, exercise and disease prevention”. [27].
There are limitations in our study that must be considered. First, our mapping exercise was largely quantitative, although student feedback also provided insight into the depth and quality of the teaching. Additionally, due to limited resources, most of the mapping during the clinical years was performed at the affiliated hospital closest to the medical school campus. Teaching is unlikely to differ significantly at the other affiliated teaching hospitals as they all follow the same curriculum. However, caution is required before generalizing about the set of clinical studies from our medical school. Unfortunately, it was difficult to determine the extent of LM teaching in family medicine rotations, as students are primarily taught individually in primary care clinics, which are likely to vary greatly in their focus on lifestyle medicine. Another limitation of the study is that we tested LM knowledge and confidence, but we did not have a proficiency record from the observation or OSCE exams. Finally, we received poor response to the questionnaires at the end of the medical training, so we could not determine the final confidence and attitudes of the students. It is hard to believe that given the lack of teaching beyond the internal medicine rotation, it is likely to increase.
Implications for Practice
Our study has led us to offer some recommendations in practice (see Table 4). With the gap in LM teaching between the preclinical and clinical years, our next steps should focus on finding ways to ensure that time for LM teaching is allocated in the clinical years. Also, emphasis should be placed on incorporating LM teaching into areas that are lacking such as sexuality, sleep, alcohol, and stress. The adage that “assessment drives learning” is particularly apt, and lifestyle medicine will only gain its rightful place in the curriculum if students are assessed on their competency in this area. While it would be relatively simple to introduce LM into written assessments, the real issue is assessing skills in counseling patients about behavior change. However, there is a notable lack of role models in teaching and demonstrating clinical ML skills in routine patient care. Therefore, faculty development is required and a focus is needed on the use of lifestyle medicine counseling as part of the teaching routine in hospitals. Faculty directors, unsurprisingly, stated that time constraints were the biggest constraint. This can only be overcome by strategic planning at the management level with increased emphasis on LM.
Table 4 Future recommendations moving forward
Policy implications
This research is of relevance to medical educators and also at the health policy level. In 2010, the AMA declared its support for legislation that incentivizes and provides funding for the inclusion of lifestyle medicine education in medical school education. [27]. Most recently, the US Bipartisan Policy Center convened a symposium of leading health organizations, which called for the inclusion of nutrition and physical activity at all levels of medical education (https://bipartisanpolicy.org /download/?file= /wp-content/uploads/2019/03/BPC-Training-Health-Professionals-for-Obesity-Care.pdf). Other action has included a demand for state and federal support for impactful and lasting change in health care delivery, launching a think tank tasked with opening communication, informing local and national elected officials, and address the possible policy needed. challenges (https://www.acpm.org/getmedia/1991b553-f955-494c-a795-1d31d587aa5f/lifestyle_medicine_legislati.pdf.aspx) [28]. As our study highlights, 20 years later, these requirements are far from being adequately implemented.
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