Summary of results
Our survey of English-speaking final-year medical students in Canada demonstrated limited knowledge and inadequate self-reported competence in managing patients with obesity. Our survey of UGME deans in Canada demonstrated an average of 14.6 curricular hours dedicated to teaching management of patients living with obesity across all years of medical school, with multiple instructional modalities used to deliver this content. Medical students were most knowledgeable on the etiology of obesity and goals of obesity treatment, and least knowledgeable on the physiology of obesity and long-term weight loss maintenance. We found no significant correlation between medical students’ knowledge scores and their self-reported competence in managing patients living with obesity. Together, these findings suggest a gap in UGME curricula regarding management of patients living with obesity.
Explanation of findings
Our finding for the mean knowledge score of Canadian students (M = 10.5) is consistent with that of Martins and Norsett-Carr among Norwegian students (M = 10.8), and lower than the Norwegian experts’ score (M = 14.6) [26]. Canadian and Norwegian students demonstrated similar strengths and weaknesses, including greatest knowledge about the etiology of obesity and poorest knowledge about weight loss maintenance. It is encouraging that knowledge of the etiology of obesity was a relative strength among students, since this is associated with decreased weight bias and improved clinical interactions among practicing physicians [18, 27, 28]. Although the experts’ score may be used for comparison, the lack of validity evidence for a cut-off score for students limits our ability to draw conclusions about students’ overall clinical competence, although mean scores for performance on individual questions remains valuable for highlighting areas of weakness. The gaps in knowledge domains identified in Fig. 2 can be used as a guide by medical educators to develop future educational interventions aimed at the management of patients living with obesity. For example, only 4% of respondents correctly answered a knowledge question addressing the topic of diagnosing obesity in children. As such, future educational interventions may wish to consider addressing this topic. It is, however, promising that most students (80%) opted to receive personalized feedback, which suggests that survey research like ours on underrepresented topics may offer a good opportunity both to gather data, and to provide an educational intervention that is popular with medical students.
Our finding that graduating medical students report limited competence in managing patients living with obesity is novel; although consistent with those of Jay et al. who found similar results among staff physicians and residents in internal medicine, pediatrics, and psychiatry [13]. It is concerning that despite further medical training, staff and residents’ scores in Jay et al’s study were similar to those of medical students in our study. This finding reinforces the need for additional education on management of patients living with obesity at the UGME, post-graduate medical education, and continuing professional development levels. Future competency-based medical educational interventions should aim to address the areas of weakness identified in Table 1. For example, we would recommend including training in behavior change counseling as a strategy to improve perceived and objective competence levels of medical students in addressing topics of psychosocial comorbidities of obesity, goal setting, motivational interviewing, and counselling. In a 2014 systematic review, Sherson et al. described a misalignment between patients’ desires and physicians’ approach to weight management, highlighting the need for additional training in behavior change counseling [29].
We identified a discrepancy between students’ self-reported competence in assessing patients’ diet using tools like the FFQ and assessing diet for common unhealthy behaviors associated with obesity. This discrepancy highlights a lack of familiarity among medical students with standardized evidence-based tools available to assess a patient’s diet. Familiarity with such tools should become a formal part of competency-based education on the topic of obesity for Canadian medical students.
Our results from the UGME dean’s survey demonstrate that, in medical schools that responded, relatively few curricular hours are dedicated to the management of patients living with obesity, with variability in the topics covered. All schools discussed nutrition and surgery in their curriculum, but topics of physical activity, behavioral therapy and pharmacotherapy were less frequently addressed. By comparison, medical students spend more time learning about obesity-related comorbidities – for example, averaging 15.4 hours for diabetes alone [30] – which stands in contrast to the 14.5 hours spent on the chronic disease of obesity itself. In a similar study conducted across 141 medical schools in the United States, Butsch and colleagues reported that medical schools spend an average of only 10 hours on obesity education, during the entire 4-year undergraduate curriculum [25]. These findings are consistent with recent studies which demonstrate a persistently low prioritization of obesity-related education in contemporary medical school curricula despite ongoing calls for improvement [31,32,33].
Future directions
A number of educational interventions are effective at improving medical students’ competence in managing patients living with obesity [19]. Such interventions should be incorporated and evaluated within the medical school curricula to address the competencies future physicians will require to meet the changing needs of their patients. Importantly, educational interventions should meet identified gaps. For example, the Association of American Medical Colleges in 2007 and the UK Royal College of Physicians in 2010 both described recommendations for obesity education reform at the UGME level [31, 34]. Similar initiatives should be adopted in Canada to meet the needs of Canadian medical students and patients. The recently published Clinical Practice Guideline for adults living with obesity [28] can serve as a guide for developing competencies (entrustable professional activities) within the competency-based UGME curriculum [35]. In addition, formal assessment of obesity-related competencies should be conducted throughout medical training and during formal licensing exams [20, 34].
In addition, future survey-based studies of educational interventions should consider including embedded personalized feedback as a way to support learning; and future research studies should explore whether there is an association between survey respondents’ performance and their propensity to request feedback on their responses.
Limitations
First, participation in our study was voluntary and the response rate was 10.7%, which did not meet the threshold indicated by our power analysis (see Additional file 1), making our results subject to response bias and selection bias. Some medical schools declined to participate, and we only surveyed English-speaking schools, limiting the generalizability of our findings. The 36% response rate by UGME deans also limits the generalizability of our findings. Second, our study relied on students’ self-assessment of their own competencies, which is susceptible to self-report bias; however, objective knowledge scores were used to complement self-report data, increasing overall reliability. Third, fewer students completed the knowledge part of the questionnaire compared to the self-reported competence part, limiting the conclusions which can be drawn from within-subject analysis of knowledge and self-reported competence. Fourth, the dean’s survey relied upon respondents’ understanding of each domain of obesity management to accurately self-report the content of the obesity management curriculum, which we were unable to verify. Fifth, the absence of validity evidence for cut-off points for the student surveys limits our ability to make inferences about students’ overall clinical competence. Lastly, we were unable to match responses from the deans’ and the students’ surveys, due to confidentiality constraints, precluding us from drawing connections between program characteristics and students’ performance on the knowledge and competence questionnaires.
