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 ofpractical knowledge about dietary facts 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 theyfeel 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 AreaHealth 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);the 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 VirginiaUniversitySchool 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 Societyof General Internal Medicine, Arlington, Virginia, May 2- 4, 1990. Supported by the Universityof 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 MedicalFoundation 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 MedicalCenter, Danville, PA, 17822. Key words: Hypercholesterolemia; dietary counseling. physician counseling, internship and residency; health promotion. J GENINTERN 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